for good morning and good afternoon, everyone. I am your moderator, Christian Custodio, and for today's research spotlight on the pandemic. Just as a reminder, we're recording this webcast. Please mute your microphones. Please put any questions for the presenters in the chat and we will try to answer every question at the end of all of the presentations. And our first speaker today is Dr. Tunch Quimaz from Temple University Moss Rehabilitation. Thank you, Dr. Custodio. Hi, everybody. Thanks for tuning in. My name is Tunch Quimaz. I'm calling in from, at the moment, not so sunny Philadelphia. I'm a fourth year PM&R resident at the Temple University Moss Rehab Program. And today I'll be talking about a case series of critical illness neuropathy and critical illness myopathy in patients hospitalized in the intensive care unit due to COVID-19 infection. Slide. Now, as we all know and have experienced, the COVID-19 pandemic has brought forth significant morbidity, mortality and costs while impacting every area of society. Some more quantitatively speaking, though, according to the World Health Organization, as of this morning, there have been approximately 251 million cases of COVID-19 infections worldwide and just over 5 million related deaths. The downstream effects of COVID-19 infection on the various organ systems is a topic of active and urgent research as we aim to understand and treat patients that continue to suffer, even after resolution of active viral infection. Now, unfortunately, many patients infected with COVID-19 require ICU level of care, oftentimes for extended periods of time. Now, the precedents of critical illness neuropathy and critical illness myopathy are well-studied following generic ICU hospitalizations even before the whole COVID-19 pandemic era. However, there is very limited data concerning the association between these neuromuscular diagnoses and COVID-19. Our observational case series here aim to determine patterns of neuromuscular diagnoses that are uncovered by electrodiagnostic studies following ICU hospitalization secondary to COVID-19 infection. A retrospective chart review was performed on patients with COVID-19 infections who underwent electrodiagnostic studies between May 2020 and September 2021, evaluating for etiology of numbness, weakness, and or paresthesia at our electrodiagnostic laboratory at Moss Rehab, a tertiary care rehabilitation hospital in Philadelphia, Pennsylvania. As you can see from table one, there were a total of 18 cases in our lab that had required ICU hospitalization secondary to COVID-19. Of these, the average age of the patients was about 58 years old, and interestingly, there was also a skew towards males at 72%. Of note, all of were intubated at some point and approximately 83% actually required trach placement. Now, over the course of 17 months that we evaluated, all 18 of the patients of COVID-related hospitalizations that underwent electrodiagnostic testing developed their presenting symptoms during or after their COVID-19 ICU hospitalization. All 18 had some degree of new significant abnormal electrodiagnostic findings, and 16 had more than one significant finding. And now a few key other results that I wanted to go ahead and highlight here. First of all, is that 83% of the cases were found to have CIM and or CIN, and 61% of those cases were also found to have both concurrently. Now, throughout this study, we also found a couple other interesting patterns that also emerged that I wanna go ahead and highlight here. About 77% of our cases, or 14 out of the 18, had isolated mononeuropathies, and the most popular of which was the ulnar mononeuropathy in about 39% of all of our cases. Also, about a quarter or five out of the 18 had brachial plexopathies, and actually one case had both a bilateral brachial plexopathy. An interesting case that's actually discussed more in detail at one of our case presentation posters at this year's AAPMNR meeting that you can also check out if you'd like. Now, the presence of CIN, excuse me, next slide. Now, this presence of CIN and CIN were certainly expected given the prolonged ICU hospitalization associated with a COVID-19 infection. While the exact incidence is debated, generally speaking, over half of patients in the ICU greater than seven days go on to develop CIN and CIN. But the significantly high percentage of patients presented here, remember, 83% of our patients had CIN and or CIN, raises suspicion that ICU hospitalizations secondary to COVID-19 infection may cause a higher incidence of these electrodiagnostic incidences, diagnoses, excuse me. The suspected pathophysiology for the higher CIN and CIN presence in our studies is believed to be related to the ACE2 receptors. COVID-19 viral particles have been found to have high binding affinity for the ACE2 receptors found in lungs and neurons, and it is possible that an increased risk of critical illness pathology may be through direct viral infection via these ACE2 receptors in the neurons. A similar result was actually found in a study in Spain that analyzed 12 COVID-related ICU cases that were referred for electrodiagnostic testing with four of those cases having evidence of CIN and seven with CIN, for a total of 11 patients out of the 12, or 92%, having one or the other diagnosis. Interestingly, their study had also a significant male predominance, just like ours. Theirs was at 83%, and ours was more at 72%. I do also want to highlight, it should be noted that these patients in both our studies, as well as the Spanish study, were referred for electrodiagnostic testing precisely because there was some suspicion of neuromuscular disease processes already, and our findings are not a true incidence. However, the such high percentage that we found in both of our studies raises the question of at least some association. Is there an association between COVID-19 ICU hospitalization and CIN-CIN? Even outside of the ICU population, long COVID studies have shown that the most common lingering symptoms are fatigue and muscle weakness, so these results bear some relevance to a greater population as well. Of course, further studies are needed to more directly compare COVID-19 versus non-COVID-19 associated ICU hospitalizations as early electrodiagnostic testing may be indicated for prognostication and appropriate planning for a post-ICU rehabilitation regimen. Thank you, everyone, for your time and interest, and Dr. Custodio, back to you. Thank you, that was an incredible talk. Our next presentation is from Dr. Susan Liu from New York University. Thank you, Dr. Custodio. I'll be presenting a case today, acute inflammatory demyelinating polyneuropathy following the first COVID vaccine dose with someone with prolonged COVID-19 infection. This case describes a 62-year-old male who had COVID-19, a very mild case, in December. He thought it was resolved. He got the initial Pfizer vaccination in February, two months after. He started developing some bilateral symmetrical weakness of the proximal extremities, around four plus out of five, distal limb paresthesias, and impaired proprioception in his toes. So he went to the ED. Neurology was consulted. They said follow-up outpatient for peripheral neuropathy. Two days later, he represented to the emergency room for worsening quadriparesis, gait instability, and also areflexia at that time. And neurology saw him and admitted him for acute inflammatory demyelinating polyneuropathy. They did an admission COVID swab, and it was tested positive. Because he was on anticoagulation for his AFib, lumbar puncture was deferred, and he was treated with the empiric treatment of five days of IVIG, which is standard treatment for AIDP. So instead, they did an EMG, which is in the figure in purple. The red highlights the abnormalities. So there are some reduced amplitudes in the right median nerve, slowed conduction velocity in the right ulnar nerve, some prolonged distal latencies in the right peroneal and tibial nerve and C-maps, and reduced amplitude still in the tibial nerve, and some borderline reduced conduction velocities in several nerves in the right upper and lower extremities. Most notable, though, were the prolonged or no responses in the F waves for the peroneal, tibial, median, and ulnar nerve. And then the EMG, needle EMG study showed some reduced recruitment. ID was consulted and said that AIDP was thought to be really triggered by that persistent COVID-19 infection, as opposed to the actual response to the Pfizer vaccine itself. And he was admitted to inpatient rehab at a modest assist for two-person assist, and then with a short stay was discharged home at an independent level. So assessment and results, the patient developed AIDP three weeks following the initial Pfizer vaccine administration after having thought that his initial COVID-19 infection was resolved. But he still tested positive on the PCR admission. His symptoms improved with standard treatment for AIDP, which is IVIG, and his rehab focused on his impaired sensation, endurance, strength, and balance. And he eventually was able to be discharged home from acute patient rehab at an independent level. As far as discussions, I mean, AIDP is uncommon with COVID-19 infections. Treatments typically include IVIG, which is standard treatment for AIDP, and then potential rehab course as guided by a physiatrist. And it is imperative for us to recognize that AIDP is a complication of COVID-19, and that can be exacerbated by the Pfizer vaccine administration if they have prolonged COVID. Conclusions, AIDP is a potential complication of COVID-19 infection that can be triggered by Pfizer vaccine administration and may require acute inpatient rehab to address the patient's resulting functional deficits after recommended treatment. Thank you so much. Dr. Custodio, back to you. Thank you, Dr. Liu. I see with that we have some audience members that have just joined us. Just as a reminder, please place questions in the chat for our presenters, and we will answer all of them at the end of all of the presentations. Thank you. So our next presenter is Dr. Hannah Farmer from the University of Missouri-Columbia PM&R Program. Thank you, Dr. Custodio. I'm a third-year resident at the University of Missouri in Columbia. Today, I'll be talking about the study that myself, Dr. Benjamin Gill, Kelly Buchanan, Dr. Zahiruddin Ahmad, Dr. Wendy Pierce-Martin, and Dr. Claire Finkel produced, entitled Evaluation of Anxiolytic and Antipsychotic Use at Inpatient Rehab Hospital during the COVID-19 pandemic. We designed this study to evaluate administration of both anxiolytic and antipsychotic medications in relation to the global pandemic. The design was a case-control study, including all patients admitted to the inpatient rehabilitation facility during the period studied. The medications we included in our study were benzodiazepines, quetiapine, propranolol, and hydroxazine, as these are commonly used medications in the inpatient rehab setting to aid in the management of anxiety, as well as agitation. The main outcome measures evaluated in this study were total number of administrations of medication by month and average administration of each medication per patient. Total number of administrations of medications included all scheduled and as-needed doses administered. Average administration of each medication per patient was determined by taking the total number of administrations of any dose of each medication, then dividing by total number of discharges at the inpatient rehab facility for that month. Data collected were divided into pre-pandemic and mid-pandemic timeframes. Pre-pandemic was determined to be October 2019 to January 2020, while mid-pandemic was from October 2020 to January 2021. An independent samples t-test was conducted to compare total administrations of each medication pre-pandemic and mid-pandemic, as well as for average administration of each medication per month during the period studied. The results of this study revealed there was a non-significant reduction in total administrations of propranolol, benzodiazepines, and hydroxyzine. Propranolol was found to have a 39% reduction, benzodiazepines were found to have a 38% reduction, and hydroxyzine was found to have a 25% reduction after the declaration of the pandemic. Total administrations of quetiapine were found to have a slight increase in pandemic, but this was not to a significant degree. The average administration of quetiapine per patient increased during the pandemic during the months of October, December, and January. However, this was not of statistical significance. The average administration of propranolol per patient decreased or remained stable mid-pandemic, while the average administration of hydroxyzine and benzodiazepines per patient did not demonstrate a consistent change relative to the pandemic. Although the initial hypothesis for this study was that use of anxiolytic medications would increase after the declaration of the pandemic, this study found there was a reduction in total administrations of anxiolytic medications at this freestanding inpatient rehab facility. This reduction in total administrations of anxiolytic medications, although not statistically significant in this study, may be due to improved non-pharmacologic means of managing anxiety, such as breathing exercises, use of essential oils, and music. All of these modalities are encouraged to be utilized in the inpatient rehab setting. This reduction in total administrations of anxiolytic medications could also be due to differences in patient population relative to the pandemic. The slight increase in average administration of quetiapine per patient may be due to increased agitation because of the pandemic itself. This increased average administration of quetiapine per patient could also be due to delirium in the rehabilitation setting due to visitor policy restrictions and masking policy during the pandemic. This study did not evaluate use of maintenance medications for anxiety, such as selective serotonin reuptake inhibitors. Future evaluation of use of such medications in the inpatient rehab setting could help further elucidate the results in this study. In conclusion, although our results did not reveal a statistically significant change in the use of anxiolytic and antipsychotic medications during the COVID-19 pandemic, we did see a reduction in total administrations of anxiolytic medications and an increase in average administrations of quetiapine per patient. Continued monitoring of the use of anxiolytic and antipsychotic medications may potentially shed light on the impacts on patients in the inpatient rehab setting during the COVID-19 pandemic. Thank you very much for taking the time to attend this presentation. Thank you, Dr. Farmer. Our next presentation is from Dr. Laura Pilgrim from McGaugh Medical School at Northwestern and Shirley Ryan Ability Lab. Thank you, Dr. Custodio. My name is Laura Pilgrim. I'm a fourth year resident at the Shirley Ryan Ability Lab in Chicago. Today, I'll be presenting a case in which a patient presented with left shoulder pain and weakness after initial COVID-19 mRNA vaccination and was found to have Parsonage-Turner syndrome. The patient is a 30-year-old gentleman with no past medical history. 10 days after receiving his first dose of an mRNA COVID-19 vaccine, he experienced sudden onset of left shoulder pain and weakness. He had no history of recent trauma or other inciting event. His pain resolved after two weeks. However, the weakness remained. Four weeks after onset of pain, he presented to an outpatient musculoskeletal clinic for evaluation. Presence of left shoulder weakness was confirmed on examination at four out of five left shoulder abduction strength and three out of five left shoulder external rotation strength, as well as notable atrophy of the infraspinous fossa. Six weeks after onset of pain, he underwent electrodiagnostic examination, including nerve conduction studies and needle electromyography. As you can see in table one, this revealed mononeuritis multiplex involving suprascapular and interosseous nerves with abnormal spontaneous activity and polyphasic units in the suprascapular and intraspinous nerves and polyphasic units in the flexor pollicis longus. All other nerve conduction studies, including left median and ulnar motor nerves, left median radial and ulnar sensory nerves were within normal limits. He subsequently completed MR neurography of the shoulder. You can see images below. This was notable for hyper enhancement of the left suprascapular nerve and denervation edema of the left supraspinatus and infraspinatus. Clinical presentation, MR neurography and electrodiagnostic findings were consistent with a diagnosis of Parsonage-Turner syndrome. Three months after symptom onset, the patient completed physical therapy, including use of electrical stimulation with mild improvement in strength, but still with residual left shoulder external rotation and abduction weakness. Given timing relative to vaccination, this case was reported to FDA MedWatch for further investigation. During MRNA vaccination trials, autoimmune neurologic events were uncommon with no pattern suggesting a causal relationship of neuroinflammatory events to vaccination. In contrast, many neurologic sequela, including Parsonage-Turner syndrome, neuropathies, plexopathies and strokes have been reported in association with COVID-19 infection. More than 80% of hospitalized patients may have neurological symptoms at some point during their course with COVID-19. Although precise pathogenesis of Parsonage-Turner remains unclear, it can occur after an autoimmune trigger such as infection or immunization, and has been documented after other vaccinations such as influenza. At the time of submission, this was the first case report to our knowledge of Parsonage-Turner syndrome after mRNA COVID-19 vaccination. In the interim, many other cases of Parsonage-Turner following mRNA COVID-19 vaccination have been published, and Parsonage-Turner syndrome has been considered as a potential adverse effect of mRNA COVID-19 vaccines in a recent pharmacovigilance monitoring report from the French National Agency for the Safety of Medicines and Health Products as of 10-8-2021. However, to our knowledge, this finding has not been replicated in other pharmacovigilance monitoring systems at this time. In conclusion, it is important to remain vigilant for potential neurologic and other complications after both COVID-19 and COVID-19 vaccination. The data continues to show that the risks of COVID-19 infection greatly exceed those of the vaccine, which is effective with an overall low rate of side effects. Thank you, everyone, for your time and attention. Thank you. I think that and some of the previous cases we've seen show that we're just starting to scratch the surface, looking at some of the neuromuscular issues associated with COVID-19 and vaccinations. So, thank you. Our next presenter is Dr. Evelyn Chin from the University of Washington. Hi, my name is Evelyn, and today I'm going to talk to you about the 30-day functional outcomes of patients after hospitalization from COVID-19. I want to first thank my PI, Dr. James Andrews. I have nothing to disclose. There are a growing number of COVID-19 survivors as a result of the COVID-19 pandemic, with common symptoms being fatigue, dyspnea, and musculoskeletal pain. The purpose of our study was to characterize the patient-reported functional outcomes of adults 30 days after discharge following acute hospitalization for COVID-19. This was a single-center, prospective cohort study. A standardized telephone questionnaire, which included several validated skills, was given to participants 30 days after hospital discharge. The questions addressed mobility, activities of daily living, instrumental activities of daily living, fatigue using the patient-reported outcomes measurement information systems with PROMIS fatigue scale, and general disability using the Health Assessment Questionnaire Disability Index, or HAC-DI. Descriptive statistics compared outcomes between older adults, which we defined as 65 years and older, and younger adults, which included adults 18 to 64 years. Table 1 shows the demographics. There was a total of 55 participants. 64% were less than 65, 53% were female, and 64% were Caucasian. The average hospital length of stay was around 11.8 days, and 42% of patients were admitted to the ICU, with 16% of those requiring mechanical ventilation. The center figure here shows the functional outcomes of the younger and older adults in the cohort. The data shows that both younger and older adults had new difficulty with ADLs, IADLs, and mobility compared to their pre-hospital baseline. Additionally, this resulted in new dependence with ADLs, IADLs, and mobility in a small proportion of these groups, which is shown in the yellow bars. Table 2 highlights general health and fatigue. In both groups, we see a worsening in their HAC score, which remember HAC is a measure of general disability, with over 60% of participants demonstrating significant worsening. Fatigue was also worse in both age groups compared to their baseline. Additional exploratory analysis was performed using univariate and multivariate analyses. Exposures included things such as age, sex, race, BMI, comorbidities at baseline, number of initial COVID symptoms, hospital length of stay, admission to the ICU, mechanical ventilation, and more. Exposures with a p-value less than 0.1 from this analysis were included in further multivariate analyses. Preliminary findings suggested that BMI and mental health at baseline may be related to risk of ADL disability. In addition, the number of COVID symptoms at presentation and hospital length of stay was related to increased risk of fatigue. However, due to the relatively small sample size, it is hard to make any clear conclusions related to these exploratory analyses. The primary takeaways from the study include, one, among adults hospitalized with COVID-19, the majority experienced a decline in their functional tasks, including ADLs, IDLs, and mobility 30 days after discharge compared to pre-hospital baseline. Two, younger adults experienced similar, if not worse, functional outcomes as older adults. And three, all adults, regardless of age, are at risk for prolonged, clinically significant functional impairment following hospitalization for COVID-19. I'd like to acknowledge Dr. Andrews again and the rest of the research team at the University of Washington. And if you're interested in any more information, our full study results are now available through the PMR Journal Online titled, Patient-Reported Functional Outcomes 30 Days After Hospitalization for COVID-19. In addition, keep an eye out for any of our future studies, which evaluate these patients more longitudinally and track their recovery trends. Thank you so much for your time. Thank you, Dr. Chin. Our final presenter is Dr. Krystal Lee from Albany Medical Center PMR Program. Thank you very much. Next slide. Hi, my name is Krystal Lee and I'm a PGY3 resident at Albany Medical Center. Today, I'm going to talk about increased falls seen during the COVID-19 pandemic at our inpatient rehabilitation facility. During our PGY2 year, we spend about 10 months inpatient at Sunnyview Rehabilitation Hospital. During that time, we take care of a wide variety of patients, including traumatic brain injury, spinal cord injury, stroke, orthopedics, amputee, and general medical patients. We also act as consultants on the cardiopulmonary unit. During 2020, which is during the time of the COVID-19 pandemic, we noticed that we had a high number of falls at our inpatient facility. We were interested to see if there was any connection with the number of falls and the local COVID-19 prevalence. Even before the pandemic, falls have always been a concern and a challenge for inpatient facilities. We're always trying to prevent them and trying to protect and keep our patients safe. Falls often happen within the first week of a patient's stay, often in their bathroom or their room. Falls were as high as like 39% in 161 stroke patients and 4% involve injuries in other studies, such by Nyberg and Gustafson. There's been a lot of research done in falls and inpatient facilities. One particular research article that sparked my interest was an article by ARIFA in a 2020 study. In that article, they noticed that there was an increased number of hip fractures due to inpatient falls during 2020 compared to 2019. That was during the pandemic. The authors attributed that to COVID-19 pandemic, which included isolation of the patients, increased use of PPE, and also understaffing. We were interested to see, will our data show the same stuff or will it show something different? What can we learn from it and how can we prevent these falls? Our study was a retrospective study done at Sunnyview Rehabilitation Hospital. We have 115 beds. The participants were patients that were admitted in 2019 and 2020. As you can see in the graph title, total number of falls in 2019 and 2020, there is a difference in 2020 and 2019. You can definitely clearly see that there's a lot more falls during that time. It's approximately about a 27% increase, which is big. The only kind of big thing that was different at the time was the pandemic. In addition, if you look at the graph titled falls in 2020, you'll see something interesting. You'll notice that in certain months, there are higher number of falls. Coincidentally, during that time was when COVID-19 prevalence was very high in our local community. During that time, which was the months of March through May and October through December, this was also when visitation was either severely restricted or in some cases completely stopped when the prevalence was very high. Also, PPE use was at its highest in the hospital. Patients also had to be isolated behind closed doors if they had COVID-19 to reduce transmission of the virus and to keep our patients and staff safe. We also evaluate the data to see, is there anything else that's affecting this? We looked at data, including how many falls happened during the different shifts, if staffing was affecting it. It turns out it didn't matter whether it was day, evening, or night. It didn't matter about staffing. It didn't seem to affect the number of falls. What was also kind of disheartening was about 31% of those falls happened while patients were on continuous video monitoring. In the past, when we've used this, it's been very helpful in preventing falls, but it seems like with the pandemic, it was a lot more difficult. In addition to continuous video monitoring, we also use other interventions such as bed alarms, wheelchair alarms, hourly monitoring, and we did continue to use a continuous video monitoring. In addition, we continued family and patient teaching. Now, during the times when visitation was restricted or in some cases completely stopped, we did have to improvise and we did use electronic technology such as FaceTime and Zoom, but they were still incorporated. Even though we use all these different interventions, we still had a high number of falls, a lot more than compared to 2019, and we felt like one thing that was unique that we've never really had to deal with before is when visitation is stopped or restricted, and we feel that the COVID-19 pandemic really affected the number of falls. Number one, because of the visitation policies, and number two, the increased need for PPE, which means it takes you longer to put on all that PPE to get to your patients. Obviously, the PPE is important, but it also does take you a longer time for staff to go to their patient when they have needs, and on top of that, we had to isolate our patients for the safety of everyone, but that results in limited visualization of the patient, which makes it very difficult to act fast, unfortunately, but it's part of the process. So, we believe that visitation and visitors play a big role, an important role, and an underappreciated role in a number of falls that we never had to deal with before. Visitors provide companionship, they provide distraction to our patients, and also an additional set of eyes, and right now, we have some idea of what we think visitors do, but there could be additional benefits that we're just not aware of, and more research has to be done. Definitely a good second research project, and something else that we have to consider is how do we measure it, like how do we measure the impact visitation has, and that's something that we also have to incorporate when we step on another project as well. For this project, the references are listed below, as on the chart. I'd like to personally thank Dr. John Pianka, my co-resident, and Mishel Koren, who helped me with this poster, and a big, big thanks to Dr. Matthew Sananjuri, who's a great mentor, always devoted to residency education, and this poster would have not been possible without him. Thank you so much for your time and attention. Thank you, Dr. Lee, and thank you to all the presenters. On behalf of your mentors, and your co-authors, and your PIs, we appreciate the shout-outs. We have some time for questions. This was a jam-packed session. Just go through the chat and see if there's anything available. I do have a question for Dr. Lee. Knowing what we know now with regards to PPE and vaccination status of visitors, is there anything that your institution, that we might do differently, given an expected next surge in COVID infections? Actually, that's a really good question. That's something I actually also asked my attending there, and the people who are the head coordinators there, just because right now we're in the flu season, and the pandemic is happening. As of now, we haven't made any big changes. They are going to keep all those things in mind, and try to keep open visitation as long as possible, but that is something that we are trying to figure out. What's the best thing? Because we've tried all these different interventions. There's also been other things that other programs have done, like the red light, green light tagging system, where you tag the patient, and people know what their fall status is, and stuff like that. Even that, we actually incorporated into our program as well, and even that didn't help. Hopefully, we won't have as many issues this session, but we are trying to figure out and brainstorm, but we don't have any good answers yet, unfortunately. Yes, I think we're all learning on the fly as we go. A question for Dr. Quimaz. From the electrodiagnostic standpoint, is there a way to tease out the differences between a typical ICU critical illness neuropathy versus something that may have been exacerbated by the COVID infection? Yes, I will say a lot of these electrodiagnostic studies are just very difficult to tease out what their initial causes. That's the other thing as well. In addition to the CIN and CIN that we see, we also see a lot of saying a lot of the isolated mononeuropathies, but also the reasoning of why these are happening. There's different theories as to whether it's direct infection of the neurons, but also microthrombi is another concern. We're in a hypercoagulable state secondary to COVID, and so if you have microthrombi going into the vasomervorum, you start having actual axon loss, and so that could theoretically be causing either these mononeuropathies or even more general multiplex, for example, or a CIN and CIN. It's difficult to tell, I will say, and no pattern was seen that was different than any non-COVID CIN or CIN. There's no real patterns, differences in patterns, but that's a good question. It's something that may need to be looked at where, yeah, there may be certain trends that are a little bit different in the flavor of CIN or CIN, if you will, but yeah, we didn't really recognize that. And this actually ties in to the next question for either Dr. Liu or Dr. Pilgrim. I just saw a patient in my clinic yesterday. She's a 70-year-old who developed a foot drop about two weeks after her booster vaccination. No other risk factors for radiculopathy or perineal neuropathy, weight loss, no habitual crossing legs. And right now, the prevailing theory is this was related to some type of hyperinflammatory autoimmune response from the vaccines. In my case, I guess it was a patient who still tested positive for COVID-19, so I'm not sure if this would apply to the patient that you're describing in your office, but I mean, I guess maybe could recommend obtaining EMG studies to see if maybe there's a mononeuropathy going on a few weeks from now. Yeah, I agree. It may be beneficial to do some further studies to assess what's going on. In terms of my study, it's really impossible to infer causality from a single case, but it is worth reporting these to national databases, which may be able to infer causality or look for a signal to see if there could be any relationship. In the early studies of both mRNA vaccines, they were not seeing a strong signal demonstrating relationship between an autoimmune neuropathy and the vaccines themselves. And then I think I have one final question for Dr. Liu again. Would you recommend screening, doing PCR testing on patients prior to vaccination? I guess it depends on how far. So when ID saw the patient, so this patient was maybe two and a half months after the initial COVID-19 infection. And he thought it was over. I guess maybe wait three, four, six months after your initial infection, if you knew, if you were positive at that time. And when ID saw him, recommended to not get any future doses of the COVID-19 vaccine. Recommended to not get any future doses of the COVID-19 vaccine in the near future, but not necessarily in the far future. Yeah, I think those are very challenging and just logistical questions that were running through my mind through all of your presentations, which were outstanding. Excellent. It's fun seeing kind of the future leaders of our field. If there are any other questions in the chat, we are actually, I think, ahead of schedule, which is a testament to your presentation skills, all of you. Well, I figure, I guess, if we have a little bit more time, I might as well add another comment. The other thing that I can think we were also seeing from the vast amount of EMGs that we were doing on these post-COVID patients, more specifically in the ICU, again, is the physical compression neuropathies that is a big concern. So, obviously, proning is a big, huge aspect of the algorithm that we've used, I think, less so more recently, but especially early on, proning was a big deal. And so that's something that, you know, there was specific, especially in New York, where, you know, the outbreak was significantly worse, where you had specific prone teams who were nonstop, you know, going around and this frequent repositioning often leading to random kind of almost, you know, again, our theory is that that could lead to these random neuropathies, maybe a reason why ulnar mononeuropathy was just the highest one within our cohort. And also, brachial plexopathy, that's, I mean, it's been shown that proning actually leads to higher rates of brachial plexopathies. But, and so even before the whole COVID era, that was something that, you know, anesthesiologists have long been studying, and actually have developed techniques. But obviously, when you're in the heat of the moment in the ICU, that's not something that a lot of people really consider. Or, you know, if you're giving immediate care attention, that's a little different than thinking about what something's going to be happening several months down the line. But something to also be aware of, you know, that is that different mononeuropathies can happen through just simple mechanically compression of the nerves. That's an excellent point. I think, I think you're right. At the beginning of the pandemic, we were all overwhelmed, all trying to figure out what was going on. And now it's just right, reviewing what we've all been through, and keeping an eye out, you know, keeping hypervigilant about all of the preventative things that we were taught as students, as residents, as attendings. So I do want to thank all of you for giving excellent presentations this afternoon, or this morning, wherever you are. And I think we can cue the AAP Menor staff for ending. Thank you. Thank you very much. Thanks, everyone. Thank you. Great work.

neurological complications

COVID-19 infection

COVID-19 vaccination

critical illness neuropathy

acute inflammatory demyelinating polyneuropathy

functional outcomes

falls

inpatient rehabilitation facility