A Learning Health System Approach to Long COVID Care.

Background: Global initiatives to mitigate COVID-19 transmission have shifted health system priorities to management of patients with prolonged long COVID symptoms. To better meet the needs of patients, clinicians, and systems, a learning health system approach can use rapid-cycle methods to integrate data and real-world experience to iteratively evaluate and adapt models of long COVID care. Observations: Employees in the Veterans Health Administration formed a multidisciplinary workgroup. We sought to develop processes to learn more about this novel long COVID syndrome and innovative long COVID care models that can be applied within and outside of our health care system. We describe our workgroup processes and goals to create a mechanism for cross-facility communication, identify gaps in care and research, and cocreate knowledge on best practices for long COVID care delivery. Conclusions: The learning health system approach will be critical in reimagining health care service delivery after the COVID-19 pandemic.

Traumatic Brain Injury Incidence, Clinical Overview, and Policies in the US Military Health System Since 2000.

Exposure to explosive armaments during Operation Iraqi Freedom and Operation Enduring Freedom contributed to approximately 14% of the 352 612 traumatic brain injury (TBI) diagnoses in the US military between 2000 and 2016. The US Department of Defense issued guidelines in 2009 to (1) standardize TBI diagnostic criteria; (2) classify TBI according to mechanism and severity; (3) categorize TBI symptoms as somatic, psychological, or cognitive; and (4) systematize types of care given during the acute and rehabilitation stages of TBI treatment. Polytrauma and associated psychological and neurologic conditions may create barriers to optimal rehabilitation from TBI. Given the completion of recent combat operations and the transition of TBI patients into long-term care within the US Department of Veterans Affairs system, a review of the literature concerning TBI is timely. Long-term follow-up care for patients who have sustained TBI will remain a critical issue for the US military.

The Rehabilitation Institute of Chicago Military Traumatic Brain Injury Screening Instrument: determination of sensitivity, specificity, and predictive value.

BACKGROUND: Traumatic brain injury (TBI) is referred to as the signature injury of the wars in Iraq and Afghanistan. Given the prevalence of TBI in military personnel, there is a need for validated instruments tailored to accurately screen for TBI in this population. METHODS: Three hundred service members or veterans underwent a novel screen and a comprehensive diagnostic assessment to identify the occurrence of TBI and/or the presence of posttraumatic stress disorder. Negative predictive value, positive predictive value, sensitivity, and specificity were calculated. RESULTS: This screening tool for TBI yielded sensitivity of 96%, specificity of 64%, negative predictive value of 95%, and positive predictive value of 69%. CONCLUSION: The Rehabilitation Institute of Chicago Military Traumatic Brain Injury Screening Instrument has a high negative predictive value and high sensitivity for TBI. This tool identifies individuals likely to have sustained a TBI. Moreover, it detects those who are likely not to have sustained such an injury and can be reassured in this regard. Because such distinction can be made with a high degree of accuracy in rapid and cost-effective fashion, it represents an important contribution to the armamentarium of TBI screening tools.

Acupuncture for treatment of insomnia in patients with traumatic brain injury: a pilot intervention study.

OBJECTIVES: : To assess the efficacy of acupuncture in treating insomnia in traumatic brain injury (TBI) survivors as compared to medication, to determine whether acupuncture has fewer cognitive and affective adverse effects than does medication. PARTICIPANTS: : Twenty-four adult TBI survivors, randomized to acupuncture or control arms. SETTING: : Outpatient rehabilitation clinic. MEASURES: : Insomnia Severity Index (degree of insomnia); actigraphy (sleep time); Hamilton Depression Rating Scale (depression); Repeatable Battery for the Assessment of Neuropsychological Status and Paced Auditory Serial Addition Test (cognitive function) administered at baseline and postintervention. RESULTS: : Sleep time did not differ between the treatment and control groups after intervention, whereas cognition improved in the former but not the latter. CONCLUSION: : Acupuncture has a beneficial effect on perception of sleep or sleep quality and on cognition in our small sample of patients with TBI. Further studies of this treatment modality are warranted to validate these findings and to explore factors that contribute to treatment efficacy.

Actigraphy for assessment of sleep in traumatic brain injury: case series, review of the literature and proposed criteria for use.

PRIMARY OBJECTIVE: To demonstrate that actigraphy is an appropriate means of measuring sleep in patients with TBI and to define parameters for its use in this population. RESEARCH DESIGN: Case series and review of the literature. METHODS AND PROCEDURES: Subjects participating in one of two externally funded studies addressing the role of acupuncture in treating insomnia in TBI underwent actigraphy for the purpose of quantifying sleep time. Cases selected for presentation illustrate challenges in use of this modality in this population. MAIN OUTCOMES AND RESULTS: Caution should be exercised in interpreting actigraphy data in patients with TBI and (1) motor impairment or (2) cognitive and behavioural impairments which include agitation and impulsivity. CONCLUSIONS: Guidelines for use of actigraphy in patients with TBI are proposed: (1) Patients should be at Rancho Los Amigos cognitive level of III or above; (2) Patients with paresis, significant spasticity or contractures of one or more limbs should have the device placed on the least affected limb; and (3) For patients with tetraparesis, the device may not be an appropriate instrument for measurement of sleep; if it is to be used, consideration should be given to placing it on the head, rather than limbs or torso.