Babar A. Khan

BACKGROUND: Many injury survivors experience persistent biopsychosocial morbidity after hospital discharge. The trauma medical home (TMH), a multidisciplinary coordinated care model, demonstrated modest benefit in a multicenter randomized trial, but its effectiveness across rural and socioeconomically deprived populations remains unclear. METHODS: This post hoc retrospective analysis of the TMH parent randomized trial included patients aged older than or equal to 50 years with an Injury Severity Score ≥9 across four level I trauma centers. For this study, patients were categorized by rurality and Area Deprivation Index (ADI). Outcomes included the SF-36 Physical and Mental Component Scores (PCS, MCS), depression [Patient Health Questionnaire-9 (PHQ-9)], anxiety [Generalized Anxiety Disorder (GAD-7)], physical function [Short Physical Performance Battery (SPPB)], and health care utilization. Interaction effects between TMH and rural/urban status or ADI were evaluated at baseline, 6 months, and 12 months RESULTS: Four hundred thirty patients were included [216 TMH and 214 in usual care (UC)]. On the basis of urbanicity, the effectiveness of TMH on quality of life, psychological, physical, and health care utilization was similar at 6 and 12 months. ADI stratification showed greater differences. In high-ADI urban areas, baseline MCS scores were similar between TMH (47.5 ± 13.0) and UC (48.6 ± 12.8). By 6 months, TMH patients improved to 54.9 ± 8.8 compared with 49.0 ± 13.1 in UC, with a predicted difference of 7.7 (95% CI: 1.32, 12.83, P =0.016), demonstrating a clinically and statistically significant benefit of TMH CONCLUSIONS: The TMH was associated with greater mental health improvement among patients with high area deprivation, particularly in urban settings, suggesting a potential role in reducing disparities through coordinated care. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III

Introduction: The Trauma Medical Home (TMH) randomized clinical trial tested the efficacy of a collaborative care intervention on the biopsychosocial recovery of older injured adults compared to usual care. Study enrollment occurred between 11 October 2017 and 13 October 2021 and study operations were impacted by the COVID-19 pandemic. It is important to measure the potential effects of COVID-19 on research study participants to ensure accurate reporting of results. The purpose of this secondary analysis was to compare depression and anxiety symptoms and health-related quality of life in older adults at TMH study enrollment pre-COVID-19 and during COVID-19. We hypothesized that those enrolled during COVID-19 would have worse symptoms and quality of life. Methods: This study was a secondary analysis of data from a multicenter randomized clinical trial (R01AG052493-01A1) TMH, that examined the ability of a collaborative care model to enhance the recovery of older injured adults compared to usual care. It was hypothesized that the TMH intervention would improve biopsychosocial recovery for injured older adults compared to usual care. The enrollment periods pre-COVID-19 and during COVID-19 were compared. Chi-square tests and Wilcoxon Rank Sum tests, then multivariable linear and logistic regressions were completed with SF-36 component scores and depression (PHQ-9) and anxiety (GAD-7) scores as the dependent variables, respectively. Results: A total of 429 participants were analyzed. There was no significant difference in anxiety and depression symptoms between the pre-COVID-19 and during-COVID-19 enrollment periods. Perceived limitations due to physical health problems were worse for those enrolled during COVID-19 (adjusted β = −9.8, 95% CI −18.3 to −1.4), but other health-related quality of life measures were similar between the two groups. Conclusions: These findings support the conclusion that the negative psychological impacts of the pandemic are likely due to individual factors other than age or COVID-19. These results suggest a high degree of psychological resiliency in older adults under stress. Future research should focus on the potential effects of socioeconomic status, demographic background, and level of physical functioning on psychological outcomes.

Background: Older adults frequently experience acute and long-term cognitive impairment following critical illness hospitalization in an intensive care unit (ICU). Delirium affects up to 80% of ICU patients and is linked to cognitive dysfunction and increased risk of cognitive decline associated with Alzheimer’s disease and related dementias (ADRD). Sleep and circadian rhythm disturbances are present in about 75%–80% of ICU patients and may exacerbate delirium and undermine cognitive interventions. Nonpharmacological interventions such as earplugs, eye masks, and computerized cognitive training show promise in reducing delirium and improving sleep but have not been rigorously tested—separately or combined—in older adult ICU survivors. Moreover, prior studies have not leveraged chronotherapeutic timing to align cognitive training with individual circadian rhythms. Objectives: We propose a multimodal combination of sleep promotion intervention [SLEEP] and computerized cognitive training program timed daily according to individual chronotype [COG], to improve cognitive function in hospitalized older adult ICU survivors. The primary aim is to test the feasibility, acceptability, and preliminary separate and combined effects of SLEEP and COG [SLEEP, COG, SLEEP+COG] versus an active control condition [AC] in improving cognitive function after the intervention period. The secondary aims are to explore (1) circadian rhythm parameters of continuous body temperature to determine the optimal window for chronotherapeutic timing of cognitive interventions; (2) if the effects of each intervention on cognitive function are mediated by sleep and activity; (3) if biopsychosocial and clinical factors moderate the effects of each intervention on cognitive function; and (4) the effects of each intervention on cognitive function at 1, 6, and 12 months. Methods: After discharge from ICU, English- or Spanish-speaking older adult ICU survivors ( n =100) are randomly assigned to 7 days of (1) SLEEP, (2) COG, (3) SLEEP+COG, or (4) AC. Cognitive function, delirium severity, sleep and circadian rhythms, patient-reported symptoms, and data regarding biopsychosocial and clinical factors are collected. Results: Results are pending study completion. Discussion: We aim to target sleep and circadian rhythm disturbances, mitigate ICU delirium, and reduce cognitive decline associated with ADRD. If hypotheses are supported, this combination of low-cost, nonpharmacological interventions could be integrated into standard care to accelerate cognitive recovery during hospitalization.

There is limited information on the relationship between multidisciplinary bundle compliance and long-term outcomes. We explored the association between bundle compliance and outcomes at 3 and 12 months after hospital discharge. We conducted secondary analyses of a randomized controlled trial comparing haloperidol, ziprasidone, and placebo for delirium in patients with critical illness. From 2011 to 2017, adult patients with respiratory failure and/or shock were recruited from 16 US medical centers. Participants received a daily ABCDE bundle during their critical illness. We assessed cognition, disability, mental health, quality of life, and survival over 12 months of follow-up. We analyzed data using linear mixed effects regression and Cox proportional hazards models. Among 566 participants, 418 survived to hospital discharge, 304 were assessed for 3-month outcomes, and 251 for 12-month outcomes. Median proportional bundle compliance was 97%, indicating high overall fidelity. After adjusting for covariates, greater proportional bundle compliance was associated with better functional independence and health-related quality of life, as evidenced by lower 12-month Functional Activity Questionnaire scores (β = - 9.6, CI = - 19.6, - 1.7, p = 0.04) and higher 12-month EuroQol-5D scores (β = 0.5, CI = 0.1, 0.9, p = 0.01). Greater bundle compliance was not associated with better long-term cognition, mental health, or survival. In this multi-site cohort with high-fidelity bundle compliance, greater bundle compliance was associated with less disability in instrumental activities of daily living and better health-related quality of life at 12 months, though associations were inconsistent and absent across other domains. Future research should evaluate integrated bundle care with post-discharge interventions to optimize long-term recovery. The Modifying the Impact of ICU-Associated Neurological Dysfunction-USA Study (MIND-USA), NCT01211522, https://clinicaltrials.gov/ct2/show/NCT01211522 .

IMPORTANCE: Delirium is a neuropsychiatric syndrome characterized by fluctuating disturbances in attention and awareness, associated with worse clinical outcomes and higher mortality. Previous research studies have noted an association between geographic disadvantage and delirium, but it is unknown if this association extends to critically ill adults. OBJECTIVES: This study aimed to explore the relationship between geographic disadvantage and ICU delirium characteristics. DESIGN, SETTING, AND PARTICIPANTS: We performed a secondary analysis of data collected from an National Institutes of Health-funded clinical trial, the Pharmacologic Management of Delirium study. Adults 18 years old or older admitted to the ICU who experienced delirium based on the Confusion Assessment Method for the ICU (CAM-ICU) were included. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The study population included 326 participants: 54.5% were female and 48% Black, with a mean age of 60.3 years, mean Acute Physiology and Chronic Health Evaluation II score of 20, and in-hospital mortality rate of 12.3%. The area deprivation index (ADI), a composite measure of geographic disadvantage derived from census data that yields a national percentile score ranging from 1 to 100 (with higher scores representing greater disadvantage), was obtained for each participant’s address. Main outcome variables included delirium duration, which was assessed by the number of delirium- and coma-free days (DCFDs), and delirium severity, which was assessed by mean CAM-ICU-7 scores. Analysis of covariance models were used to examine differences in DCFDs and mean CAM-ICU-7 scores between ADI quintiles while controlling for demographic and clinical variables. Other clinical outcomes of interest included discharge home rates and in-hospital mortality. The sample was heavily skewed toward higher national ADI percentile scores (indicating greater disadvantage); only 11.7% of patients had an ADI score lower than 50. Our regression analyses did not reveal any associations between ADI quintile and DCFDs or mean CAM-ICU-7 scores, or between ADI quintile and discharge home rates or in-hospital mortality. However, the Black race was associated with longer delirium duration and greater delirium severity in the first week of ICU hospitalization. CONCLUSIONS: Our study did not find an association between geographic disadvantage and delirium duration or severity in the ICU. However, an association with race was observed, highlighting the need for further research into how socioeconomic determinants of health relate to delirium.

Importance: Over 50% of Acute Respiratory Failure (ARF) survivors experience cognitive, physical, and psychological impairments that negatively impact their quality of life (QOL).Objective: To evaluate the efficacy of a post–intensive care unit (ICU) program, the Mobile Critical Care Recovery Program (m-CCRP) consisting of a nurse care coordinator supported by an interdisciplinary team, in improving the QOL of ARF survivors.Design, Setting, and Participants: This randomized clinical trial with concealed outcome assessments among ARF survivors was conducted from March 1, 2017, to April 30, 2022, with a 12-month follow-up. Patients were admitted to the ICU services of 4 Indiana hospitals (1 community, 1 county, 2 academic), affiliated with the Indiana University School of Medicine.Intervention: A 12-month nurse-led collaborative care intervention (m-CCRP) supported by an interdisciplinary group of clinicians (2 intensivists, 1 geriatrician, 1 ICU nurse, and 1 neuropsychologist) was compared with a telephone-based control. The intervention comprised longitudinal symptom monitoring coupled with nurse-delivered care protocols targeting cognition, physical function, personal care, mobility, sleep disturbances, pain, depression, anxiety, agitation or aggression, delusions or hallucinations, stress and physical health, legal and financial needs, and medication adherence.Main Outcomes and Measures: The primary outcome was QOL as measured by the 36-item Medical Outcomes Study Short Form Health Survey (SF-36) physical component summary (PCS) and mental component summary (MCS), with scores on each component ranging from 0-100, and higher scores indicating better health status.Results: In an intention-to-treat analysis among 466 ARF survivors (mean [SD] age, 56.1 [14.4] years; 250 [53.6%] female; 233 assigned to each group), the m-CCRP intervention for 12 months did not significantly improve the QOL compared with the control group (estimated difference in change from baseline between m-CCRP and control group: 1.61 [95% CI, −1.06 to 4.29] for SF-36 PCS; −2.50 [95% CI, −5.29 to 0.30] for SF-36 MCS. Compared with the control group, the rates of hospitalization were higher in the m-CCRP group (117 [50.2%] vs 95 [40.8%]; P = .04), whereas the 12-month mortality rates were not statistically significantly lower (24 [10.3%] vs 38 [16.3%]; P = .05).Conclusions and Relevance: Findings from this randomized clinical trial indicated that a nurse-led 12-month comprehensive interdisciplinary care intervention did not significantly improve the QOL of ARF survivors after ICU hospitalization. These results suggest that further research is needed to identify specific patient groups who could benefit from tailored post-ICU interventions.Trial Registration: ClinicalTrials.gov Identifier: NCT03053245

Background: Background: Migraine, a debilitating neurological condition, significantly impacts quality of life. Despite various treatments, some cases remain refractory to conventional therapies. This study explores the efficacy of Botulinum Toxin Type A (BOTOX) injections compared to Conventional Oral Drugs (CODs) in treating refractory migraines, offering potential advancements in migraine management. Objectives: This single-center retrospective cohort study compared the efficacy and safety of Botulinum toxin (BOTOX) injection and Conventional Oral Drugs (COD) for treating the refractory migraine. Methods: Between May and August of 2023, 78 adults with refractory migraine were enrolled at tertiary care center in Islamabad. Their demographic data revealed the mean age of 46.5 years (SD=10.09), gender distribution of 28 males (35.90%) and 50 females (64.10%), and distribution of 27 employed (34.61%) and 51 unemployed (65.30%). Results: Average duration of refractory migraines was 9.72 years and average number of migraines per month was 22. The number of headache days per month decreased from 22 at baseline to 19 after two months and to 12 after three months (p=0.239) as the primary outcome measure (p>0.05). The VAS scores decreased substantially from 7.6 to 5.5 (p=0.049), indicating decrease in headache severity (p0.05). The Migraine Disability Assessment (MIDAS) scores decreased from 66 to 48 (p=0.047) and Headache Impact Test (HIT-6) scores decreased from 69 to 40 (p=0.025), indicating an improvement in disability and quality of life (pConclusion: While BOTOX treatment significantly improved measures of headache severity, disability, and quality of life, patient tolerability and potential distress must be considered when selecting this treatment.

Background: Studies suggest Angiotensin‐Converting Enzyme inhibitors (ACEI) and Angiotensin Receptor Blockers (ARB) may slow the decline of memory function in individuals with mild to moderate Alzheimer's disease by regulating migroglial activation and oxidative stress within the brain's reticular activating system. Therefore, we evaluated the relationship between delirium prevalence and being prescribed ACEI and ARB in participants admitted to the intensive care units (ICU). Methods: A secondary analysis of data from two parallel pragmatic randomized controlled trials was performed. ACEI and ARB exposure was defined as being prescribed an ACEI or an ARB within six months prior to the ICU admission. The primary endpoint was the first positive delirium assessment based on Confusion Assessment Method for the ICU (CAM‐ICU) for up to thirty days. Results: A total of 4791 patients admitted to the medical, surgical, and progressive ICU and screened for eligibility for the parent studies between February 2009 and January 2015 from two level 1 trauma and one safety net hospital in a large urban academic health system were included. Delirium rates in the ICU were not significantly different among participants with no exposure to ACEI/ARB (12.6%), or exposure to ACEI (14.4%), ARB (11.8%), or ACEI and ARB in combination (15.4%) in six months prior to the ICU admission. Exposure to ACEI (OR = 0.97[0.77, 1.22]), ARB (OR = 0.70 [0.47, 1.05]), or both (OR = 0.97 [0.33, 2.89]) in six months prior to ICU admission was not significantly associated with odds of delirium during the ICU admission after adjusting for age, gender, race, co‐morbidities, and insurance status. Conclusions: While the impact of ACEI and ARB exposure prior to the ICU admission was not associated with the prevalence of delirium in this study, further research is needed to fully understand the impact of antihypertensive medications on delirium.

Introduction Sleep tracker data have not been utilized routinely in sleep-related disorders and their management. Sleep-related disorders are common in primary care practice and incorporating sleep tracker data may help in improving patient care. We conducted a pilot study to assess the feasibility of a sleep program using the Fitbit Charge 2™ device and SleepLife^® application. The main aim of the study was to examine whether a program using a commercially available wearable sleep tracker device providing objective sleep data would improve communication in primary care settings between patients and their providers. Secondary aims included whether patient satisfaction with care would improve as result of the program. Methods A prospective, randomized, parallel group, observational pilot study was conducted in 20 primary care clinics in Indianapolis, IN from June 2018 to February 2019. Inclusion criteria included patients over the age of 18, have a diagnosis of insomnia identified by electronic medical record and/or a validated questionnaire, and were on a prescription sleep aid. The study was not specific to any sleep aid prescription, branded or generic, and was not designed to evaluate a drug or drug class. Each primary care clinic was randomized to either the SleepLife^® intervention or the control arm. All patients were provided with a Fitbit Charge 2™ device. Only patients in the intervention arm were educated on how to use the SleepLife^® application. Physicians in the intervention arm were set up with the SleepLife® portal on their computers. Results Forty-nine physicians and 75 patients were enrolled in the study. Patients had a mean age of 57 (SD 12.8) years and 61% were female. Mean age of physicians was 47 (SD 10.6) years. Patients showed high rates of involvement in the program with 83% completing all survey questions. Physician survey completion rate was 55%. Only one physician logged into the SleepLife portal to check their patients’ sleep status. At the end of the 6-week intervention, patients’ composite general satisfaction scores with sleep health management decreased significantly in the intervention arm when compared to controls (p = 0.03). Patients’ satisfaction with communication also decreased significantly in the intervention group (p = 0.01). The sleep outcomes, which were calculated on the basis of study questionnaire answers, improved significantly in the intervention group as compared to the control group (p = 0.04). Physician communication satisfaction scores remained unchanged (p = 0.12). Conclusions SleepLife^® and its related physician portal can facilitate physician–patient communication, and it captures patient sleep outcomes including behaviors and habits. Patients were highly engaged with the program, while physicians did not demonstrate engagement. The study design and questionnaires do not specifically address the reasons behind the decreased patient satisfaction with care and communication, but it was perceived to be a result of physician non-responsiveness. Sleep quality scores on the other hand showed an improvement among SleepLife^® users, suggesting that patients may have implemented good sleep practices on their own. Given that it was a feasibility study, and the sample size was small, we were not able to make major inferences regarding the difference between sleep disorder types. Additionally, we excluded patients with a history of alcohol use, substance abuse, or depression because of concerns that they may affect sleep independently. To promote the growth of technology in primary care, further research incorporating results from this study and physician engagement techniques should be included.