Bloodstream and respiratory coinfections in patients with COVID-19 on ECMO.

BACKGROUND: Although several studies have characterized the risk of coinfection in COVID pneumonia, the risk of the bloodstream and respiratory coinfection in patients with COVID-19 pneumonia on extracorporeal membrane oxygenation (ECMO) supports severe acute respiratory distress syndrome (ARDS) is poorly understood. METHODS: This is a retrospective analysis of patients with COVID-19 ARDS on ECMO at a single center between January 2020 and December 2021. Patient characteristics and clinical outcomes were compared. RESULTS: Of 44 patients placed on ECMO support for COVID-19 ARDS, 30 (68.2%) patients developed a coinfection, and 14 (31.8%) patients did not. Most patients underwent venovenous ECMO (98%; 43/44) cannulation in the right internal jugular vein (98%; 43/44). Patients with coinfection had a longer duration of ECMO (34 [interquartile range, IQR: 19.5, 65] vs. 15.5 [IQR 11, 27.3] days; p = .02), intensive care unit (ICU; 44 [IQR: 27,75.5] vs 31 [IQR 20-39.5] days; p = .03), and hospital (56.5 [IQR 27,75.5] vs 37.5 [IQR: 20.5-43.3]; p = .02) length of stay. When stratified by the presence of a coinfection, there was no difference in hospital mortality (37% vs. 29%; p = .46) or Kaplan-Meier survival (logrank p = .82). Time from ECMO to first positive blood and respiratory culture were 12 [IQR: 3, 28] and 10 [IQR: 1, 15] days, respectively. Freedom from any coinfection was 50 (95% confidence interval: 37.2-67.2)% at 15 days from ECMO initiation. CONCLUSIONS: There is a high rate of co-infections in patients placed on ECMO for COVID-19 ARDS. Although patients with coinfections had a longer duration of extracorporeal life support, and longer length of stays in the ICU and hospital, survival was not inferior.

Changes in Resilience Following Engagement With a Virtual Mental Health System: Real-world Observational Study.

BACKGROUND: Digital health services can serve as scalable solutions to address the growing demand for mental health care. However, more research is needed to better understand the association between engagement with care and improvements in subclinical outcomes. OBJECTIVE: This study aims to fill this research gap by examining the relationship between members' engagement with the Ginger platform and changes in their psychological resilience. METHODS: We conducted a retrospective observational study of 3272 members who accessed Ginger, an on-demand mental health service, between January 2021 and November 2021. Each member completed the 10-item Connor-Davidson Resilience Scale questionnaire, a measure of psychological resilience, at baseline and again during a 6- to 16-week follow-up window. Depression and anxiety symptoms (9-item Patient Health Questionnaire and 7-item Generalized Anxiety Disorder) were also measured. Linear regression was used to identify the association between engagement with Ginger's multiple care modalities and changes in resilience. Moderator analysis was conducted to test whether clinical depression or anxiety at baseline moderated the relationship between engagement level and changes in resilience. RESULTS: Of the 3272 members, 2683 (82%) reported low resilience at baseline. The mean change in resilience was 0.77 (SD 5.50) points. Linear regression models showed that age and census region did not predict changes in resilience; however, male members showed larger improvements (coefficient=0.58; P=.04). Baseline mental health outcomes, including resilience and depression and anxiety symptoms, were strong predictors of changes in resilience. Every point decrease in baseline resilience is associated with a 0.28-point increase in change in resilience (P<.001), and members with no or mild depression and anxiety at baseline saw changes in resilience that were 1.44 points (P<.001) larger than their clinical counterparts. Engagement with the Ginger system predicted changes in resilience. Members who engaged with Ginger coaching, clinical services, or both improved their resilience by 1.82, 1.55, and 1.40 points, respectively (P<.001), more than those who only engaged with Ginger content. Screening negative for moderate to severe depression and anxiety at baseline was associated with larger improvements in resilience (coefficient=1.30; P<.001); however, subclinical status was not shown to be a moderator for the association between level of engagement and changes in resilience. CONCLUSIONS: Engagement with Ginger services was associated with improvements in resilience. Members who engaged in coaching or clinical care had significantly larger improvements compared with those who only engaged in self-guided content, regardless of whether a member screened positive for clinical depression or anxiety at baseline.

Association Between Care Modality and Use With Treatment Response Among Members Accessing Virtual Mental Health Services: Real-world Observational Study.

BACKGROUND: There is a growing bottleneck in mental health care, as the demand for services has outpaced the availability of mental health professionals. Consequently, many health systems have shifted to teletherapy as a scalable approach to increasing accessibility to care. Within these care models, various treatment modalities (eg, coaching and clinical care) are used to deliver support for anxiety and depression. However, more research is needed to better understand the differences in treatment responses. OBJECTIVE: The purpose of this study was to examine the association between different care modalities and the levels of use with symptom score changes for members seeking virtual care services. METHODS: We conducted an observational study of 4219 members who accessed Ginger, an on-demand mental health service, between September 2020 and September 2021. Using a mobile app, members can access text-based behavioral health coaching and virtual clinical services. This study focused on members with clinically elevated depression or anxiety levels at baseline. Logistic regressions were used to assess the association between care modalities and the levels of use with treatment response in depression and anxiety, using the Patient Health Questionnaire and Generalized Anxiety Disorder Assessment, respectively. RESULTS: Of the 4219 members, 1623 (38.47%) demonstrated a full response to depression, and 1684 (39.91%) demonstrated a full response to anxiety. Members who completed care (ie, text-based coaching, virtual clinical therapy, hybrid of coaching, and clinical care) beyond the introductory session showed significantly increased odds of a full response compared with those who completed only limited care. Members who completed a hybrid of care had the highest odds of improvement; the odds of showing a full response in depression were 2.31 times higher (95% CI 1.91-2.80; P<.001) and in anxiety were 2.23 times higher (95% CI 1.84-2.70; P<.001) compared with members who completed limited care. For members who completed only coaching or clinical care, the largest effects were observed among those with high use. For members who completed a hybrid care program, we observed similar treatment responses across all levels of use. CONCLUSIONS: Our real-world study found that members who completed text-based coaching achieved full treatment responses at similar rates compared with members who completed virtual clinical care and members who completed a hybrid of care. There were no significant differences in the predicted probabilities of full treatment response between coaching and clinical care. Generally, the odds for a full response were highest among members with high use within each care modality; however, there were no differences in full-response treatment odds across levels of use with hybrid care. The results support the utility of digital behavioral health interventions and further highlight text-based coaching protocols as an accessible and suitable option when considering virtual care for treating anxiety and depression.

Health-Related Quality of Life Among Members Using an On Demand Behavioral Health Platform: Pilot Observational Study.

BACKGROUND: Despite the well-known adverse health conditions and negative economic outcomes associated with mental health problems, accessing treatment is difficult due to reasons such as availability and cost. As a solution, digital mental health services have flooded the industry, and new studies are quickly emerging that support their potential as an accessible and cost-effective way to improve mental health outcomes. However, many mental health platforms typically use clinical tools such as the Patient Health Questionnaire-9 (PHQ-9) or General Anxiety Disorder-7 (GAD-7). Yet, many individuals that seek out care do not have clinical symptomatology and thus, traditional clinical measures may not adequately capture symptom improvement in general well-being. As an alternative, this study used the health-related quality of life (HRQoL) tool from the Centers for Disease Control and Prevention "Healthy Days" measure. This subjective measure of well-being is an effective way to capture HRQoL and might be better suited as an outcome measure for treatments that include both clinical and subclinical individuals. OBJECTIVE: The purpose of this study was to describe changes in HRQoL in clinical and subclinical members assessing virtual care and to examine the association between text-based behavioral coaching and virtual clinical sessions with changes in HRQoL. METHODS: A total of 288 members completed the 4-item HRQoL measure at baseline and at 1 month following use of the Ginger on demand behavioral health platform. Baseline anxiety and depression levels were collected using the GAD-7 and PHQ-9, respectively. RESULTS: Members completed on average 1.92 (SD 2.16) coaching sessions and 0.91 (SD 1.37) clinical sessions during the assessment month. Paired samples t tests revealed significant reductions in the average number of unhealthy mental health days between baseline (mean 16, SD 8.77 days) and follow-up (mean 13.2, SD 9.02 days; t287=5.73; P<.001), and in the average number of days adversely impacted (meanbaseline 10.9, meanfollow-up 8.19; t287=6.26; P<.001). Both subclinical members (t103=3.04; P=.003) and clinical members (t183=5.5; P<.001) demonstrated significant improvements through reductions in adversely impacted days over a month. Clinical members also demonstrated significant improvements through reductions in unhealthy mental health days (t183=5.82; P<.001). Finally, member engagement with virtual clinical sessions significantly predicted changes in unhealthy mental health days (B=-0.96; P=.04). CONCLUSIONS: To our knowledge, this study is one of the first to use the HRQoL measure as an outcome in an evaluation of a digital behavioral health platform. Using real-world longitudinal data, our preliminary yet promising results show that short-term engagement with virtual care can be an effective means to improve HRQoL for members with subclinical and clinical symptoms. Further follow-up of reported HRQoL over several months is needed.

Directed Hypercapnia as a Strategy to Wean Extracorporeal Membrane Oxygenation in COVID-19 Pneumonia.

Coronavirus disease 2019 pneumonia with respiratory failure refractory to maximum medical therapy has been successfully managed with venovenous extracorporeal membrane oxygenation. This report describes a process of using directed hypercapnia in 5 patients to wean them from prolonged extracorporeal support secondary to refractory hypercarbic respiratory failure.

Extracorporeal membrane oxygenation for respiratory failure in phases of COVID-19 variants.

BACKGROUND: Adaptive mutations of the severe acute respiratory syndrome-related coronavirus (SARS-CoV-2) virus have emerged throughout the coronavirus disease 2019 (COVID-19) pandemic. The characterization of outcomes in patients requiring extracorporeal membrane oxygenation (ECMO) for severe respiratory distress from COVID-19 during the peak prevalence of different variants is not well known. METHODS: There were 131 patients with laboratory-confirmed SARS-CoV-2 infection supported by ECMO at two referral centers within a large healthcare system. Three predominant variant phase time windows (Pre-Alpha, Alpha, and Delta) were determined by a change-point analyzer based on random population sampling and viral genome sequencing. Patient demographics and outcomes were compared. RESULTS: The average age of patients was 46.9 ± 10.5 years and 70.2% (92/131) were male. Patients cannulated for ECMO during the Delta variant wave were younger compared to earlier Pre-Alpha (39.3 ± 7.8 vs. 48.0 ± 11.1 years) and Alpha phases (39.3 ± 7.8 vs. 47.2 ± 7.7 years) (p < .01). The predominantly affected race in the Pre-Alpha phase was Hispanic (52.2%; 47/90), while in Alpha (61.5%; 16/26) and Delta (40%; 6/15) variant waves, most patients were White (p < .01). Most patients received a tracheostomy (82.4%; 108/131) with a trend toward early intervention in later phases compared to Pre-Alpha (p < .01). There was no significant difference between the duration of ECMO, mechanical support, intensive care unit (ICU) length of stay (LOS), or hospital LOS over the three variant phases. The in-hospital mortality was overall 41.5% (54/131) and was also similar. Six-month survival of patients who survived to discharge was 92.2% (71/77). CONCLUSIONS: There was no significant difference in survival or time on ECMO support in patients during the peak prevalence of the three variants.

Resilience in 2021-Descriptive Analysis of Individuals Accessing Virtual Mental Health Services: Retrospective Observational Study.

BACKGROUND: Psychological resilience has been extensively studied by developmental researchers, and there is a growing body of literature regarding its role in psychiatry and psychopathology research and practice. This study contributes to this growing literature by providing real-world evidence on the relationship between resilience and clinical symptoms among a large sample of employed Americans. OBJECTIVE: This study aimed to describe resilience levels in individuals accessing Ginger, a virtual mental health system, in addition to the association of resilience with demographic characteristics, baseline depression, and anxiety symptoms. METHODS: We conducted a retrospective observational study of 9165 members who signed up for Ginger and completed a baseline survey between January 1 and August 5, 2021. We used multivariate regression models to test for associations between baseline resilience and other member characteristics. RESULTS: Baseline resilience scores centered on a mean of 23.84 (SD 6.56) and median of 24 (IQR 8) out of 40, with 81.0% (7424/9165) of the sample having low resilience at baseline. Despite having relatively higher resilience scores, members with no or mild depression or anxiety still had low resilience scores on average. Self-reported suicidal ideation was associated with lower resilience. CONCLUSIONS: Overall, members had low baseline resilience, similar to resilience levels observed in trauma survivors in prior studies. Younger members and those with higher levels of depression and anxiety at intake reported lower levels of resilience at baseline. Notably, members with no or mild depression or anxiety still had low resilience scores on average, suggesting a need for mental health support among individuals who might not typically be recommended for treatment based on traditional clinical assessments, such as the 9-item Patient Health Questionnaire (PHQ-9) and the 7-item Generalized Anxiety Disorder scale (GAD-7). Two suggestions for topics of future research are to develop treatment recommendations based on the Connor-Davidson Resilience Scale and to understand the interaction between resilience levels and symptom-based outcome measures, such as the PHQ-9 and the GAD-7.

Blood Product Utilization in Patients With COVID-19 on ECMO.

INTRODUCTION: Although extracorporeal membrane oxygenation (ECMO) has been associated with improved outcomes in COVID patients with respiratory failure, data regarding the need for blood product utilization in this population is inadequate. METHODS: We conducted a retrospective review of all COVID patients requiring ECMO support at our facility. Patient demographics, co-morbidities, measures of acuity, and blood product utilization were identified. Patients were stratified by the presence of a major bleed and the need for dialysis. The primary outcome was blood product utilization. Linear regression models were used to assess predictors of the need for blood products. RESULTS: From 2020 to 2021, 41 patients with COVID-19 were included in our study. Overall 1601 d of support, COVID ECMO patients received 755 units of packed red blood cells (PRBC), 51 units of fresh frozen plasma (FFP), 326 platelets, and 1702 cryoprecipitate, amounting to 18.4 units PRBC per patient or 3.30 units per week of ECMO support. Both major bleeding and the need for dialysis were associated with higher rates of transfusion of PRBC, FFP, and platelets. The average non-bleeding COVID ECMO patient who did not need dialysis required 2.17 units of PRBC, 0.12 units of FFP, 0.76 platelets, and 8.36 of cryoprecipitate per week of ECMO support. On multivariable linear regression analysis, each day on ECMO was associated with 0.30 [0.19-0.42, P < 0.01] units of PRBC. CONCLUSIONS: In conclusion, COVID ECMO is associated with a significant need for blood and blood products. Major bleeding and dialysis are important drivers of blood product requirements.

Intermediate-term survival and functional outcomes of COVID-19 extracorporeal membrane oxygenation patients.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has been associated with acceptable short-term survival in patients with refractory respiratory failure secondary to coronavirus disease 2019 (COVID-19) pneumonia. Previous studies have demonstrated acceptable long-term outcomes in patients supported with ECMO for respiratory failure of other etiologies. However, long-term survival and functional outcomes in COVID ECMO patients remain unknown. METHODS: We conducted a retrospective review of all COVID patients requiring ECMO at our hospital. The primary outcomes measured were survival to discharge and contemporary survival. Secondary outcomes included two simple functional assessments: the ongoing need for oxygen supplementation and the ability to return to work. Survival was calculated using the Kaplan-Meier method. Hazard ratios were calculated using Cox hazards regression models. RESULTS: From 2020 to 2021, 48 COVID patients have been supported with ECMO at our hospital. Four patients remain on support and were excluded from further analysis. The average age was 47 ± 8 years, 34 (77%) were males, and the plurality (19, 43%) were Hispanic. Median duration of support was 23 (12-51) days. Median follow-up was 106 (29-226) days. Survival to discharge was 59%. Kaplan-Meier 180-day survival was 51%. Long-term survival conditioned on survival to discharge was 89%. In evaluating functional outcomes, the overwhelming majority of patients no longer required oxygen supplementation (74%), and most had returned to work (52%). CONCLUSION: In conclusion, COVID ECMO patients have acceptable intermediate-term survival with adequate functional recovery.

Treatment of acute respiratory distress syndrome from COVID-19 with extracorporeal membrane oxygenation in obstetrical patients.

BACKGROUND: Extracorporeal membrane oxygenation therapy has been used as a rescue therapy for patients with severe acute respiratory distress syndrome from COVID-19 who have failed conventional ventilatory strategies. Little is known about the outcome of pregnant and postpartum patients on extracorporeal membrane oxygenation therapy. OBJECTIVE: To describe the medical and surgical outcomes of pregnant and postpartum patients who were placed on extracorporeal membrane oxygenation therapy for severe acute respiratory distress syndrome from COVID-19. STUDY DESIGN: A case series reviewing pregnant or postpartum patients with laboratory-confirmed COVID-19 who were placed on extracorporeal membrane oxygenation therapy was conducted within the Baylor Scott & White Healthcare system. The demographics and the medical and surgical outcomes were collected and reviewed. RESULTS: Between March 2020 and October 2021, 5 pregnant and 5 postpartum women were supported with venovenous extracorporeal membrane oxygenation therapy. The median age was 30 years (interquartile range, 26-33.5) and the median body mass index was 36.6 kg/m2 (interquartile range, 29.5-42.0). There was a median of 4.5 days (interquartile range, 1.5-6.8) from admission to any hospital to intubation and 9 days (interquartile range, 7-13) to extracorporeal membrane oxygenation therapy cannulation. One patient had an ischemic stroke, 1 patient had a presumed hemorrhagic stroke, and 9 patients developed bleeding while on extracorporeal membrane oxygenation therapy. Of the 5 pregnant women, 2 patients had intrauterine fetal demise and 3 underwent delivery for maternal hemodynamic instability. The 5 postpartum women were initiated on extracorporeal membrane oxygenation therapy a median of 10 days (interquartile range, 3-11) after delivery. The median length of time on extracorporeal membrane oxygenation therapy was 22 days (interquartile range, 11-31). At the time of the study, there were 2 inpatient mortalities, 6 patients survived to discharge from the extracorporeal membrane oxygenation therapy hospital, and 2 patients were still admitted. CONCLUSION: There is limited information regarding the use of extracorporeal membrane oxygenation therapy for COVID-19 acute respiratory distress syndrome in obstetrical patients. This case series describes the use of extracorporeal membrane oxygenation therapy and survival in pregnant and postpartum patients with COVID-19.

Outcomes of Extracorporeal Membrane Oxygenation in Patients With Severe Acute Respiratory Distress Syndrome Caused by COVID-19 Versus Influenza.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) can be effective for refractory acute respiratory distress syndrome (ARDS) in patients with influenza, but its utility in patients with coronavirus disease 2019 (COVID-19) is uncertain. We compared outcomes of patients with refractory ARDS from COVID-19 and influenza placed on ECMO. METHODS: We conducted a retrospective analysis of 120 patients with refractory ARDS due to COVID-19 or influenza placed on ECMO at 2 referral centers from January 2013 to October 2020. Patient characteristics and clinical outcomes were compared. The primary endpoint was survival to discharge. RESULTS: Baseline characteristics and comorbidities were similar. During the study period, 53 patients with COVID-19 and 67 patients with influenza were supported. Venovenous ECMO was the predominant initial cannulation strategy in both groups (COVID 92.5% vs influenza 95.5%; P = .5). Survival to hospital discharge was 62.3% (33 of 53 patients) in the COVID-19 group and 64.2% (43 of 67 patients) in the influenza group (P = .8). In patients successfully decannulated, median length of time on ECMO was longer in COVID-19 patients (14 [interquartile range (IQR), 9-30] days vs influenza 10.5 [IQR, 6.8-14.3] days; P = .004). Among patients discharged alive, COVID-19 patients had longer overall length of stay (COVID-19 37 [IQR, 27-62] days vs influenza 13.5 [IQR, 9.3-24] days; P = .007). CONCLUSIONS: In patients with refractory ARDS from COVID-19 or influenza placed on ECMO, there was no significant difference in survival to hospital discharge. In patients surviving to decannulation, the duration of ECMO support and total length of stay were longer in COVID-19 patients.

Venovenous extracorporeal membrane oxygenation for patients with refractory coronavirus disease 2019 (COVID-19): Multicenter experience of referral hospitals in a large health care system.

BACKGROUND: The benefit of extracorporeal membrane oxygenation (ECMO) for patients with severe acute respiratory distress from coronavirus disease 2019 refractory to medical management and lung-protective mechanical ventilation has not been adequately determined. METHODS: We reviewed the clinical course of 37 patients with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection supported by venovenous ECMO at 4 ECMO referral centers within a large health care system. Patient characteristics, progression of hemodynamics and inflammatory markers, and clinical outcomes were evaluated. RESULTS: The patients had median age of 51 years (interquartile range, 40-59), and 73% were male. Peak plateau pressures, vasopressor requirements, and arterial partial pressure of carbon dioxide all improved with ECMO support. In our patient population, 24 of 37 patients (64.8%) survived to decannulation and 21 of 37 patients (56.8%) survived to discharge. Among patients discharged alive from the ECMO facility, 12 patients were discharged to a long-term acute care or rehabilitation facility, 2 were transferred back to the referring hospital for ventilatory weaning, and 7 were discharged directly home. For patients who were successfully decannulated, median length of time on ECMO was 17 days (interquartile range, 10-33.5). CONCLUSIONS: Venovenous ECMO represents a useful therapy for patients with refractory severe acute respiratory distress syndrome from coronavirus disease 2019.