Pressure Support Ventilation During Extracorporeal Membrane Oxygenation Support in Patients With Acute Respiratory Distress Syndrome.

In the initial phases of veno-venous extracorporeal membrane oxygenation (VV ECMO) support for severe acute respiratory distress syndrome (ARDS), ultraprotective controlled mechanical ventilation (CMV) is typically employed to limit the progression of lung injury. As patients recover, transitioning to assisted mechanical ventilation can be considered to reduce the need for prolonged sedation and paralysis. This study aimed to evaluate the feasibility of transitioning to pressure support ventilation (PSV) during VV ECMO and to explore variations in respiratory mechanics and oxygenation parameters following the transition to PSV. This retrospective monocentric study included 191 adult ARDS patients treated with VV ECMO between 2009 and 2022. Within this population, 131 (69%) patients were successfully switched to PSV during ECMO. Pressure support ventilation was associated with an increase in respiratory system compliance (p = 0.02) and a reduction in pulmonary shunt fraction (p < 0.001). Additionally, improvements in the cardiovascular Sequential Organ Failure Assessment score and a reduction in pulmonary arterial pressures (p < 0.05) were recorded. Ninety-four percent of patients who successfully transitioned to PSV were weaned from ECMO, and 118 (90%) were discharged alive from the intensive care unit (ICU). Of those who did not reach PSV, 74% died on ECMO, whereas the remaining patients were successfully weaned from extracorporeal support. In conclusion, PSV is feasible during VV ECMO and potentially correlates with improvements in respiratory function and hemodynamics.

Perfusion deficits may underlie lung and kidney injury in severe COVID-19 disease: insights from a multicenter international cohort study.

BACKGROUND: Lung perfusion defects, mainly due to endothelial and coagulation activation, are a key contributor to COVID-19 respiratory failure. COVID-19 patients may also develop acute kidney injury (AKI) because of renal perfusion deficit. We aimed to explore AKI-associated factors and the independent prediction of standardized minute ventilation (MV)-a proxy of alveolar dead space-on AKI onset and persistence in COVID-19 mechanically ventilated patients. METHODS: This is a multicenter observational cohort study. We enrolled 157 COVID-19 patients requiring mechanical ventilation and intensive care unit (ICU) admission. We collected clinical information, ventilation, and laboratory data. AKI was defined by the 2012 KDIGO guidelines and classified as transient or persistent according to serum creatinine criteria persistence within 48 h. Ordered univariate and multivariate logistic regression analyses were employed to identify variables associated with AKI onset and persistence. RESULTS: Among 157 COVID-19 patients on mechanical ventilation, 47% developed AKI: 10% had transient AKI, and 37% had persistent AKI. The degree of hypoxia was not associated with differences in AKI severity. Across increasing severity of AKI groups, despite similar levels of paCO2, we observed an increased MV and standardized MV, a robust proxy of alveolar dead space. After adjusting for other clinical and laboratory covariates, standardized MV remained an independent predictor of AKI development and persistence. D-dimer levels were higher in patients with persistent AKI. CONCLUSIONS: In critically ill COVID-19 patients with respiratory failure, increased wasted ventilation is independently associated with a greater risk of persistent AKI. These hypothesis-generating findings may suggest that perfusion derangements may link the pathophysiology of both wasted ventilation and acute kidney injury in our population.

Signs of Hemolysis Predict Mortality and Ventilator Associated Pneumonia in Severe Acute Respiratory Distress Syndrome Patients Undergoing Veno-Venous Extracorporeal Membrane Oxygenation.

Cell-free hemoglobin (CFH) is used to detect hemolysis and was recently suggested to trigger acute lung injury. However, its role has not been elucidated in severe acute respiratory distress syndrome (ARDS) patients undergoing extracorporeal membrane oxygenation (ECMO). We investigated the association of carboxyhemoglobin (COHb) and haptoglobin-two indirect markers of hemolysis-with mortality in critically ill patients undergoing veno-venous ECMO (VV-ECMO) with adjusted and longitudinal models (primary aim). Secondary aims included assessment of association between COHb and haptoglobin with the development of ventilator-associated pneumonia (VAP) and with hemodynamics. We retrospectively collected physiological, laboratory biomarkers, and outcome data in 147 patients undergoing VV-ECMO for severe ARDS. Forty-seven patients (32%) died in the intensive care unit (ICU). Average levels of COHb and haptoglobin were higher and lower, respectively, in patients who died. Higher haptoglobin was associated with lower pulmonary (PVR) and systemic vascular resistance, whereas higher COHb was associated with higher PVR. Carboxyhemoglobin was an independent predictor of VAP. Both haptoglobin and COHb independently predicted ICU mortality. In summary, indirect signs of hemolysis including COHb and haptoglobin are associated with modulation of vascular tone, VAP, and ICU mortality in respiratory ECMO. These findings suggest that CFH may be a mechanism of injury in this patient population.

Perioperative Care for Children With Syndromic Craniofacial Synostosis Undergoing Le Fort III Surgery: A Retrospective Cohort Study.

OBJECTIVE: To present characteristics, surgical variables, complications, and postoperative care in pediatric patients with craniofacial synostosis undergoing Le Fort III osteotomy. BACKGROUND: Craniofacial synostoses are a group of genetic syndromes that result in premature fusion of cranial and facial sutures, leading to craniofacial deformities and associated complications. Midface advancement through Le Fort III osteotomy is the most frequent surgical option for these conditions. METHODS: Retrospective monocentric cohort study including patients with syndromic craniofacial synostosis who underwent Le Fort III osteotomy between 2009 and 2022 in a specialized referral center. Data collection encompassed surgical time, blood loss, intraoperative transfusions, fluid balance, and postoperative parameters such as duration of invasive mechanical ventilation and intensive care unit (ICU) length of stay. RESULTS: Twenty-six children were included in the analysis. The median surgical time was 345 minutes (300-360), with an estimated blood loss of 15 (9.9-24) mL/kg. Patients required a median transfusion of 12.63 (7.1-24.5) mL/kg of packed red blood cells and 19.82 (11.1-33) mL/kg of fresh frozen plasma. Intraoperative fluid balance was + 12.5 (0.8-22.8) mL/kg, with a median infusion of 30.4 (23.9-38.7) mL/kg of crystalloids. All patients were transferred to the ICU after surgery to ensure a safe environment for extubation. The median duration of mechanical ventilation in the ICU was 30 (20.25-45) hours, and postoperative ICU length of stay was 2 (2-4) days, and complications were infrequent, with only one extubation failure recorded. CONCLUSION: Le Fort III osteotomy in craniofacial synostosis patients may be characterized by a complex perioperative course. A multidisciplinary approach in the care of these patients allows for minimizing complications in the perioperative phase. Further research is needed to enhance perioperative management in this unique patient population.

Shorter communications: Exploring the impact of a brief smartphone-based alcohol intervention app (DrinksRation) on the quality of life of UK military veterans.

Alcohol misuse - defined as consuming more than 14 units of alcohol per week - is a well-established problem among veterans. This study investigated the change in quality of life among help-seeking UK veterans who completed a 28-day brief alcohol intervention delivered via a digital smartphone application (called DrinksRation) and have previously sought clinical help for a mental health disorder. This study was a secondary outcome analysis of data collected during a randomised control trial. In total, 123 UK veterans participated in the study and were randomly allocated to either the intervention or control arm. Participants completed self-report questionnaires regarding their alcohol use and quality of life (WHOQOL-BREF) at baseline, day 28 (end of intervention), day 84, and day 168. At the primary endpoint (day 84), we found significantly greater improvements in the intervention arm compared to the control arm for psychological quality of life (Cohen's d = 0.47), and environmental quality of life (d = 0.34). However, we observed no statistically significant differences between the intervention and control arm for social relationships and physical quality of life. Further, for day 168 we found no significant differences. Findings suggest that DrinksRation can increase quality of life among help-seeking veterans who have previously sought help for a mental health disorder, but the increases were modest and restricted to certain domains. Additional treatment may be needed for long-term and sustained improvements in quality of life.

The "ZEEP-PEEP test" to evaluate the response to positive end-expiratory pressure delivered by helmet: A prospective physiologic study.

Introduction: The improvement in oxygenation after helmet application in hypoxemic patients may be explained by the alveolar recruitment obtained with positive end expiratory pressure (PEEP) or by the administration of a more accurate inspiratory fraction of oxygen (FiO2). We have designed the "ZEEP-PEEP test", capable to distinguish between the FiO2-related or PEEP-related oxygenation improvement. Our primary aim was to describe the use of this test during helmet CPAP to assess the oxygenation improvement attributable to PEEP application. Material and methods: We performed a prospective physiological study including adult critically ill patients. Respiratory and hemodynamic parameters were recorded before helmet application (PRE step), after helmet application without PEEP (ZEEP step) and after the application of the PEEP valve (PEEP step), while maintaining a constant FiO2. We defined as "PEEP responders" patients showing a PaO2/FiO2 ratio improvement ≥10% after PEEP application. Results: 93 patients were enrolled. Compared to the PRE step, PaO2/FiO2 ratio was significantly improved during helmet CPAP both at ZEEP and PEEP step (189 ± 55, 219 ± 74 and 241 ± 82 mmHg, respectively, p < 0.01). Both PEEP responders (41%) and non-responders showed a significant improvement of PaO2/FiO2 ratio after the application of helmet at ZEEP, PEEP responders also showed a significant improvement of oxygenation after PEEP application (208 ± 70 vs 267 ± 85, p < 0.01). Conclusions: Helmet CPAP improved oxygenation. This improvement was not only due to the PEEP effect, but also to the increase of the effective inspired FiO2. Performing the ZEEP-PEEP test may help to identify patients who benefit from PEEP.

Determinants of increased nursing workload in the COVID-era: A retrospective analysis of prospectively collected data.

BACKGROUND: COVID-19 is associated with increased nursing workload, therefore a high nurse-to-patient ratio would be required. AIM: To analyse difference in nursing workload, as expressed with the Nursing Activities Score (NAS), between COVID-19 patients versus control patients without COVID-19 disease (NCOVID-19 group) in an Italian Extracorporeal Membrane Oxygenation (ECMO) centre. STUDY DESIGN: Retrospective analysis of prospectively collected data, enrolling consecutive patients admitted to a general Intensive Care Unit, between 1st May 2019 and 28th February 2021. A multivariate analysis was then performed to assess if COVID-19 disease was an independent predictor of higher NAS and to assess which other factors and procedures are independently associated with increased workload. RESULTS: We enrolled 574 patients, of which 135 (24%) were in the COVID-19 group and 439 (76%) in the NCOVID-19 group. The average NAS was higher in the COVID-19 group (79 ± 11 vs. 65 ± 15, T = -10.026; p < 0.001). Prone positioning, continuous renal replacement therapy (CRRT) and ECMO were used more frequently in the COVID-19 group. A higher fraction of patients in the COVID group showed colonization from multidrug resistant bacteria. COVID-19 group had a higher duration of mechanical ventilation and longer ICU stay. The COVID-19 diagnosis was independently associated with a higher NAS. Other independent predictors of higher NAS were the use of prone positioning and continuous renal replacement therapy (CRRT). Colonization from multidrug resistant bacteria and ECMO support were not independently associated with higher NAS. CONCLUSIONS: The higher nursing workload in COVID-19 patients is mainly due to specific procedures required to treat the most hypoxemic patients, such as prone positioning. Colonization with multidrug resistant bacteria and ECMO support were not independently associated with a higher NAS. RELEVANCE TO CLINICAL PRACTICE: Higher workload in COVID-19 patients was due to specific interventions, such as prone positioning and CRRT, with the related nursing activities, as continuous presence at patient's bed, mobilization, positioning and complex hygienic procedures.

The role of intensive care unit diaries in the grieving process: A monocentric qualitative study.

BACKGROUND: The growing importance of psychological recovery for patients and their families following intensive care unit (ICU) experiences in recent years cannot be overemphasized. The ICU diary is used to aid patients in reducing the prevalence of post-traumatic stress disorder, anxiety, and depression. The usefulness of maintaining a diary during the grieving process has not yet been thoroughly investigated. AIM: To investigate the role of ICU diaries in the grief process experienced by family members of a person who died in the intensive care unit. STUDY DESIGN: Nine family members of seven deceased ICU patients with an ICU diary were contacted and interviewed by phone using a semi-structured interview. A qualitative data analysis was performed using thematic synthesis. SETTING: Italian general intensive care unit. FINDINGS: Interviewed family members felt that the diary helped them during the grieving process. The return of diaries was desired by family members for support and to remember one's loved one. The diary helped them process their losses in various ways, including signs of evidence of care, emotional involvement, consideration, and coping with grief. Four main themes emerged from the analysis: writing the diary, reading the diary, talking about the diary, and the diary during the grieving process. CONCLUSIONS: The overall perception of the ICU diary was positive. The diary mostly helped relatives to "give back something of what we lost". This study also affirms the positive link between ICU diaries and bereavement in Italian ICU. Further studies are required to confirm the usefulness of this tool in the grieving process. RELEVANCE TO CLINICAL PRACTICE: The ICU diary can help patients' family members understand what happened to their loved one and play an important role in the grieving process. The diary served as a valuable source of information that aided in providing bereavement support to the family by helping them to gain a rational and emotional understanding of the patient's death.

Lessons from the COVID-19 Pandemic.

The COVID-19 pandemic was an unprecedented global crisis that significantly impacted around the world [...].

Long-Term Physical, Cognitive, and Psychological Outcomes in Severe COVID-19 Patients Managed With Extracorporeal Membrane Oxygenation: A Prospective Study.

Extracorporeal membrane oxygenation (ECMO) has been used in highly selected COVID-19 patients with severe respiratory failure. Scarce data exist on long-term outcomes of these patients. We performed a single-center prospective evaluation of consecutive COVID-19 ECMO patients successfully discharged from the intensive care unit between February 2020 and January 2022. Physical, cognitive and psychological outcome was assessed at 3, 6, and 12 months by in-person evaluation. All the 34 discharged patients (median age 49 years old) were alive at one year, and 25 of them were evaluated at the follow-up clinic. 67% of patients had muscle weakness, with improvement over time (p = 0.032). The percentage of patients able to return to work progressively increased, up to 86% at 1 year. 23% of patients experienced fatigue. Participation restriction improved over time for both physical (p = 0.050) and emotional (p = 0.005) problems. Cognitive impairment, anxiety, and depression occurred in 29%, 29%, and 23% of patients, respectively, with no changes over time. Health-related quality of life was good. In conclusion, COVID-19 ECMO patients suffer from significant long-term sequelae. However, multidimensional outcomes continued to improve over the follow-up time.

Midline catheters for blood gas and acid/base monitoring in critical patients: A prospective observational study.

BACKGROUND: Arterial lines and central venous catheter (CVC) allow to monitor patients' acid-base status and gas exchange. Their placement and maintenance may however be burdened by severe complications. Midline Catheters (MC) are peripheral venous accesses that are less invasive and easier to insert compared to CVC and arterial lines. METHODS: A prospective observational study was performed including stabilized critical patients with clinical indication to midline positioning before intensive care unit (ICU) discharge. The primary aim was to assess if venous sampling from MCs can be a reliable alternative to CVC for pH and CO2 monitoring. The secondary aim was to evaluate the correlation between samplings from MC, CVC and arterial line with regards to pH, carbon dioxide tension (pCO2), lactates and electrolytes. Three samples from CVC, arterial line and MC were collected simultaneously. Agreement and correlation of the studied parameters between different sampling sites were explored. RESULTS: 40 patients were included in the analysis. A good agreement for pH and pCO2 was recorded between MC and CVC: mean differences were 0.001 (95% CI -0.006 to 0.007) and 0.7 (-0.1 to 1.5), percentage error 0.4% and 11.2%, respectively. Correlation between MC and both central venous and arterial samples for pH, pCO2, lactates and electrolytes was found to be moderate-to-strong (Pearson's R coefficient range 0.59-0.99, p < 0.001 for all these parameters). CONCLUSIONS: In stabilized critical patients, midline catheters represent a reliable alternative to CVC and arterial lines to monitor acid-base disturbances, CO2 levels and electrolytes. The present findings add to the known advantages of MC, which might be considered a first-line vascular access for non-critical or stabilized patients who do not require infusion of vesicant or irritant drugs.

Impact of SARS-CoV-2 Omicron and Delta variants in patients requiring intensive care unit (ICU) admission for COVID-19, Northern Italy, December 2021 to January 2022.

This multicenter observational study included 171 COVID-19 adult patients hospitalized in the ICUs of nine hospitals in Lombardy (Northern Italy) from December, 1st 2021, to February, 9th 2022. During the study period, the Delta/Omicron variant ratio of cases decreased with a delay of two weeks in ICU patients compared to that in the community; a higher proportion of COVID-19 unvaccinated patients was infected by Delta than by Omicron whereas a higher rate of COVID-19 boosted patients was Omicron-infected. A higher number of comorbidities and a higher comorbidity score in ICU critically COVID-19 inpatients was positively associated with the Omicron infection as well in vaccinated individuals. Although people infected by Omicron have a lower risk of severe disease than those infected by Delta variant, the outcome, including the risk of ICU admission and the need for mechanical ventilation due to infection by Omicron versus Delta, remains uncertain. The continuous monitoring of the circulating SARS-CoV-2 variants remains a milestone to counteract this pandemic.

How to avoid rapid carbon dioxide changes at the start of veno-venous extracorporeal membrane oxygenation: Role of end-tidal CO2 monitoring.

Background: Venovenous ECMO is a lifesaving technique for patients with severe respiratory failure. Management of carbon dioxide (CO2) levels at ECMO start is crucial, as recent studies found an association between rapid CO2 shifts and increased incidence of neurological complications.Purpose: To describe the role of end tidal CO2 (etCO2) monitoring at the ECMO start to minimize carbon dioxide shifts.Research design: Retrospective cohort study.Methods: We performed a retrospective analysis of patients who started venovenous ECMO support at our institution between 2011 and 2021. We analysed the minute-by-minute variations of etCO2, ventilatory parameters and arterial blood gas before and after the ECMO start.Results: 36 patients with a complete dataset of parameters were included. After the ECMO start, minute ventilation was progressively reduced from 10.8±;3.3 to 2.9±1.2 L/min (p<0.001). etCO2 did not vary significantly (baseline 37±10 vs 35±9 mmHg 20 minutes after ECMO start, p = 0.36). Despite a stable etCO2 level, a mild drop of arterial CO2 tension (9.5 mmHg, corresponding to a 18% change) was recorded at the first ABG sampled after the ECMO start. No patient developed neurological complications after the ECMO commencement.Conclusion: etCO2 monitoring during ECMO start is feasible and allows to adjust gas flow and ventilator settings to limit changes in arterial CO2 levels.

The evolution of PTSD symptoms in serving and ex-serving personnel of the UK armed forces from 2004 to 16: A longitudinal examination.

Whilst most military personnel do not develop Post-Traumatic Stress Disorder (PTSD), ex-serving personnel exhibit higher levels compared to those in the military. The heterogeneity of symptom development for serving and ex-serving personnel has not yet been compared in the UK Armed Forces (UK AF). Latent class growth modelling was employed to estimate the trajectories of PTSD symptoms from three waves of data from the PTSD Checklist (PCL-C) from a UK AF sample (N = 7357). Regression mixture models were conducted to investigate covariates of class membership. Five trajectory classes were identified. Most of the sample reported no-low symptoms (71.3%). Of those reporting probable PTSD during the 12 year-period, 4.6% showed improvements, 4.9% worsened, and 1.8% displayed chronic symptoms. A class with subthreshold elevated symptoms (17.3%) was also identified. Trajectories of serving and ex-serving personnel were not substantially different, but more ex-serving personnel were symptomatic and those with chronic symptoms worsened over time. Chronic disorder was associated with lower rank, experiencing violent combat, and proximity to wounding/death on deployment. Worsening symptoms were associated with childhood stress/violence, lower rank, not being in a relationship, inconsistent post-deployment social support, proximity to wounding/death, and voluntary, or medical discharge. The present study found most UKAF personnel did not report PTSD symptoms between 2004 and 16 but, among those experiencing probable PTSD, more participants reported deteriorating/persistent symptoms than who improved. PTSD-onset was related to adversities across childhood and deployment, and lack of social support. Findings underscore the importance of addressing the through-life contributors of PTSD in order to prevent ingrained disorder.

One hundred ECMO retrivals before and during the Covid-19 pandemic: an observational study.

OBJECTIVES: Patients with severe acute respiratory distress syndrome may require veno-venous extracorporeal membrane oxygenation (V-V ECMO) support. For patients in peripheral hospitals, retrieval by mobile ECMO teams and transport to high-volume centers is associated with improved outcomes, including the recent COVID-19 pandemic. To enable a safe transport of patients, a specialised ECMO-retrieval program needs to be implemented. However, there is insufficient evidence on how to safely and efficiently perform ECMO retrievals. We report single-centre data from out-of-centre initiations of VV-ECMO before and during the COVID-19 pandemic. DESIGN & SETTING: Single-centre retrospective study. We include all the retrievals performed by our ECMO centre between January 1st, 2014, and April 30th, 2021. RESULTS: One hundred ECMO missions were performed in the study period, for a median retrieval volume of 13 (IQR: 9-16) missions per year. the cause of the acute respiratory distress syndrome was COVID-19 in 10 patients (10 %). 98 (98 %) patients were retrieved and transported to our ECMO centre. To allow safe transport, 91 of them were cannulated on-site and transported on V-V ECMO. The remaining seven patients were centralised without ECMO, but they were all connected to V-V ECMO in the first 24 hours. No complications occurred during patient transport. The median duration of the ECMO mission was 7 hours (IQR: 6-9, range: 2 - 17). Median duration of ECMO support was 14 days (IQR: 9-24), whereas the ICU stay was 24 days (IQR:18-44). Overall, 73 patients were alive at hospital discharge (74 %). Survival rate was similar in non-COVID-19 and COVID-19 group (73 % vs 80 %, p = 0.549). CONCLUSION: In this single-centre experience, before and during COVID-19 era, retrieval and ground transportation of ECMO patients was feasible and was not associated with complications. Key factors of an ECMO retrieval program include a careful selection of the transport ambulance, training of a dedicated ECMO mobile team and preparation of specific checklists and standard operating procedures.

Management of vascular access for extracorporeal life support: A cohort study.

Extracorporeal membrane oxygenation (ECMO) is required for patients with refractory cardiac or respiratory failure. Inadequate securement of ECMO cannulae may lead to adverse events, ranging from line kinking to catastrophic accidents, such as air entrainment into the circuit or massive bleeding. Furthermore, the micro-motion of the cannulae at the entry site might increase the risk of local infections. Since 2015, we implemented a written protocol for management of ECMO cannulae and tubing, which specifically includes the securement of each cannula with three sutureless devices. The aim of the present study was to retrospectively assess cannulae micro-motion and the rate of bleeding events at the insertion site. Secondarily we aimed to evaluate the impact of prone positioning maneuvers during ECMO on these events. We performed a single-centre retrospective analysis of prospectively collected data on nursing care of ECMO cannulae. We included adult patients treated with veno-venous (V-V) or veno-arterial (V-A) ECMO between 2015 and 2018 in our general intensive care unit. The distance between the insertion site and the end of the wire-wound part of the cannula was recorded daily. Variations of this distance (defined as "cannula micro-motion") were recorded. Forty-five ECMO consecutive adult patients (40 V-V and 5 V-A) were included. No accidental cannula dislodgement was recorded. Median daily "cannula micro-motion" was 0.0 (-0.5 to 0.2) cm, without any significant difference between ECMO configuration, cannula type, and insertion site. Twelve patients (26%) presented at least one bleeding episode at cannula insertion site, none of which required surgical intervention. In the subgroup of patients who underwent prone positioning, no difference in cannulae micro-motion was recorded. An ECMO nursing protocol for cannulae management providing sutureless devices for cannula and tubing securement allows safe line stabilization, with the potential to reduce complications related to ECMO vascular access.

Tracheal stenting on venovenous ECMO with a dual lumen right atrium-to-pulmonary artery cannula in a COVID-19 patient with an inferior vena cava filter.

A 47-year-old man, with no medical history, was diagnosed with severe COVID-19 ARDS and pulmonary embolism. Venovenous extracorporeal membrane oxygenation (ECMO) was required for impossibility to deliver protective ventilation. The patient was weaned from ECMO after clinical improvement. An inferior vena cava filter was then positioned to prevent embolization from a persistent left femoral deep venous thrombosis. Two days after the ECMO removal, a large lesion of the tracheal posterior wall was diagnosed. Tracheal stenting was deemed necessary. ECMO support was then re-established, to safely perform the bronchoscopic procedure. Due to the presence of the inferior vena cava filter, the patient was cannulated via the right internal jugular vein with a double lumen ProtekDuo cannula. The patient was then weaned from ECMO support and invasive ventilation. The tracheal stent was removed after 40 days, showing a full recovery of the tracheal lesion. The patient was discharged home in good condition.

Recruiting Military Veterans into Alcohol Misuse Research: The Role of Social Media and Facebook Advertising.

Background: The use of digital technology within health care service delivery, monitoring, and research is becoming progressively popular, particularly given the ongoing COVID-19 pandemic. Mobile health (m-health) apps, one form of digital technology, are increasingly being used to promote positive health related behavior change. Therefore, it is important to conduct research to understand the efficacy of m-health apps. The process of participant recruitment is an essential component in producing strong research evidence, along with ensuring an adequately powered sample to conduct meaningful analyses and draw robust conclusions. Methods: In this work we outline and reflect on the strategies used to recruit help-seeking military veterans into an intervention study, which aimed to evaluate the efficacy of an app (Drinks:Ration) to modify behavior in alcohol misusers. Recruitment strategies included through (1) partner organizations and (2) social media and Facebook advertising (ads). Results: Facebook ads were live for a period of 88 days and were viewed by a total audience of 29,416 people. In total 168 military veterans were recruited across all recruitment strategies, meaning that Drinks:Ration exceeded its recruitment targets. Half of the sample (n = 84) were recruited through social media, including Facebook ads. Conclusions: The current article highlighted that targeted Facebook ads were an efficient strategy to recruit military veterans into a digital intervention trial aiming to reduce alcohol consumption because they reduced the amount of time and resources required to contact a large number of potentially eligible individuals for our study. This article acts as a starting point for other researchers to evaluate their recruitment pathways for recruiting military veterans into alcohol misuse research.