Outcomes and Management After COVID-19 Critical Illness.

TOPIC IMPORTANCE: COVID-19 has caused > 7 million deaths worldwide since its onset in 2019. Although the severity of illness has varied throughout the pandemic, critical illness related to COVID-19 persists. Survivors of COVID-19 critical illness can be left with sequelae of both the SARS-CoV-2 virus and long-term effects of critical illness included within post-intensive care syndrome. Given the complexity and heterogeneity of COVID-19 critical illness, the biopsychosocial-ecological model can aid in evaluation and treatment of survivors, integrating interactions among physical, cognitive, and psychological domains, as well as social systems and environments. REVIEW FINDINGS: Prolonged illness after COVID-19 critical illness generally can be classified into effects on physical, cognitive, and psychosocial function, with much interaction among the various effects, and includes a wide range of symptoms such as ICU-acquired weakness, prolonged respiratory symptoms, cognitive changes, post-traumatic stress disorder post-traumatic stress disorder, anxiety, and depression. Risk factors for COVID-19 critical illness developing are complex and include preexisting factors, disease course, and specifics of hospitalization in addition to psychological comorbidities and socioenvironmental factors. Recovery trajectories are not well defined, and management requires a comprehensive, interdisciplinary, and individualized approach to care. SUMMARY: The onset of vaccinations, new therapeutics, and new strains of SARS-CoV-2 virus have decreased COVID-19 mortality; however, the number of survivors of COVID-19 critical illness remains high. A biopsychosocial-ecological approach is recommended to guide care of COVID-19 critical illness survivors.

Survivorship After Critical Illness and Post-Intensive Care Syndrome.

Improvements in critical care medicine have led to a marked increase in survivors of the intensive care unit (ICU). These survivors encounter many difficulties following ICU discharge. The term post -intensive care syndrome (PICS) provides a framework for identifying the most common symptoms which fall into three domains: cognitive, physical, and mental health. There are numerous risk factors for the development of PICS including premorbid conditions and specific elements of ICU hospitalizations. Management is complex and should take an individualized approach with interdisciplinary care. Future research should focus on prevention, identification, and treatment of this unique population.

Interprofessional collaboration and communication to facilitate implementation of cognitive rehabilitation in persons with brain injury.

Cognitive rehabilitation encompasses therapeutic services directed at improving cognitive functioning and functional abilities in individuals with brain injury. The term cognitive rehabilitation, however, is often broadly defined, and interventions delivered by individual disciplines may vary in their conceptualizations. This paper, written by an interprofessional collaborative group of speech-language pathologists and rehabilitation psychologists/ neuropsychologists identifies challenges in interprofessional rehabilitation of cognitive problems as well as solutions for addressing those challenges. Specifically, the challenge of defining elements of cognitive rehabilitation is addressed with a recommendation for interprofessional training and development of a shared perspective; the problem of "siloed" care is addressed by recommendations for consistent and considerable efforts at interprofessional communication, use of shared language and emphasis on health literacy; and the challenge of access to collaborative care is addressed with the recommendation to increase utilization of telerehabilitation interventions. Our goal is to empower clinicians to not only turn to evidence-based practice to address patient needs, but to go further in implementing the evidence base by facilitating true collaborative interdisciplinary services via improved knowledge of best practice, and advocacy avenues within systems of care. Such an approach will maximize the ability of rehabilitation professionals to provide meaningful, person-centered interventions that will maximize patient outcomes.

Addressing Post-COVID Symptoms: A Guide for Primary Care Physicians.

BACKGROUND: Post-COVID symptoms, defined as symptoms lasting >4 weeks postinfection, have been identified not only among those patients who were hospitalized with severe symptoms but also among those who were asymptomatic or with only mild symptoms. Primary care providers (PCPs) will often be the first point of contact for patients experiencing potential complications of post-COVID symptoms. The aim of this article is to present a post-COVID management tool for PCPs to use as a quick reference and guide to the initial workup and management of the most common post-COVID symptoms. METHODS: Published guidance, recent literature, and expert specialist opinion were used to create the structure outlining the outpatient evaluation and treatment for post-COVID symptoms. RESULTS: A quick-reference guide for management of post-COVID symptoms was created for PCPs. Educational materials were created for clinicians to share with patients. Our article reviews several common complaints including respiratory, cognitive, and neurological symptoms, chronic fatigue, dysautonomia, and anosmia and presents recommendations for management. CONCLUSIONS: Data on long-term effects of COVID-19 are still emerging, and rapid dissemination of this data to front-line PCPs is crucial. This table was our effort to make the currently available evidence accessible for our PCPs in a simple, easy-to-use format.

One-Year Functional, Cognitive, and Psychological Outcomes Following the Use of Extracorporeal Membrane Oxygenation in Coronavirus Disease 2019: A Prospective Study.

To prospectively describe 1-year outcomes, with a focus on functional outcome, cognitive outcome, and the burden of anxiety, depression, and post-traumatic stress disorder, in coronavirus disease 2019 patients managed with extracorporeal membrane oxygenation. DESIGN: Prospective case series. SETTING: Tertiary extracorporeal membrane oxygenation center in the United States. PATIENTS: Adult coronavirus disease 2019 acute respiratory distress syndrome patients managed with extracorporeal membrane oxygenation March 1, 2020, to July 31, 2020. INTERVENTIONS: Baseline variables, treatment measures, and short-term outcomes were obtained from the medical record. Survivors were interviewed by telephone, a year following the index intensive care admission. Functional outcome was assessed using the modified Rankin Scale and the World Health Organization Disability Assessment Scale 2.0. Cognitive status was assessed with the 5-minute Montreal Cognitive Assessment. The Hospital Anxiety and Depression Scale was used to screen for anxiety and depression. Screening for post-traumatic stress disorder was performed with the Posttraumatic Stress Disorder Checklist 5 instrument. MEASUREMENTS AND MAIN RESULTS: Twenty-three patients were managed with extracorporeal membrane oxygenation, 14 (61%) survived to hospital discharge. Thirteen (57%) were alive at 1 year. One patient was dependent on mechanical ventilation, another intermittently required supplemental oxygen at 1 year. The median modified Rankin Scale score was 2 (interquartile range, 1-2), median World Health Organization Disability Assessment Scale 2.0 impairment score was 21% (interquartile range, 6-42%). Six of 12 previously employed individuals (50%) had returned to work, and 10 of 12 (83%) were entirely independent in activities of daily living. The median Montreal Cognitive Assessment score was 14 (interquartile range, 13-14). Of 10 patients assessed with Hospital Anxiety and Depression Scale, 4 (40%) screened positive for depression and 6 (60%) for anxiety. Four of 10 (40%) screened positive for post-traumatic stress disorder. CONCLUSIONS: Functional impairment was common a year following the use of extracorporeal membrane oxygenation in coronavirus disease 2019, although the majority achieved independence in daily living and about half returned to work. Long-term anxiety, depression, and post-traumatic stress disorder were common, but cognitive impairment was not.

Montreal Cognitive Assessment as a screening tool: Influence of performance and symptom validity.

BACKGROUND: We evaluated Montreal Cognitive Assessment (MoCA) performance in a veteran traumatic brain injury (TBI) population, considering performance validity test (PVT) and symptom validity test (SVT) data, and explored associations of MoCA performance with neuropsychological test performance and self-reported distress. METHODS: Of 198 consecutively referred veterans to a Veterans Administration TBI/Polytrauma Clinic, 117 were included in the final sample. The MoCA was administered as part of the evaluation. Commonly used measures of neuropsychological functioning and performance and symptom validity were also administered to aid in diagnosis. RESULTS: Successively worse MoCA performances were associated with a greater number of PVT failures (ps < 0.05). Failure of both the SVT and at least 1 PVT yielded the lowest MoCA scores. Self-reported distress (both posttraumatic stress disorder symptoms and neurobehavioral cognitive symptoms) was also related to MoCA performance. CONCLUSIONS: Performance on the MoCA is influenced by task engagement and symptom validity. Causal inferences about neurologic and neurocognitive impairment, particularly in the context of mild TBI, wherein the natural course of recovery is well known, should therefore be made cautiously when such inferences are based heavily on MoCA scores. Neuropsychologists are well versed in the assessment of performance and symptom validity and thus may be well suited to explore the influences of abnormal performances on cognitive screening.

Outcomes after Concussion Recovery Education: Effects of Litigation and Disability Status on Maintenance of Symptoms.

This study examined the hypothesis that people who receive concussion recovery education would have better outcomes than those who received usual discharge paperwork from the emergency department (ED) and tested whether participants who were in litigation or seeking disability compensation had more symptoms than individuals not engaged in these activities. Two hundred and fifty-five persons with a diagnosis of concussion were assigned randomly to a brief education group (one-page double-sided document), a longer education group (10-page document), and usual care (standard ED discharge instructions), and were these documents in the ED. A (non-concussion) trauma comparison group was enrolled to determine the symptom rate unrelated to brain injury. The Concussion Symptom Checklist (CSC) and litigation and disability status questions were completed by telephone at one week, three months, and six months. Neither long nor brief information handouts had a significant impact on symptoms over time; the standard form had an average decrease of 1.20 symptoms compared with the brief instructional intervention group (p = 0.031). Litigation status and disability seeking status were significant predictors of symptoms on CSC over time: disability seeking (p = 0.017) and litigation status (p = 0.05). Persons seeking Social Security disability or legal compensation endorsed more symptoms over time than those who were not. Number of symptoms on the CSC for the trauma control group was the same as those who sustained concussion. Type of recovery material was not as important as noting that concussion symptoms resolve over time, and that remaining symptoms are not specific to brain injury. Litigation and disability seeking behavior accounted for maintained symptoms, rather than the concussion itself.

Pre-injury psychosocial and demographic predictors of long-term functional outcomes post-TBI.

OBJECTIVE: To determine whether pre-injury psychosocial and demographic factors differentially influence long-term functional outcomes post-TBI. SETTING: Urban rehabilitation hospital. PARTICIPANTS: 149 individuals, ages 16-75, who sustained a mild complicated, moderate or severe TBI, were enrolled in a TBI Model System (TBIMS), and had functional outcome data five-15 years post-injury. DESIGN: Archival data were analysed with SPSS-18 using multiple regression to determine amount of variance accounted for in five functional domains. Predictors included age at injury, pre-injury education, Glasgow Coma Scale (GCS), pre-injury incarceration and psychiatric history. MEASURES: Craig Handicap Assessment and Reporting Technique (CHART), including Cognitive Independence, Physical Independence, Mobility, Occupation and Social Integration domains. RESULTS: Models were significant for Cognitive and Physical Independence, Mobility, and Occupation. Incarceration and psychiatric history accounted for the most variance in Cognitive and Physical Independence, over and above GCS and age at injury. Psychiatric history was also the strongest predictor of Occupation. Mobility was the only domain in which GCS accounted for the most variance. CONCLUSION: Pre-injury psychosocial and demographic factors may be more important than injury severity for predicting some long-term functional outcomes post-TBI. It would likely be beneficial to assess these factors in the inpatient setting, with input from a multidisciplinary team, as an early understanding of prognostic indicators can help guide treatment for optimal functional outcomes.