Trainee advocacy for medical education on the care of people with intellectual and/or developmental disabilities: a sequential mixed methods analysis.

BACKGROUND: Medical trainees (medical students, residents, and fellows) are playing an active role in the development of new curricular initiatives; however, examinations of their advocacy efforts are rarely reported. The purpose of this study was to understand the experiences of trainees advocating for improved medical education on the care of people with intellectual and/or developmental disabilities. METHODS: In 2022-23, the authors conducted an explanatory, sequential, mixed methods study using a constructivist paradigm to analyze the experiences of trainee advocates. They used descriptive statistics to analyze quantitative data collected through surveys. Participant interviews then yielded qualitative data that they examined using team-based deductive and inductive thematic analysis. The authors applied Kern's six-step approach to curriculum development as a framework for analyzing and reporting results. RESULTS: A total of 24 participants completed the surveys, of whom 12 volunteered to be interviewed. Most survey participants were medical students who reported successful advocacy efforts despite administrative challenges. Several themes were identified that mapped to Steps 2, 4, and 5 of the Kern framework: "Utilizing Trainee Feedback" related to Needs Assessment of Targeted Learners (Kern Step 2); "Inclusion" related to Educational Strategies (Kern Step 4); and "Obstacles", "Catalysts", and "Sustainability" related to Curriculum Implementation (Kern Step 5). CONCLUSIONS: Trainee advocates are influencing the development and implementation of medical education related to the care of people with intellectual and/or developmental disabilities. Their successes are influenced by engaged mentors, patient partners, and receptive institutions and their experiences provide a novel insight into the process of trainee-driven curriculum advocacy.

Burn Center Verification and Safety-net Status: Are There Differences in Discharge to Inpatient Rehabilitation?

Discharge to acute rehabilitation following major burn injury is crucial for patient recovery and quality of life. However, barriers to acute rehabilitation, including race and payor type impede access. The effect of burn center organizational structure on discharge disparities remains unknown. This study aims to investigate associations between patient demographics, burn center factors, and discharge to acute rehabilitation on a population level. Using the California Healthcare Access and Information Database, 2009-2019, all inpatient encounters at verified and non-verified burn centers were extracted. The primary outcome was the proportion of patients discharged to acute rehabilitation. Key covariates included age, race, burn center safety net status, diagnosis related group, American Burn Association (ABA) verification status, and American College of Surgeons (ACS) Level 1 trauma center designation. Logistic regression and mixed-effects modeling were performed, with Bonferroni adjustment for multiple testing. Among 27,496 encounters, 0.8% (228) were discharged to inpatient rehabilitation. By race/ethnicity, the proportion admitted to inpatient rehabilitation was 0.9% for White, 0.6% for Black, 0.7% for Hispanic, and 1% for Asian. After adjusting for burn severity and age, notable predictors for discharge to inpatient rehabilitation included Medicare as payor (OR 0.30-0.88, p=0.015) compared to commercial insurance, trauma center status (OR 1.45-3.43, p<.001), ABA verification status (OR 1.16-2.74, p=0.008), and safety-net facility status (OR 1.09-1.97, p=0.013). Discharge to inpatient rehabilitation varies by race, payor status, and individual burn center. Verified and safety-net burn centers had more patients discharge to inpatient rehabilitation adjusted for burn severity and demographics.

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.