Emerging Outlook on Personalized Neuromodulation for Depression: Insights From Tractography-Based Targeting.

BACKGROUND: Deep brain stimulation has shown promise in treating individual patients with treatment-resistant depression, but larger-scale trials have been less successful. Here, we created what is, to our knowledge, the largest meta-analysis with individual patient data to date to explore whether the use of tractography enhances the efficacy of deep brain stimulation for treatment-resistant depression. METHODS: We systematically reviewed 1823 articles, selecting 32 that contributed data from 366 patients. We stratified the individual patient data based on stimulation target and use of tractography. Using 2-way type III analysis of variance, Welch's 2-sample t tests, and mixed-effects linear regression models, we evaluated changes in depression severity 1 year (9-15 months) postoperatively and at last follow-up (4 weeks to 8 years) as assessed by depression scales. RESULTS: Tractography was used for medial forebrain bundle (MFB) (n = 17 tractography/32 total), subcallosal cingulate (SCC) (n = 39 tractography/241 total), and ventral capsule/ventral striatum (n = 3 tractography/41 total) targets; it was not used for bed nucleus of stria terminalis (n = 11), lateral habenula (n = 10), and inferior thalamic peduncle (n = 1). Across all patients, tractography significantly improved mean depression scores at 1 year (p < .001) and last follow-up (p = .009). Within the target cohorts, tractography improved depression scores at 1 year for both MFB and SCC, though significance was met only at the α = 0.1 level (SCC: ß = 15.8%, p = .09; MFB: ß = 52.4%, p = .10). Within the tractography cohort, patients with MFB tractography showed greater improvement than patients with SCC tractography (72.42 ± 7.17% vs. 54.78 ± 4.08%) at 1 year (p = .044). CONCLUSIONS: Our findings underscore the promise of tractography in deep brain stimulation for treatment-resistant depression as a method for personalization of therapy, supporting its inclusion in future trials.

Stigma and discrimination against transgender men in Bhutan.

BACKGROUND: While transgender people worldwide face high rates of stigma and discrimination, there are few studies of transgender men (also "trans men") in Asia. We measured the prevalence of, and factors associated with, stigma and discrimination faced by trans men in Bhutan to bring visibility to their experiences and inform health and social policy changes. METHODS: This cross-sectional survey was conducted in nine regions in Bhutan from November 2019 to January 2020. A total of 124 trans men were recruited using a hybrid venue-based and peer-referral approach. Data were collected using an interviewer-administered questionnaire. Multivariate logistic regression characterized associations with experiencing stigma and discrimination when accessing health services. FINDINGS: Participants were young (48.0% 18-24 years) and 48.4% had migrated from a rural to an urban area. The majority (95.2%) experienced stigma because people knew or thought they were trans men. Associations with frequent experiences of stigma were living with their partner as a couple (adjusted odds ratio [AOR] 3.07, 95% CI 1.27-7.44) and being unemployed or a student (3.22, 1.44-7.19). Nearly half (47.6%) said they experienced discrimination when accessing health care because people knew or thought they were a trans man; this experience was associated with migration (2.42, 1.08-5.39) and having >15 trans men in their social network (3.73, 1.69-8.26). Most (94.4%) experienced verbal violence, 10.5% experienced physical violence, and 4.8% experienced sexual violence. INTERPRETATION: Our study found high rates of stigma, discrimination, and interpersonal violence due to being a trans man in Bhutan. Findings highlight the urgent need for strengthening laws and regulations to protect the rights of transgender persons, particularly when accessing health services, recognizing partnerships, and preventing violence in public spaces.

Barriers to Telemedicine Video Visits for Older Adults in Independent Living Facilities: Mixed Methods Cross-sectional Needs Assessment.

BACKGROUND: Despite the increasing availability of telemedicine video visits during the COVID-19 pandemic, older adults have greater challenges in getting care through telemedicine. OBJECTIVE: We aim to better understand the barriers to telemedicine in community-dwelling older adults to improve the access to and experience of virtual visits. METHODS: We conducted a mixed methods needs assessment of older adults at two independent living facilities (sites A and B) in Northern California between September 2020 and March 2021. Voluntary surveys were distributed. Semistructured interviews were then conducted with participants who provided contact information. Surveys ascertained participants' preferred devices as well as comfort level, support, and top barriers regarding telephonic and video visits. Qualitative analysis of transcribed interviews identified key themes. RESULTS: Survey respondents' (N=249) average age was 84.6 (SD 6.6) years, and 76.7% (n=191) of the participants were female. At site A, 88.9% (111/125) had a bachelor's degree or beyond, and 99.2% (124/125) listed English as their preferred language. At site B, 42.9% (51/119) had a bachelor's degree or beyond, and 13.4% (16/119) preferred English, while 73.1% (87/119) preferred Mandarin. Regarding video visits, 36.5% (91/249) of all participants felt comfortable connecting with their health care team through video visits. Regarding top barriers, participants at site A reported not knowing how to connect to the platform (30/125, 24%), not being familiar with the technology (28/125, 22.4%), and having difficulty hearing (19/125, 15.2%), whereas for site B, the top barriers were not being able to speak English well (65/119, 54.6%), lack of familiarity with technology and the internet (44/119, 36.9%), and lack of interest in seeing providers outside of the clinic (42/119, 35.3%). Three key themes emerged from the follow-up interviews (n=15): (1) the perceived limitations of video visits, (2) the overwhelming process of learning the technology for telemedicine, and (3) the desire for in-person or on-demand help with telemedicine. CONCLUSIONS: Substantial barriers exist for older adults in connecting with their health care team through telemedicine, particularly through video visits. The largest barriers include difficulty with technology or using the video visit platform, hearing difficulty, language barriers, and lack of desire to see providers virtually. Efforts to improve telemedicine access for older adults should take into account patient perspectives.