A Novel Curriculum for Internal Medicine Residents to Care for High-Need, High-Cost Patients.

OBJECTIVES: High-need, high-cost (HNHC) patients represent a small proportion of patients in the US, but result in disproportionately higher healthcare utilization. Teaching Internal Medicine (IM) resident trainees to provide high value care for HNHC patients is critical. We sought to improve resident attitudes and increase clinical skills associated with treating HNHC patients by creating a curriculum that leveraged the UCLA Extensivist Program, a patient-centered medical home for HNHC patients. METHODS: We developed a curriculum for PGY-2 and PGY-3 IM residents centered on caring for HNHC patients over the course of 6, 4h sessions during 1 academic year. Participants completed pre- and post-intervention surveys assessing self-rated attitudes and skills associated with caring for an HNHC patient population. RESULTS: Twenty-one IM residents completed the curriculum and 41 were in the control group. There were no statistically significant differences in assessed attitudes and skills, but there were trends of improvement, including a decrease in participants who agreed or strongly agreed they felt overwhelmed when seeing patients for posthospital discharge follow up (45.0% pre- to 41.7% post-intervention) and an increase in participants who agreed or strongly agreed they have the skills to successfully transition HNHC patients between inpatient and ambulatory settings (20.0% pre- to 33.3% post-intervention). Participants reported better understanding of resources available to HNHC patients, effective coordination of transitions of care, and comprehensive assessment of social determinants of health. CONCLUSION: A curriculum to improve resident attitudes and skills associated with caring for HNHC patients was successfully implemented in an IM program at a large academic medical center. The curriculum may be adapted for other training programs; long-term training woven throughout training may be important to significantly improve resident education on how to care for HNHC patients.

The effect of older age on outcomes of rTMS treatment for treatment-resistant depression.

Clinical outcomes of repetitive transcranial magnetic stimulation (rTMS) for treatment of treatment-resistant depression (TRD) vary widely and there is no mood rating scale that is standard for assessing rTMS outcome. It remains unclear whether TMS is as efficacious in older adults with late-life depression (LLD) compared to younger adults with major depressive disorder (MDD). This study examined the effect of age on outcomes of rTMS treatment of adults with TRD. Self-report and observer mood ratings were measured weekly in 687 subjects ages 16-100 years undergoing rTMS treatment using the Inventory of Depressive Symptomatology 30-item Self-Report (IDS-SR), Patient Health Questionnaire 9-item (PHQ), Profile of Mood States 30-item, and Hamilton Depression Rating Scale 17-item (HDRS). All rating scales detected significant improvement with treatment; response and remission rates varied by scale but not by age (response/remission ≥ 60: 38%-57%/25%-33%; <60: 32%-49%/18%-25%). Proportional hazards models showed early improvement predicted later improvement across ages, though early improvements in PHQ and HDRS were more predictive of remission in those < 60 years (relative to those ≥ 60) and greater baseline IDS burden was more predictive of non-remission in those ≥ 60 years (relative to those < 60). These results indicate there is no significant effect of age on treatment outcomes in rTMS for TRD, though rating instruments may differ in assessment of symptom burden between younger and older adults during treatment.

A comparison of self- and observer-rated scales for detecting clinical improvement during repetitive transcranial stimulation (rTMS) treatment of depression.

Clinical outcomes of repetitive Transcranial Magnetic Stimulation (rTMS) for treatment of Major Depressive Disorder (MDD) vary widely, and no single mood rating scale is standard for assessing rTMS outcomes. This study of 708 subjects undergoing clinical rTMS compared the performance of four scales in measuring symptom change during rTMS treatment. Self-report and observer ratings were examined weekly with the Inventory of Depressive Symptomatology 30-item (IDS), Patient Health Questionnaire 9-item (PHQ), Profile of Mood States 30-item (POMS), and Hamilton Depression Rating Scale 17-item (HDRS). While all scales were correlated and detected significant improvement, the degree of improvement over time as well as response (33-50%) and remission (20-24%) rates varied significantly. Higher baseline severity was associated with lower likelihood of remission, and greater improvement by sessions 5 and 10 predicted response across all scales. Use of only a single scale to assess outcome conferred 14-36% risk of failing to detect response/remission indicated by another scale. The PHQ was most likely to indicate improvement and least likely to miss response or remission. These findings indicate that assessment of symptom burden during rTMS treatment may be most accurately assessed through use of multiple instruments.

A Longitudinal Mediation Analysis of the Interrelations among Exclusionary Immigration Policy, Ethnic Identity, and Self-Esteem of Latinx Early Adolescents.

Little is known about how exclusionary immigration laws affect ethnic identity and self-esteem among Latinx middle school students. Arizona's SB 1070, which required local officers to verify the legal status of detained individuals, garnered national attention for its impact on immigrant and Latinx communities. This study tested a longitudinal parallel multiple mediation model where perceptions of the effects of an exclusionary immigration law (Arizona's SB 1070) on self-esteem were mediated by dimensions of ethnic identity (ethnic centrality, ethnic private regard, ethnic public regard). Data were collected from a two-wave survey of 891 early adolescents ranging in age from 10 to 14 years (M = 12.09 years; SD = 0.99), a majority (71%) of whom were of Mexican descent. Analyses revealed an indirect effect of T1 perceptions of this law on T2 self-esteem (7 months later), holding T1 measures constant, with T2 ethnic centrality, private regard, and public regard acting as mediators. Perceived effects of this exclusionary law led to increased self-esteem through increased dimensions of ethnic identity. Results reveal how ethnic identity functions as a multidimensional construct in the process through which exclusionary immigration policy may impact the self-esteem of Latinx early adolescents.

Autophagy inducer rapamycin treatment reduces IFN-I-mediated Inflammation and improves anti-HIV-1 T cell response in vivo.

A hallmark of HIV-1 infection is chronic inflammation, even in patients treated with antiretroviral therapy (ART). Chronic inflammation drives HIV-1 pathogenesis, leading to loss of CD4+ T cells and exhaustion of antiviral immunity. Therefore, strategies to safely reduce systematic inflammation are needed to halt disease progression and restore defective immune responses. Autophagy is a cellular mechanism for disposal of damaged organelles and elimination of intracellular pathogens. Autophagy is pivotal for energy homeostasis and plays critical roles in regulating immunity. However, how it regulates inflammation and antiviral T cell responses during HIV infection is unclear. Here, we demonstrate that autophagy is directly linked to IFN-I signaling, which is a key driver of immune activation and T cell exhaustion during chronic HIV infection. Impairment of autophagy leads to spontaneous IFN-I signaling, and autophagy induction reduces IFN-I signaling in monocytic cells. Importantly, in HIV-1-infected humanized mice, autophagy inducer rapamycin treatment significantly reduced persistent IFN-I-mediated inflammation and improved antiviral T cell responses. Cotreatment of rapamycin with ART led to significantly reduced viral rebound after ART withdrawal. Taken together, our data suggest that therapeutically targeting autophagy is a promising approach to treat persistent inflammation and improve immune control of HIV replication.

Correcting the Bias Correction for the Bootstrap Confidence Interval in Mediation Analysis.

The bias-corrected bootstrap confidence interval (BCBCI) was once the method of choice for conducting inference on the indirect effect in mediation analysis due to its high power in small samples, but now it is criticized by methodologists for its inflated type I error rates. In its place, the percentile bootstrap confidence interval (PBCI), which does not adjust for bias, is currently the recommended inferential method for indirect effects. This study proposes two alternative bias-corrected bootstrap methods for creating confidence intervals around the indirect effect: one originally used by Stine (1989) with the correlation coefficient, and a novel method that implements a reduced version of the BCBCI's bias correction. Using a Monte Carlo simulation, these methods were compared to the BCBCI, PBCI, and Chen and Fritz (2021)'s 30% Winsorized BCBCI. The results showed that the methods perform on a continuum, where the BCBCI has the best balance (i.e., having closest to an equal proportion of CIs falling above and below the true effect), highest power, and highest type I error rate; the PBCI has the worst balance, lowest power, and lowest type I error rate; and the alternative bias-corrected methods fall between these two methods on all three performance criteria. An extension of the original simulation that compared the bias-corrected methods to the PBCI after controlling for type I error rate inflation suggests that the increased power of these methods might only be due to their higher type I error rates. Thus, if control over the type I error rate is desired, the PBCI is still the recommended method for use with the indirect effect. Future research should examine the performance of these methods in the presence of missing data, confounding variables, and other real-world complications to enhance the generalizability of these results.

Child eyewitness researchers often bin age: Prevalence of the practice and recommendations for analyzing developmental trends.

OBJECTIVE: Effective practices for eliciting and analyzing children's eyewitness reports rely on accurate conclusions about age differences in how children retain information and respond to memory probes. Binning, which is the practice of categorizing continuous variables into discrete groups, can lower studies' power to detect age differences and, in some situations, produce significant but spurious effects. In this article, we (a) describe a systematic review that estimated the frequency of binning age in child eyewitness studies, (b) analyze real and simulated data to illustrate how binning can distort conclusions about age and covariate effects, and (c) demonstrate best practices for analyzing and reporting age trends. HYPOTHESES: We expected that researchers would frequently bin age and that we would replicate the negative consequences of binning in the demonstration data sets. METHOD: For the systematic review, we retrieved 58 articles describing child eyewitness studies and determined whether researchers binned age for one randomly selected analysis per article. We then compared alternative ways of analyzing actual and simulated data sets. RESULTS: Researchers binned age for 64% of the analyses (88% of analyses involving experimental manipulations vs. 35% of the nonexperimental analyses, φ = .55, p < .01). A significant age trend in the real data example was nonsignificant when age was treated as categorical, and in the simulated data sets we demonstrate how this practice may lead to detecting a spurious effect. CONCLUSIONS: Treating age as a continuous variable maximizes power to detect real differences without inflating the frequency of spurious results, thereby ensuring that policies regarding child eyewitnesses reflect developmental changes in children's needs and abilities. (PsycInfo Database Record (c) 2020 APA, all rights reserved).