Organizations in science and medicine must hold each other accountable for discriminatory practices.

Many organizations persist in working with others that engage in known, remediable structural discrimination. We name this practice interorganizational structural discrimination (ISD) and argue it is a pivotal contributor to inequities in science and medicine. We urge organizations to leverage their relationships and demand progress from collaborators.

Evaluating Diversity and Inclusion Content on Graduate Medical Education Websites.

Websites are important tools for programs to provide future residency applicants with freely accessible information regarding their program, including diversity, equity, and inclusion (DEI) initiatives. OBJECTIVE: To describe the variability of DEI content in residency programs and compare DEI website content by specialty. METHODS: Using the 2021 Accreditation Council for Graduate Medical Education (ACGME) list of residency programs, residency training websites were identified and evaluated. Information was extracted from program websites as indicators of DEI content. Chi-square analysis and one-way ANOVA were chosen to assess for statistical differences. RESULTS: In total, 4644 program websites representing 26 specialties were assessed. Among all the programs, the average DEI completeness of a program website was 6.1±14.6% (range 0-100%). While 6.2% of all programs had a diversity webpage, only 13.3% included a commitment to DEI, and few programs (2.7%) provided information about underrepresented in medicine (URiM) faculty. CONCLUSIONS: Graduate medical education programs can enhance information for current and prospective applicants about DEI initiatives on their websites. Including DEI initiatives on residency websites may improve diversity recruitment efforts.

Acute and post-acute sequelae of SARS-CoV-2 infection: a review of risk factors and social determinants.

SARS-CoV-2 infection leading to Coronavirus Disease 2019 (COVID-19) has caused more than 762 million infections worldwide, with 10-30% of patients suffering from post-acute sequelae of SARS-CoV-2 infections (PASC). Initially thought to primarily affect the respiratory system, it is now known that SARS-CoV-2 infection and PASC can cause dysfunction in multiple organs, both during the acute and chronic stages of infection. There are also multiple risk factors that may predispose patients to worse outcomes from acute SARS-CoV-2 infection and contribute to PASC, including genetics, sex differences, age, reactivation of chronic viruses such as Epstein Barr Virus (EBV), gut microbiome dysbiosis, and behavioral and lifestyle factors, including patients' diet, alcohol use, smoking, exercise, and sleep patterns. In addition, there are important social determinants of health, such as race and ethnicity, barriers to health equity, differential cultural perspectives and biases that influence patients' access to health services and disease outcomes from acute COVID-19 and PASC. Here, we review risk factors in acute SARS-CoV-2 infection and PASC and highlight social determinants of health and their impact on patients affected with acute and chronic sequelae of COVID-19.

Distal and Proximal Predictors of Rehospitalization Over 10 Years Among Survivors of TBI: A National Institute on Disability, Independent Living, and Rehabilitation Research Traumatic Brain Injury Model Systems Study.

OBJECTIVE: To describe the rates and causes of rehospitalization over a 10-year period following a moderate-severe traumatic brain injury (TBI) utilizing the Healthcare Cost and Utilization Project (HCUP) diagnostic coding scheme. SETTING: TBI Model Systems centers. PARTICIPANTS: Individuals 16 years and older with a primary diagnosis of TBI. DESIGN: Prospective cohort study. MAIN MEASURES: Rehospitalization (and reason for rehospitalization) as reported by participants or their proxies during follow-up telephone interviews at 1, 2, 5, and 10 years postinjury. RESULTS: The greatest number of rehospitalizations occurred in the first year postinjury (23.4% of the sample), and the rates of rehospitalization remained stable (21.1%-20.9%) at 2 and 5 years postinjury and then decreased slightly (18.6%) at 10 years postinjury. Reasons for rehospitalization varied over time, but seizure was the most common reason at 1, 2, and 5 years postinjury. Other common reasons were related to need for procedures (eg, craniotomy or craniectomy) or medical comorbid conditions (eg, diseases of the heart, bacterial infections, or fractures). Multivariable logistic regression models showed that Functional Independence Measure (FIM) Motor score at time of discharge from inpatient rehabilitation was consistently associated with rehospitalization at all time points. Other factors associated with future rehospitalization over time included a history of rehospitalization, presence of seizures, need for craniotomy/craniectomy during acute hospitalization, as well as older age and greater physical and mental health comorbidities. CONCLUSION: Using diagnostic codes to characterize reasons for rehospitalization may facilitate identification of baseline (eg, FIM Motor score or craniotomy/craniectomy) and proximal (eg, seizures or prior rehospitalization) factors that are associated with rehospitalization. Information about reasons for rehospitalization can aid healthcare system planning. By identifying those recovering from TBI at a higher risk for rehospitalization, providing closer monitoring may help decrease the healthcare burden by preventing rehospitalization.

Five Strategies Leaders in Academic Medicine Can Implement Now to Enhance Gender Equity.

Abundant disparities for women in medicine contribute to many women physicians considering leaving medicine. There is a strong financial and ethical case for leaders in academic medicine to focus on strategies to improve retention. This article focuses on five immediate actions that leaders can take to enhance gender equity and improve career satisfaction for all members of the workplace.

Telemedicine Use Among Physiatrists During the Early Phase of the COVID-19 Pandemic and Potential for Future Use.

Introduction: With the coronavirus disease 2019 (COVID-19) pandemic causing the need for social distancing, telemedicine saw a significant increase in use to provide routine medical care. As a field, physiatry had already been implementing telemedicine prior to the pandemic. In this study, we characterized the use of telemedicine among physiatrists during the early phase of the COVID-19 pandemic to understand the barriers and facilitators to implementing telemedicine use in the field of physiatry in the future. Methods: Online survey of a cross-sectional sample of physiatrists. Analysis was conducted using logistic regression. Results: One hundred seventy one (n = 171) participants completed the survey. Before the pandemic, only 17.5% of respondents used telemedicine. In the logistic regression, physicians who used a hospital-provided platform were more likely to use telemedicine in the future compared with those who used their own secure platform, conducted a phone visit, and used a non-secure platform or other platforms. The three most popular barriers identified were "inability to complete the physical examination," "patients lack of access to technology," and "patients lack of familiarity with the technology." Discussion: Focus on education on telemedicine functional examination strategies and technology strategies for patients and providers (including addressing the digital divide and hospital-provided secure platforms) are potential targets of implementation strategies for greater telemedicine uptake for physiatrists in the future.

Cost Efficiency Analysis for Spasticity Management Based on Physician Botulinum Toxin Prescribing Habits.

OBJECTIVE: To estimate differences in botulinum toxin type A (BoNT-A) treatment costs per patient for spasticity-injecting physicians, with a focus on physicians' use of alternative BoNT-A agents other than onabotulinumtoxinA. DESIGN: Retrospective cohort study. SETTING: National Medicare data for fee-for-service beneficiaries in 2017. PARTICIPANTS: A total of 116 physicians, 6829 BoNT-A procedures, and 3051 patients were included in this analysis. Most physicians were physiatrists (84%) and used only onabotulinumtoxinA (82%). INTERVENTIONS: Type of BoNT-A selected by physicians was the independent variable of interest. Included physicians were separated into 2 groups: (1) onabotulinumtoxinA only injectors and (2) abobotulinumtoxinA and/or incobotulinumtoxinA injectors (may still use onabotulinumtoxinA). MAIN OUTCOME MEASURE: Average cost per patient per year. RESULTS: The total average BoNT-A cost per patient per year was significantly less for physicians who used abobotulinumtoxinA and/or incobotulinumtoxinA vs those who used only onabotulinumtoxinA ($3684 vs $4739; P=.01). Patients' average annual out-of-pocket costs also reflected a similar difference ($855 vs $1082; P=.02) between the groups. Doses used and numbers of injections per patient per year were not significantly different between groups. CONCLUSIONS: The present analysis demonstrated lower cost per patient for both the payer and patient when physicians used types of BoNT-A other than onabotulinumtoxinA for spasticity. Nevertheless, most physicians in this spasticity-focused study used exclusively onabotulinumtoxinA, the most expensive BoNT-A available. Reasons for this are complex and include history on the market and approved indications beyond those associated with spasticity. However, future research should continue to identify such issues with a goal of finding solutions to improve cost inefficiencies.

Acoustic startle reflex in patients with chronic stroke at different stages of motor recovery: a pilot study.

BACKGROUND: Acoustic startle reflex (ASR) can be used as a tool to examine reticulospinal excitability. The potential role of reticulospinal mechanisms in the development of spasticity has been suggested but not tested. OBJECTIVE: To examine reticulospinal excitability at different stages of motor recovery in patients with chronic stroke using the ASR. METHODS: Sixteen subjects with hemiplegic stroke participated in the study. We examined ASR responses at rest and contralateral motor overflow during voluntary elbow flexion. RESULTS: ASR responses in impaired biceps muscles showed different patterns at different stages. In subjects without spasticity, ASR responses were less frequent (10% on impaired side) and had normal duration (<200 ms). In subjects with spasticity, the responses were more frequent (58.3% on impaired side) and longer lasting (up to 1 minute). However, no correlation between exaggerated reflex responses and Modified Ashworth Scale (MAS) scores was observed. During voluntary elbow flexion on the impaired side, similar positive linear force-electromyogram (EMG) relationships were found in subjects with and without spasticity. Electromyographic activity of the resting nonimpaired limb increased proportionally in subjects with spasticity (r = 0.6313, P = .0004), but no such correlation was found in subjects without spasticity (r = 0.0191, P = .9612). CONCLUSIONS: Preliminary findings of exaggerated ASR responses and associated contralateral overflow only in spastic biceps muscles in patients with chronic stroke suggest the important role of reticulospinal mechanisms in the development of spasticity.

Disparities in Access to Spasticity Chemodenervation Specialists in the United States: A Retrospective Cross-Sectional Study.

OBJECTIVE: The aim of the study is to explore variations in access to spasticity chemodenervation specialists across several geographical, ethnic, racial, and population density factors. DESIGN: This is a retrospective cross-sectional study on Medicare Provider Utilization and Payment Data. Providers with substantial adult spasticity chemodenervation practices were included. Ratios were assessed across geographical regions as well as hospital referral regions. A multivariate linear regression model for the top 100 hospital referral regions by beneficiary population was created, using backward stepwise selection to eliminate variables with P values > 0.10 from final model. RESULTS: A total of 566 providers with spasticity chemodenervation practices were included. Unadjusted results showed lower access in nonurban versus urban areas in the form of higher patient:provider ratios (83,106 vs. 51,897). Access was also lower in areas with ≥25% Hispanic populations (141,800 vs. 58,600). Multivariate linear regression results showed similar findings with urban hospital referral regions having significantly lower ratios (-45,764 [ P = 0.004] vs. nonurban) and areas with ≥25% Hispanic populations having significantly higher ratios (+96,249 [ P = 0.003] vs. <25% Hispanic areas). CONCLUSIONS: Patients in nonurban and highly Hispanic communities face inequities in access to chemodenervation specialists. The Medicare data set analyzed only includes 12% of the US patient population; however, this elderly national cross-sectional cohort represents a saturated share of patients needing access to spasticity chemodenervation therapy. Future studies should venture to confirm whether findings are limited to this specialization, and strategies to improve access for these underserved communities should be explored.

Examining Diversity Recruitment Efforts in US-Based Physical Medicine and Rehabilitation Residencies: A Survey of Program Directors on Gender, Ethnic and Racial Diversity, and Implications for Recruitment Efforts.

As the population of the United States continues to grow and diversify, it is critical that the medical profession follows. This study aimed to evaluate aspects of the current landscape of diversity within physical medicine and rehabilitation by surveying program directors of US-based physical medicine and rehabilitation residencies. The secondary aim was to identify program characteristics that correlate with more diverse residency classes. An online, cross-sectional 17-question survey was distributed to program directors of all US-based physical medicine and rehabilitation residencies with known contact information (95/100), with a completed survey response rate of 53% (50/95). Race and ethnicity categories of the survey were based on those used by the US Census. The percentages of individuals identifying as women or those underrepresented in medicine in this survey were below those of the general US population, a trend also seen within the field of physical medicine and rehabilitation overall. Linear regression revealed no statistically significant association between the percentage of underrepresented in medicine residents and commonly used diversity recruitment initiatives. There was a significant association between the presence of a departmental role for diversity, equity and inclusion and the percentage of women residents (odds ratio, 1.13; P = 0.017). Continued research is required to identify additional strategies with demonstrated efficacy in recruiting diverse residency applicants.

Long-COVID symptoms improved after MDMA and psilocybin therapy: A case report.

Key Clinical Message: Long-COVID syndrome lacks effective holistic treatment options. We present a case of a 41-year-old fully vaccinated female with Long-COVID syndrome who obtained significant symptomatic relief after self-medicating with psilocybin and MDMA. Abstract: Long-COVID, a syndrome persisting after the acute phase of coronavirus disease 2019 (COVID-19), lacks effective holistic treatment options. We present a case of a 41-year-old fully vaccinated female with Long-COVID syndrome who obtained significant symptomatic relief by self-prescribing psilocybin and MDMA. Future research is needed to assess safety and efficacy.

Enhanced External Counterpulsation Improves Cognitive Function of Persons With Long COVID.

OBJECTIVE: The aim of this study is to determine the effects of enhanced external counterpulsation (EECP) in patients with long COVID and objectively assessed cognitive impairment. DESIGN: A retrospective evaluation of long COVID patients referred for EECP, with cognitive sequela, and having completed an objective digital assessment before and after therapy. Patients had either cognitive impairment or no cognitive impairment at baseline. We assessed changes in composite score using multifactor analysis of variance. Multiple linear and logistic regression analyses were conducted to evaluate several independent variables. RESULTS: Eighty long COVID patients (38 cognitive impairment vs. 42 no cognitive impairment) were included for analyses. All baseline characteristics were well matched. There was significant improvement in composite score post EECP in those with objective cognitive impairment at baseline. There were no notable documented safety concerns. CONCLUSIONS: This is the first study showing that EECP led to significant improvement in cognitive functioning of long COVID patients with objectively defined cognitive impairment. Although a lack of a negative control group is a limitation of this study, EECP seems to be highly safe and effective with the potential for widespread application.

Upper Limb Spasticity: The Quality of Online Patient Resources.

OBJECTIVE: The aim of the study is to assess the quality, readability, content, accessibility, and structure of online resources for patients with upper limb spasticity. DESIGN: This was a cross sectional study examined Internet searches across three search engines related to patient resources for upper limb spasticity. Search phrases for either hand or upper limb spasticity were used. The top 20 Websites from each search were evaluated using the four readability metrics and the DISCERN scale for quality assessment. YouTube videos with exact search phrases were evaluated using DISCERN. Descriptive statistical analyses were performed using SPSS software. RESULTS: Thirty-six Websites and 33 videos met the inclusion criteria for this study. The average Flesh-Kincaid Grade Level of the Websites was 11.7 ± 3.1, showing low Website readability. According to this index, only two Websites were written at the suggested sixth-grade level (5.4%). With a maximum score of 75, the mean DISCERN score for both Websites and videos scored in the "good" range (53.5 ± 8 and 50.5 ± 6.6), respectively. CONCLUSIONS: Current online resources for upper limb spasticity are good in quality but are written above the health literacy level of American citizens. Organizations should consider reviewing their present materials and developing high-quality patient education materials that are easier to understand.

Delphi Analysis: Optimizing Anatomy Teaching and Ultrasound Training for Botulinum Neurotoxin Type A Injection in Spasticity and Dystonia.

Our objective was to provide expert consensus on best practices for anatomy teaching and training on ultrasound-guided botulinum neurotoxin type A (BoNT-A) injection for specialists involved in treating spasticity and dystonia. Nine experts (three neurologists; six physical medicine and rehabilitation physicians) participated in a three-round modified Delphi process. Over three rounds, experts reached consensus on 15 of 16 statements describing best practices for anatomy and BoNT-A injection training. They unanimously agreed that knowledge of the target audience, including their needs and current competency, is crucial when designing training programs. Experts also agreed that alignment between instructors is essential to ensure consistency of approach over time and between regions, and that training programs should be simple, adaptable, and "hands-on" to enhance engagement and learning. Consensus was also reached for several other key areas of training program development. The best-practice principles identified by expert consensus could aid in the development of effective, standardized programs for anatomy teaching and BoNT-A injection training for the purposes of treating spasticity and dystonia. This will enhance the exchange of knowledge, skills, and educational approaches between global experts, allowing more specialists to treat important movement disorders and ultimately improving patient outcomes.

Assessing the Burden and Cost of COVID-19 Across Variants in Commercially Insured Immunocompromised Populations in the United States: Updated Results and Trends from the Ongoing EPOCH-US Study.

INTRODUCTION/METHODS: EPOCH-US is an ongoing, retrospective, observational cohort study among individuals identified in the Healthcare Integrated Research Database (HIRD®) with ≥ 12 months of continuous health plan enrollment. Data were collected for the HIRD population (containing immunocompetent and immunocompromised [IC] individuals), individual IC cohorts (non-mutually exclusive cohorts based on immunocompromising condition and/or immunosuppressive [IS] treatment), and the composite IC population (all unique IC individuals). This study updates previous results with addition of the general population cohort and data specifically for the year of 2022 (i.e., Omicron wave period). To provide healthcare decision-makers the most recent trends, this study reports incidence rates (IR) and severity of first SARS-CoV-2 infection; and relative risk, healthcare utilization, and costs related to first COVID-19 hospitalizations in the full year of 2022 and overall between April 2020 and December 2022. RESULTS: These updated results showed a 2.9% prevalence of immune compromise in the population. From April 2020 through December 2022, the overall IR of COVID-19 was 115.7 per 1000 patient-years in the composite IC cohort and 77.8 per 1000 patient-years in the HIRD cohort. The composite IC cohort had a 15.4% hospitalization rate with an average cost of $42,719 for first COVID-19 hospitalization. Comparatively, the HIRD cohort had a 3.7% hospitalization rate with an average cost of $28,848 for first COVID-19 hospitalization. Compared to the general population, IC individuals had 4.3 to 23 times greater risk of hospitalization with first diagnosis of COVID-19. Between January and December 2022, hospitalizations associated with first COVID-19 diagnosis cost over $1 billion, with IC individuals (~ 3% of the population) generating $310 million (31%) of these costs. CONCLUSION: While only 2.9% of the population, IC individuals had a higher risk of COVID-19 hospitalization and incurred higher healthcare costs across variants. They also disproportionately accounted for over 30% of total costs for first COVID-19 hospitalization in 2022, amounting to ~ $310 million. These data highlight the need for additional preventive measures to decrease the risk of developing severe COVID-19 outcomes in vulnerable IC populations.

Individual, organizational, and policy strategies to enhance the retention and a sense of belonging for health care professionals in rehabilitation medicine.

The retention of physicians and other health care professionals in rehabilitation medicine is a critical issue that affects patients' access to care and the quality of the care they receive. In the United States and globally, there are known shortages of clinicians including, but not limited to, physicians, nurses, physical therapists, occupational therapists, and speech-language pathologists. These shortages are predicted to worsen in the future. It is known that attrition occurs in a variety of ways such as a clinician reducing work hours or effort, taking a position at another organization, leaving the field of medicine altogether, stress-related illness, and suicide. Retention efforts should focus on stay factors by creating a positive culture that supports a sense of belonging as well as addressing a myriad of push and pull factors that lead to attrition. In this commentary, we provide a roadmap that includes examples of stay strategies for individuals and organizations to adopt that are aimed at enhancing the retention of rehabilitation medicine professionals.

Social media adoption and utilization by Physical Medicine & Rehabilitation residency programs and implications for remote resident recruitment.

ABSTRACT: We aim to investigate the association of Instagram and Twitter (rebranded X) adoption by Physical Medicine & Rehabilitation (PM&R) residencies with the number of National Resident Matching Program (NRMP) applications received in the 2020-2021 application cycle. Among 88 PM&R residency programs, 67 (77%) had Instagram accounts, 45 (51%) had Twitter accounts, and 41 (47%) had both. Forty (60%) Instagram accounts and 19 (42%) Twitter accounts were opened during the 2020-2021 application cycle, correlating with the introduction of virtual interviews and the COVID-19 pandemic. Residency programs with active Instagram or Twitter accounts had more NRMP applications (F(2,85) = 7.49, P = 0.001). Simple main effects analysis showed that programs with an Instagram account (P = 0.03) or a Twitter account (P = 0.03) received more residency applications. In multivariate linear regression analysis including presence of an Instagram account, program size, program setting, and program region, the presence of a Twitter account (coefficient 37.3, P = 0.04, 95% CI 1.71-72.96) and ≥ 16 residents in the residency program (coefficient 77.9, P < 0.001, 95% CI 44.43-111.31) were positively correlated with the number of residency applications. In conclusion, residency programs that were larger and adopted Twitter had more applicants in 2020-2021. Future research is needed to determine how social media activity impacts residency applicant decision-making.

Understanding the Sequelae of Invasive Meningococcal Disease in the United States.

Invasive meningococcal disease (IMD) is an uncommon but serious and potentially fatal condition that can result in reduced life expectancy and a broad spectrum of sequelae, many of which may be lifelong and devastating for those who survive the acute disease period. In the United States of America (USA), vaccination is available against the five meningococcal serogroups (A, B, C, W, and Y), but meningococcal vaccination rates among healthy USA adolescents and individuals at high risk because of medical conditions are low, rendering them vulnerable to IMD and its sequelae. Despite the severity of the disease, the clinical impact and rates of IMD sequelae in the USA are poorly understood, as USA-specific data are limited, and the methodology of existing research is heterogenous. This commentary presents clinical experts' perspectives on IMD sequelae based on the available published evidence and direct clinical experience. Among sequelae previously identified in a global systematic literature review, 16 conditions were considered as related to IMD by the present authors. These sequelae include short- and long-term physical, neurological, and emotional consequences that impose a substantial humanistic burden on survivors and their caregivers and result in considerable healthcare and societal costs. This commentary highlights existing knowledge gaps concerning IMD sequelae, including the unclear relationship between IMD and mental health disorders, the contribution of sequelae to the disease burden, prevalence of late-onset sequelae among survivors, and timing of the development of sequelae in different age groups. Addressing these knowledge gaps can inform decisions regarding clinical management in the post-acute period and help quantify the impact of prevention through meningococcal vaccination.

Invasive meningococcal disease is uncommon but life-threatening. Those who survive may have lasting conditions, also known as sequelae, that negatively impact their health. In this commentary, expert physicians used previous publications to identify 16 sequelae of invasive meningococcal disease, many of which, including loss of limbs, blindness, and intellectual disabilities, can severely affect the lives of survivors and their caregivers. It is important to better understand how sequelae affect patients and the cost of living with these conditions for the healthcare system and society. This information would help policymakers make decisions on preventing invasive meningococcal disease with vaccination and managing its sequelae.