The role of ECMO in COVID-19 acute respiratory failure: Defining risk factors for mortality.

BACKGROUND: Veno-venous extracorporeal membrane oxygenation (VV ECMO) utilization increased substantially during the COVID-19 pandemic, but without patient selection criteria. METHODS: We conducted a retrospective review of all adult patients with COVID-19-associated ARDS placed on VV ECMO at our institution from April 2020 through June 2022. RESULTS: 162 patients were included (n = 95 Pre-Delta; n = 58 Delta; n = 9 Omicron). The frequency of ECMO duration greater than three weeks was variable by pandemic period (17% pre-Delta, 41% Delta, 22% Omicron, p = 0.003). In-hospital mortality was 60.5%. Age ≥50 years (RR 1.28, 95% CI 1.01, 1.62), ≥7 days of respiratory support (1.39, 95% CI 1.05, 1.83) and pre-cannulation renal failure requiring dialysis (RR 1.42, 95% CI 1.13, 1.78) were associated with mortality. CONCLUSIONS: In this cohort of VV ECMO patients with COVID-19, older age, a longer duration of pre-ECMO respiratory support, and pre-ECMO renal failure all increased the risk of mortality by approximately 30%.

COVID-19 community pantries as community health engagement: the case of Maginhawa community pantry in the Philippines

The COVID-19 pandemic has exacerbated and surfaced long-standing inadequacies in the country's health and social systems. In response to the Philippine government's inefficient and ineffective COVID-19 response and their dismissal of the calls for accountability, Filipinos at the barangay level organized community pantries to respond to the needs of the community. Using WHO's Framework for Community Health Engagement, this study positions community pantries as a unique health phenomenon during the COVID-19 pandemic within the Philippine context. This study explores the ways that the Maginhawa Community Pantry-the critical case study-addresses both emergent and pre-existing health needs among Filipinos during the COVID-19 pandemic. By examining community pantries from the perspective of the Maginhawa Community Pantry organizer, this paper elucidates how community pantries engage in diverse initiatives that: (1) mobilize the community for health, (2) improve access to healthcare, (3) ensure community collaboration and (4) call for collective action for systemic issues. The findings of this paper highlight the capacity and potential of community pantries as a health response beyond the COVID-19 pandemic and address gaps in the Philippine healthcare system.

The effect of COVID-19 on burn management and outcomes in a resource-limited setting.

INTRODUCTION: Optimal burn care includes fluid resuscitation and early excision and grafting. During the COVID-19 pandemic, resource-constrained environments were susceptible to interruptions in burn care. We sought to characterize pre- and intra-pandemic burn-associated outcomes at a busy tertiary hospital in Malawi. METHODS: This is a retrospective analysis of burn patients that presented to Kamuzu Central Hospital Lilongwe from 2011 through December 2021. We compared patients based on whether they presented pre- or intra-pandemic, starting on March 11, 2020, the date of official WHO designation. Comparing these cohorts, we used modified Poisson modeling to estimate the adjusted risk of undergoing an operation and the risk of death. RESULTS: We included 2969 patients, with 390 presenting during the pandemic. Patient factors were similar between the cohorts. More patients underwent surgery pre-pandemic (21.1 vs 10.3 %, p < 0.001) but crude mortality was similar at 17.3 % vs. 21.2 % (p = 0.08). The RR of undergoing surgery during the pandemic was 0.45 (95 % CI 0.32, 0.64) adjusted for age, sex, % TBSA, flame burns, and time to presentation. During the pandemic, the risk ratio for in-hospital mortality was 1.23 (95 % CI 1.01, 1.50) adjusted for age, sex, % TBSA, surgical intervention, flame burns, and time to presentation. CONCLUSIONS: During the pandemic, the probability of undergoing burn excision or grafting was significantly lower for patients, independent of the severity. Consequently, the adjusted risk of mortality was higher. To improve patient outcomes, efforts to preserve operative capacity for burn patients during periods of severe resource constraint are imperative.

Reallocation of Hospital Resources During COVID-19 Pandemic and Effect on Trauma Outcomes in a Resource-Limited Setting.

BACKGROUND: The COVID-19 pandemic has caused unprecedented disruptions to surgical care worldwide, particularly in low-resource countries. We sought to characterize the association between pre-and intra-pandemic trauma clinical outcomes at a busy tertiary hospital in Malawi. METHODS: We analyzed trauma patients that presented to Kamuzu Central Hospital in Lilongwe, Malawi, from 2011 through July 2021. Burn patients were excluded. We compared patients based on whether they presented before or during the pandemic (defined as starting March 11, 2020, the date of the official WHO designation). We used logistic regression modeling to estimate the adjusted odds ratio of death based on presentation. RESULTS: A total of 137,867 patients presented during the study period, with 13,526 patients during the pandemic. During the pandemic, patients were more likely to be older (mean 28 vs. 25 years, p < 0.001), male (79 vs. 74%, p < 0.001), and suffer a traumatic brain injury (TBI) as their primary injury (9.7 vs. 4.9%, p < 0.001). Crude trauma-associated mortality was higher during the pandemic at 3.7% vs. 2.1% (p < 0.001). The odds ratio of mortality during the pandemic compared to pre-pandemic presentation was 1.28 (95% CI 1.06, 1.53) adjusted for age, sex, initial AVPU score, transfer status, injury type, and mechanism. CONCLUSIONS: During the pandemic, adjusted trauma-associated mortality significantly increased at a tertiary trauma center in a low-resource setting despite decreasing patient volume. Further research is urgently needed to prepare for future pandemics. Potential targets for improvement include improving pre-hospital care and transportation, planning for intensive care utilization, and addressing nursing shortages.

Posthospitalization outcomes after extracorporeal membrane oxygenation (ECMO) for COVID-19.

BACKGROUND: Critical illness from COVID-19 is associated with prolonged hospitalization and high mortality rates. Extracorporeal membrane oxygenation is used for refractory severe acute respiratory distress syndrome in COVID-19 with outcomes comparable to other indications for extracorporeal membrane oxygenation. However, long-term functional outcomes have yet to be fully elucidated. METHODS: We performed a retrospective chart review of 24 consecutive patients who required extracorporeal membrane oxygenation due to COVID-19 associated severe acute respiratory distress syndrome and survived to hospital discharge. After hospitalization, we contacted patients and administered the Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 tool to assess longer-term outcomes. We abstracted demographics, clinical course, outcomes, and disposition variables from the electronic medical record. Descriptive statistical analysis was used on the retrospective data collection. RESULTS: Inpatient data were analyzed for 24 patients, and 21 of 24 (88%) patients completed the Patient-Reported Outcomes Measurement Information System tool at an average of 8.8 months posthospitalization. At hospital discharge, 62.5% of patients had ongoing oxygen requirements (nasal cannula, trach collar, or mechanical ventilation); 70.8% were discharged to a location other than home. However, at the time of follow-up, only 9.5% of patients required supplemental oxygen, all tracheostomies had been removed, and all patients resided at home. Patients reported relatively high levels of global physical function, and though there was a high reported incidence of fatigue, overall pain scores were low. CONCLUSION: Long-term outcomes after extracorporeal membrane oxygenation for severe acute respiratory distress syndrome from coronavirus disease 2019 are promising. Extracorporeal membrane oxygenation therapy may confer morbidity benefits in patients with coronavirus disease and remains a valuable modality with excellent functional outcomes and preserved quality of life for survivors.

Major Bleeding and Thrombosis Events in COVID-19 Versus Influenza Patients Requiring Extracorporeal Membrane Oxygenation.

Initial reports described a hypercoagulable state and an increased risk of thrombosis in patients who tested positive for SARS-CoV-2. Infected patients with severe acute respiratory distress syndrome in the setting of coronavirus disease 2019 (COVID-19) may require extracorporeal membrane oxygenation (ECMO), leading to coagulopathies and further increasing the risk for bleeding and thrombosis. We conducted a single-center retrospective cohort study to compare the incidence of major bleeding and thrombosis in COVID-19 versus influenza-positive patients requiring ECMO. There was no difference in the incidence of major bleeding (67.7% vs. 85.7%, p = 0.287) or major thrombosis (9.7% vs. 21.4%, p = 0.356) between COVID-19 and influenza patients, respectively. COVID-19 patients experienced significantly fewer major bleeding events per ECMO days compared with influenza (0.1 [interquartile range 0-0.2] vs. 0.2 [interquartile range 0.1-0.5], p = 0.026). Influenza patients may be at higher risk for developing coagulopathies that contribute to bleeding. Larger evaluations are needed to confirm these results and further assess bleeding and thrombosis risk in these populations.

Cultural Competence, Safety, Humility, and Dexterity in Surgery.

PURPOSE OF REVIEW: As the United States' population diversifies, urgent action is required to identify, dismantle, and eradicate persistent health disparities. The surgical community must recognize how patients' values, beliefs, and behaviors are influenced by race, ethnicity, nationality, language, gender, socioeconomic status, physical and mental ability, sexual orientation, and occupation. RECENT FINDINGS: Lately, health disparities have been highlighted during the COVID-19 pandemic. Surgery is no exception, with notable disparities occurring in pediatric, vascular, trauma, and cardiac surgery. In response, numerous curricula and training programs are being designed to increase cultural competence and safety among surgeons. SUMMARY: Cultural competence, safety, humility, and dexterity are required to improve healthcare experiences and outcomes for minorities. Various opportunities exist to enhance cultural competency and can be implemented at the medical student, resident, attending, management, and leadership levels.

Characterizing COVID-19 clinical phenotypes and associated comorbidities and complication profiles.

PURPOSE: Heterogeneity has been observed in outcomes of hospitalized patients with coronavirus disease 2019 (COVID-19). Identification of clinical phenotypes may facilitate tailored therapy and improve outcomes. The purpose of this study is to identify specific clinical phenotypes across COVID-19 patients and compare admission characteristics and outcomes. METHODS: This is a retrospective analysis of COVID-19 patients from March 7, 2020 to August 25, 2020 at 14 U.S. hospitals. Ensemble clustering was performed on 33 variables collected within 72 hours of admission. Principal component analysis was performed to visualize variable contributions to clustering. Multinomial regression models were fit to compare patient comorbidities across phenotypes. Multivariable models were fit to estimate associations between phenotype and in-hospital complications and clinical outcomes. RESULTS: The database included 1,022 hospitalized patients with COVID-19. Three clinical phenotypes were identified (I, II, III), with 236 [23.1%] patients in phenotype I, 613 [60%] patients in phenotype II, and 173 [16.9%] patients in phenotype III. Patients with respiratory comorbidities were most commonly phenotype III (p = 0.002), while patients with hematologic, renal, and cardiac (all p<0.001) comorbidities were most commonly phenotype I. Adjusted odds of respiratory, renal, hepatic, metabolic (all p<0.001), and hematological (p = 0.02) complications were highest for phenotype I. Phenotypes I and II were associated with 7.30-fold (HR:7.30, 95% CI:(3.11-17.17), p<0.001) and 2.57-fold (HR:2.57, 95% CI:(1.10-6.00), p = 0.03) increases in hazard of death relative to phenotype III. CONCLUSION: We identified three clinical COVID-19 phenotypes, reflecting patient populations with different comorbidities, complications, and clinical outcomes. Future research is needed to determine the utility of these phenotypes in clinical practice and trial design.

Racial and Ethnic Disparities in Hospital Admissions from COVID-19: Determining the Impact of Neighborhood Deprivation and Primary Language.

BACKGROUND: Despite past and ongoing efforts to achieve health equity in the USA, racial and ethnic disparities persist and appear to be exacerbated by COVID-19. OBJECTIVE: Evaluate neighborhood-level deprivation and English language proficiency effect on disproportionate outcomes seen in racial and ethnic minorities diagnosed with COVID-19. DESIGN: Retrospective cohort study SETTING: Health records of 12 Midwest hospitals and 60 clinics in Minnesota between March 4, 2020, and August 19, 2020 PATIENTS: Polymerase chain reaction-positive COVID-19 patients EXPOSURES: Area Deprivation Index (ADI) and primary language MAIN MEASURES: The primary outcome was COVID-19 severity, using hospitalization within 45 days of diagnosis as a marker of severity. Logistic and competing-risk regression models assessed the effects of neighborhood-level deprivation (using the ADI) and primary language. Within race, effects of ADI and primary language were measured using logistic regression. RESULTS: A total of 5577 individuals infected with SARS-CoV-2 were included; 866 (n = 15.5%) were hospitalized within 45 days of diagnosis. Hospitalized patients were older (60.9 vs. 40.4 years, p < 0.001) and more likely to be male (n = 425 [49.1%] vs. 2049 [43.5%], p = 0.002). Of those requiring hospitalization, 43.9% (n = 381), 19.9% (n = 172), 18.6% (n = 161), and 11.8% (n = 102) were White, Black, Asian, and Hispanic, respectively. Independent of ADI, minority race/ethnicity was associated with COVID-19 severity: Hispanic patients (OR 3.8, 95% CI 2.72-5.30), Asians (OR 2.39, 95% CI 1.74-3.29), and Blacks (OR 1.50, 95% CI 1.15-1.94). ADI was not associated with hospitalization. Non-English-speaking (OR 1.91, 95% CI 1.51-2.43) significantly increased odds of hospital admission across and within minority groups. CONCLUSIONS: Minority populations have increased odds of severe COVID-19 independent of neighborhood deprivation, a commonly suspected driver of disparate outcomes. Non-English-speaking accounts for differences across and within minority populations. These results support the ongoing need to determine the mechanisms that contribute to disparities during COVID-19 while also highlighting the underappreciated role primary language plays in COVID-19 severity among minority groups.

Comparative outcomes between COVID-19 and influenza patients placed on veno-venous extracorporeal membrane oxygenation for severe ARDS.

BACKGROUND: ECMO is an established supportive adjunct for patients with severe, refractory ARDS from viral pneumonia. However, the exact role and timing of ECMO for COVID-19 patients remains unclear. METHODS: We conducted a retrospective comparison of the first 32 patients with COVID-19-associated ARDS to the last 28 patients with influenza-associated ARDS placed on V-V ECMO. We compared patient factors between the two cohorts and used survival analysis to compare the hazard of mortality over sixty days post-cannulation. RESULTS: COVID-19 patients were older (mean 47.8 vs. 41.2 years, p = 0.033), had more ventilator days before cannulation (mean 4.5 vs. 1.5 days, p < 0.001). Crude in-hospital mortality was significantly higher in the COVID-19 cohort at 65.6% (n = 21/32) versus 36.3% (n = 11/28, p = 0.041). The adjusted hazard ratio over sixty days for COVID-19 patients was 2.81 (95% CI 1.07, 7.35) after adjusting for age, race, ECMO-associated organ failure, and Charlson Comorbidity Index. CONCLUSION: ECMO has a role in severe ARDS associated with COVID-19 but providers should carefully weigh patient factors when utilizing this scarce resource in favor of influenza pneumonia.

Time to Cannulation after ICU Admission Increases Mortality for Patients Requiring Veno-venous ECMO for COVID-19 Associated Acute Respiratory Distress Syndrome.

OBJECTIVE: COVID-19 can cause ARDS that is rapidly progressive, severe, and refractory to conventional therapies. ECMO can be used as a supportive therapy to improve outcomes but evidence-based guidelines have not been defined. SUMMARY BACKGROUND DATA: Initial mortality rates associated with ECMO for ARDS in COVID-19 were high, leading some to believe that there was no role for ECMO in this viral illness. With more experience, outcomes have improved. The ideal candidate, timing of cannulation, and best postcannulation management strategy, however, has not yet been defined. METHODS: We conducted a retrospective review from April 1 to July 31, 2020 of the first 25 patients with COVID-19 associated ARDS placed on V-V ECMO at our institution. We analyzed the differences between survivors to hospital discharge and those who died. Modified Poisson regression was used to model adjusted risk factors for mortality. RESULTS: Forty-four patients (11/25) survived to hospital discharge. Survivors were significantly younger (40.5 years vs 53.1 years; P < 0.001) with no differences between cohorts in mean body mass index, diabetes, or PaO2:-FiO2 at cannulation. Survivors had shorter duration from symptom onset to cannulation (12.5 days vs 19.9 days, P = 0.028) and shorter duration of intensive care unit (ICU) length of stay before cannulation (5.6 days vs 11.7 days, P = 0.045). Each day from ICU admission to cannulation increased the adjusted risk of death by 4% and each year increase in age increased the adjusted risk 6%. CONCLUSIONS: ECMO has a role in severe, refractory ARDS associated with COVID-19. Increasing age and time from ICU admission were risk factors for mortality and should be considered in patient selection. Further studies are needed to define best practices for V-V ECMO use in COVID-19.

mTOR inhibition in COVID-19: A commentary and review of efficacy in RNA viruses.

In this commentary, we shed light on the role of the mammalian target of rapamycin (mTOR) pathway in viral infections. The mTOR pathway has been demonstrated to be modulated in numerous RNA viruses. Frequently, inhibiting mTOR results in suppression of virus growth and replication. Recent evidence points towards modulation of mTOR in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We discuss the current literature on mTOR in SARS-CoV-2 and highlight evidence in support of a role for mTOR inhibitors in the treatment of coronavirus disease 2019.

Characterizing COVID-19 Clinical Phenotypes and Associated Comorbidities and Complication Profiles.

BACKGROUND: There is limited understanding of heterogeneity in outcomes across hospitalized patients with coronavirus disease 2019 (COVID-19). Identification of distinct clinical phenotypes may facilitate tailored therapy and improve outcomes. OBJECTIVE: Identify specific clinical phenotypes across COVID-19 patients and compare admission characteristics and outcomes. DESIGN, SETTINGS, AND PARTICIPANTS: Retrospective analysis of 1,022 COVID-19 patient admissions from 14 Midwest U.S. hospitals between March 7, 2020 and August 25, 2020. METHODS: Ensemble clustering was performed on a set of 33 vitals and labs variables collected within 72 hours of admission. K-means based consensus clustering was used to identify three clinical phenotypes. Principal component analysis was performed on the average covariance matrix of all imputed datasets to visualize clustering and variable relationships. Multinomial regression models were fit to further compare patient comorbidities across phenotype classification. Multivariable models were fit to estimate the association between phenotype and in-hospital complications and clinical outcomes. Main outcomes and measures: Phenotype classification (I, II, III), patient characteristics associated with phenotype assignment, in-hospital complications, and clinical outcomes including ICU admission, need for mechanical ventilation, hospital length of stay, and mortality. RESULTS: The database included 1,022 patients requiring hospital admission with COVID-19 (median age, 62.1 [IQR: 45.9-75.8] years; 481 [48.6%] male, 412 [40.3%] required ICU admission, 437 [46.7%] were white). Three clinical phenotypes were identified (I, II, III); 236 [23.1%] patients had phenotype I, 613 [60%] patients had phenotype II, and 173 [16.9%] patients had phenotype III. When grouping comorbidities by organ system, patients with respiratory comorbidities were most commonly characterized by phenotype III (p=0.002), while patients with hematologic (p<0.001), renal (p<0.001), and cardiac (p<0.001) comorbidities were most commonly characterized by phenotype I. The adjusted odds of respiratory (p<0.001), renal (p<0.001), and metabolic (p<0.001) complications were highest for patients with phenotype I, followed by phenotype II. Patients with phenotype I had a far greater odds of hepatic (p<0.001) and hematological (p=0.02) complications than the other two phenotypes. Phenotypes I and II were associated with 7.30-fold (HR: 7.30, 95% CI: (3.11-17.17), p<0.001) and 2.57-fold (HR: 2.57, 95% CI: (1.10-6.00), p=0.03) increases in the hazard of death, respectively, when compared to phenotype III. CONCLUSION: In this retrospective analysis of patients with COVID-19, three clinical phenotypes were identified. Future research is urgently needed to determine the utility of these phenotypes in clinical practice and trial design.