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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., (© 2024. GSK.)

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., Competing Interests: Conflict of Interest Statement: Christopher Lewis has no conflicts of interest to report. Alethea Appavu has no conflicts of interest to report. Tiffany Holland has no conflicts of interest to report. Oksana Witt has no conflicts of interest to report. Katrina Ngo has no conflicts of interest to report. Hannah Uhlig-Reche has no conflicts of interest to report. Toqa Afifi has no conflicts of interest to report. Michael Galibov has no conflicts of interest to report. Alexandra Fry has no conflicts of interest to report. Monica Verduzco-Gutierrez has no conflicts of interest to report., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Spasticity management should be provided within the context of a comprehensive person-centered rehabilitation program. Furthermore, active goal setting for specific spasticity interventions is also important, with a well-established "more is better" approach. It is critical to consider adjunctive therapy and multimodal approaches if patients are not attaining their treatment goals. Often used interchangeably, there may be confusion between the terms adjunctive and multimodal therapy. Yet it is imperative to understand the differences between these approaches to achieve treatment goals in spasticity management. Addition of a secondary pharmacologic or non-pharmacologic treatment to optimize the efficacy of the initial modality, such as adding electrical stimulation or casting to BoNT-A, is considered an adjunctive therapy. Adjunctive therapy is time-specific and requires the added therapy be initiated within a specific period to enhance the primary treatment; usually within 2 weeks. Multimodal therapy is an integrated, patient-centric program of pharmacologic and non-pharmacologic strategies utilized in a concurrent/integrated or sequential manner to enhance the overall treatment effect across a variety of spasticity-associated impairments (e.g., neural and non-neural components). Moreover, within a multimodal approach, adjunctive therapy can be used to help enhance the treatment effect of one specific modality. The objectives of this paper are to clarify the differences between adjunctive and multimodal therapies, provide a brief evidence-based review of such approaches, and highlight clinical insights on selecting multimodal and adjunctive therapies in spasticity management., Competing Interests: MO'D was employed by Weill Cornell Medicine and NeuroRehabilitation Consultants. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. SC declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2024 Reebye, Jacinto, Balbert, Biering-Soerensen, Carda, Draulans, Molteni, O’Dell, Picelli, Santamato, Verduzco-Gutierrez, Walker, Wissel and Francisco.)

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.

Background: The American Academy of Physical Medicine and Rehabilitation (AAPM&R) conducted a comprehensive review in 2021 to identify opportunities for enhancing the care of adult and pediatric patients with spasticity. A technical expert panel (TEP) was convened to develop consensus-based practice recommendations aimed at addressing gaps in spasticity care., Objective: To develop consensus-based practice recommendations to identify and address gaps in spasticity care., Methods: The Spasticity TEP engaged in a 16-month virtual meeting process, focusing on formulating search terms, refining research questions, and conducting a structured evidence review. Evidence quality was assessed by the AAPM&R Evidence, Quality and Performance Committee (EQPC), and a modified Delphi process was employed to achieve consensus on recommendation statements and evidence grading. The Strength of Recommendation Taxonomy (SORT) guided the rating of individual studies and the strength of recommendations., Results: The TEP approved five recommendations for spasticity management and five best practices for assessment and management, with one recommendation unable to be graded due to evidence limitations. Best practices were defined as widely accepted components of care, while recommendations required structured evidence reviews and grading. The consensus guidance statement represents current best practices and evidence-based treatment options, intended for use by PM&R physicians caring for patients with spasticity., Conclusion: This consensus guidance provides clinicians with practical recommendations for spasticity assessment and management based on the best available evidence and expert opinion. Clinical judgment should be exercised, and recommendations tailored to individual patient needs, preferences, and risk profiles. The accompanying table summarizes the best practice recommendations for spasticity assessment and management, reflecting principles with little controversy in care delivery., (© 2024 American Academy of Physical Medicine and Rehabilitation.)

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., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: Declaration of competing interest Dr. Fox is an employee of Flow Therapy. The remaining authors have no competing interests to declare.

Background: Physiatry is a specialty with high rates of burnout. Although organizational strategies to combat burnout are key, it is also important to understand strategies that individual physiatrists can use to address burnout., Objective: The aim of the study is to identify changes that resulted in improvement of occupational well-being of physiatrists over a 6- to 9-mo period., Design: We employed two quantitative surveys spaced 6-9 mos apart to identify physiatrists who experienced meaningful improvement in occupational burnout and/or professional fulfillment between the two survey time points. These physiatrists were subsequently recruited to participate in a qualitative study using semistructured interviews to identify changes that respondents felt contributed to improvements in burnout and professional fulfillment., Setting: Online surveys and interviews., Participants: Physiatrists in the American Academy of Physical Medicine and Rehabilitation (AAPM&R) Membership Masterfile., Main Outcome Measure: Burnout and professional fulfillment were assessed using the Stanford Professional Fulfillment Index., Results: One hundred twelve physiatrists responded to the baseline and follow-up surveys. Of these, 35 were eligible for interviews based on improvements in the Stanford Professional Fulfillment Index, and 23 (64%) agreed to participate. Themes from the qualitative interviews highlighted the importance of personal lifestyle choices, approaches to improve professional satisfaction, and strategies to foster work-life harmony. Personal lifestyle strategies included investing in wellness and mental health. Efforts to improve professional satisfaction included decreasing work intensity, prioritizing meaningful aspects of work, and building relationships with colleagues. Fostering work-life harmony also included making trade-offs in both domains, setting boundaries at work, setting expectations at home, and overcoming personal challenges., Conclusions: Our findings illustrate that in addition to organizational strategies demonstrated to be effective, there are actions that individual physiatrists can take to recover from burnout and foster professional fulfillment., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

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., (© 2024 American Academy of Physical Medicine and Rehabilitation.)

Importance: Faculty diversity in academic medicine may better prepare the next generation of equity-minded health care practitioners and leaders. Prefaculty development is an emerging concept to support trainees in achieving key knowledge, skills, and experiences to become successful faculty., Objective: To outline competencies, with corresponding milestones, to support the academic career development of learners, inclusive of racial, ethnic, sexual, and gender identities minoritized in medicine., Design, Setting, and Participants: Using a modified Delphi process, a national working group consisting of 13 members was established. The group used the published literature and listening sessions with diverse stakeholders to draft a set of competencies and milestones in July 2022. Diverse expert panelists reviewed the draft set over 2 rounds between September 2022 and January 2023. The group considered qualitative data to further refine the draft set between rounds. Consensus was reached when competencies and milestones were rated as agree or strongly agree on importance or appropriateness by 75% or greater of expert panelists after the second round. A final set of competencies and milestones was generated in February 2023. Data from round 1 were analyzed in October 2022 and data from round 2 were analyzed in January 2023., Main Outcomes and Measures: The development of prefaculty competencies with corresponding milestones by expert panel rankings and comments., Results: The national working group consisted of 13 members who represented diversity across racial, ethnic, and gender identities and academic and career tracks. The working group developed an initial set of 36 competencies and corresponding milestones across 12 domains. After 2 rounds, consensus among 46 expert panelists generated a final list of 32 competencies with corresponding milestones across 11 domains. A total of 26 panelists (56.5%) were women, 11 (23.9%) were Black or African American, 17 (37.0%) were Latina/o/x/e, Hispanic, or of Spanish origin, and 10 (21.7%) were White. Competency domains were divided into 2 groups: foundational (academic career choice and professional identity, mentorship, networking, financial skills, diversity and inclusion, personal effectiveness and self-efficacy, and leadership) and focused (education, community engagement, research, and clinical medicine). Consensus for inclusion or elimination of items was greater than 90% between the 2 rounds., Conclusions and Relevance: There was consensus among the working group and expert panelists regarding the importance and appropriateness of the competencies and milestones for diverse trainees to successfully obtain faculty positions. Institutions and national organizations can use these competencies as a framework to develop curricula that support diverse learners' career development toward academia.

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., (© 2024. The Author(s).)

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., Competing Interests: RK was an employee of Merz Pharmaceuticals, LLC, at the time of this analysis. MV-G also served as a consultant for Merz Pharmaceuticals, LLC, at the time of this analysis and also has served as a consultant for Allergan, Inc, Ipsen Biopharmaceuticals, Inc, Medtronic USA, Inc, and Piramal. The other authors declare no conflict of interest and received no compensation or funding for this research project. Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

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., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

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., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To assess the gender composition of upper-level specialty-specific editor positions among United States (U.S.) medical society-affiliated journals and to evaluate the equitable inclusion of women and women physicians. Materials and Methods: The gender composition of upper-level ( e.g. , editor-in-chief, deputy) specialty-specific editor positions among 39 U.S. medical society-affiliated journals as of January 5, 2023, was analyzed. Editor positions below the level of associate editor were excluded. Parity (50:50 representation) and equity (compared with the proportion of practicing physicians in each medical specialty) benchmarks were utilized to determine if women are underrepresented in editor positions. Results: A total of 862 editor positions among 39 journals were assessed. Women held 32.9% (284/862) of positions (95% confidence interval [CI]: 29.9%-36.2%), significantly less than expected based on the U.S. population ( p  < 0.001). Physicians comprised 90.8% (783/862) of positions, of whom 30.4% (238/783) were women physicians (95% CI: 27.3%-33.7%), significantly less than expected ( p  < 0.001). Thirty-three (84.6%, 95% CI: 70.3%-92.8%) journals were below parity for women overall, whereas 34 (87.2%, 95% CI: 73.3%-94.4%) were below parity for women physicians. Fourteen (35.9%, 95% CI: 22.7%-51.6%) journals were below equity for women physicians. Notably, 13 (33.3%, 95% CI: 20.6%-49.0%) journals were below both parity and equity for women overall and women physicians. Conclusions: This study reveals mixed results in the equitable inclusion of women in editor positions of journals affiliated with U.S. medical societies. Despite the equitable inclusion of women in editorial roles being a remediable issue, approximately one third of journals affiliated with major U.S. medical societies remain inequitable.

Background: As the proportion of women and individuals who are underrepresented in medicine slowly rises, disparities persist in numerous arenas and specialties. In physical medicine and rehabilitation (PM&R), there is a continued need to focus on diversity among trainees. This study aims to evaluate diversity among PM&R applicants and residents over the past 6 years., Objective: To describe the demographic trends in PM&R over the last 6 years and compare those findings with trends in other specialties., Design: Surveillance., Setting: Analyses of national databases from self-reported questionnaires., Participants: The study consists of 126,833 medical school matriculants, 374,185 resident applicants, and 326,134 resident trainees over the last 6 years., Main Outcome Measures: Self-reported demographic data from the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education were analyzed for medical school matriculants, PM&R applicants, and current residents for the cycles of 2014-2015 to 2019-2020. The data were then comparatively reviewed between PM&R and other medical specialties., Results: In the 6 cycles evaluated, women accounted for 36%-39% of PM&R residents, but 47%-48% in non-PM&R specialties. Women applicants to the PM&R specialty averaged 34.4% over the 6 years analyzed, which was the fourth lowest of the 11 specialties examined. Black or African American and Hispanic, Latino, or of Spanish Origin populations each accounted for only 6% of PM&R residents. PM&R demonstrated a noticeably higher proportion of White (62.1% vs. 60.3%) and an observably lower proportion of Black or African American (6.0% vs. 7.1%) and Hispanic, Latino, or of Spanish Origin (6.3% vs. 7.9%) residents compared with non-PM&R specialties., Conclusion: There is underrepresentation of women and multiple racial and ethnic minority groups in the field of PM&R from applicants to trainees demonstrating a need to improve recruitment efforts., (© 2023 American Academy of Physical Medicine and Rehabilitation.)

Background: Real-world data regarding the impact of onabotulinumtoxinA on healthcare resource utilization and costs for post-stroke spasticity are scarce., Objective: To compare differences in 12-month healthcare resource utilization and costs before and after post-stroke spasticity management including onabotulinumtoxinA., Methods: This retrospective claims analysis of IBM MarketScan Commercial and Medicare Supplemental databases included adults with ≥ 1 onabotulinumtoxinA claim for post-stroke spasticity (1 January 2010 to 30 June 2018) and continuous enrolment for ≥ 12 months pre- and post-index (first onabotulinumtoxinA claim date). All-cause and spasticity-related healthcare resource utilization and costs were compared 12 months pre- and post-index (McNemar's χ2 test or paired t-test). A subgroup analysis assessed effect of stroke-to-index interval on costs., Results: Among 735 patients, mean (standard deviation) stroke-date-to-index-date interval was 284.5 (198.8) days. Decreases were observed post-index for mean all-cause outpatient (62.9 vs 60.5; p ≤ 0.05) and emergency department visits (1.1 vs 0.8; p ≤ 0.0001), and hospital admissions (1.5 vs 0.4; p ≤ 0.0001). Increase in prescription fills (43.0 vs 53.7) was seen post-index. Post-index decreases in all-cause (-66%) and spasticity-related (-51%) costs were driven by reduced inpatient care costs. Findings were consistent regardless of stroke-date-to-index-date interval., Conclusion: Significant reductions in healthcare resource utilization and costs were observed after 1 year of post-stroke spasticity management including onabotulinumtoxinA. Long-term studies are needed to establish causality.

Telehealth refers to the use of telecommunication devices and other forms of technology to provide services outside of the traditional in-person health care delivery system. Growth in the use of telehealth creates new challenges and opportunities for implementation in clinical practice. The American Academy of Physical Medicine and Rehabilitation (AAPM&R) assembled an expert group to develop a white paper to examine telehealth innovation in Physical Medicine and Rehabilitation (PM&R). The resultant white paper summarizes how telehealth is best used in the field of PM&R while highlighting current knowledge deficits and technological limitations. The report identifies new and transformative opportunities for PM&R to advance translational research related to telehealth and enhance patient care., (© 2023 American Academy of Physical Medicine and Rehabilitation.)

It is known that there can be neurologic complications related to acute infection with SARS-CoV-2, the virus that causes COVID-19. Currently, there is a growing body of evidence that postacute sequelae of SARS-CoV-2 infection can manifest as neurologic sequelae as a result of direct neuroinvasion, autoimmunity, and possibly lead to chronic neurodegenerative processes. Certain complications can be associated with worse prognosis, lower functional outcome, and higher mortality. This article provides an overview of the known pathophysiology, symptoms presentation, complications and treatment approaches of the post-acute neurologic and neuromuscular sequelae of SARS-CoV-2 infection., (Copyright © 2023 Elsevier Inc. All rights reserved.)

The COVID-19 pandemic has resulted in a significant number of people developing long-term health effects of postacute sequelae SARS-CoV-2 infection (PASC). Both acute COVID-19 and PASC are now recognized as multiorgan diseases with multiple symptoms and disease causes. The development of immune dysregulation during acute COVID-19 and PASC is of high epidemiologic concern. Both conditions may also be influenced by comorbid conditions such as pulmonary dysfunction, cardiovascular disease, neuropsychiatric conditions, prior autoimmune conditions and cancer. This review discusses the clinical symptoms, pathophysiology, and risk factors that affect both acute COVID-19 and PASC., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To estimate the prevalence of patients with an immunocompromising condition at risk for COVID-19, estimate COVID-19 prevalence rate (PR) and incidence rate (IR) by immunocompromising condition, and describe COVID-19-related healthcare resource utilization (HCRU) and costs., Methods: Using the Healthcare Integrated Research Database (HIRD), patients with ≥1 claim for an immunocompromising condition of interest or ≥2 claims for an immunosuppressive (IS) treatment and COVID-19 diagnosis during the infection period (1 April 2020-31 March 2022) and had ≥12 months baseline data were included. Cohorts (other than the composite cohort) were not mutually exclusive and were defined by each immunocompromising condition. Analyses were descriptive in nature., Results: Of the 16,873,161 patients in the source population, 2.7% ( n  = 458,049) were immunocompromised (IC). The COVID-19 IR for the composite IC cohort during the study period was 101.3 per 1000 person-years and the PR was 13.5%. The highest IR (195.0 per 1000 person-years) and PR (20.1%) were seen in the end-stage renal disease (ESRD) cohort; the lowest IR (68.3 per 1000 person-years) and PR (9.4%) were seen in the hematologic or solid tumor malignancy cohort. Mean costs for hospitalizations associated with the first COVID-19 diagnosis were estimated at nearly $1 billion (2021 United States dollars [USD]) for 14,516 IC patients, with a mean cost of $64,029 per patient., Conclusions: Immunocompromised populations appear to be at substantial risk of severe COVID-19 outcomes, leading to increased costs and HCRU. Effective prophylactic options are still needed for these high-risk populations as the COVID-19 landscape evolves.

Persistence of symptoms beyond the initial acute phase of coronavirus disease-2019 (COVID-19) is termed postacute SARS-CoV-2 (PASC) and includes neurologic, autonomic, pulmonary, cardiac, psychiatric, gastrointestinal, and functional impairment. PASC autonomic dysfunction can present with dizziness, tachycardia, sweating, headache, syncope, labile blood pressure, exercise intolerance, and "brain fog." A multidisciplinary team can help manage this complex syndrome with nonpharmacologic and pharmacologic interventions., (Copyright © 2023 Elsevier Inc. All rights reserved.)

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., (© 2023. The Author(s).)

Importance: SARS-CoV-2 infection is associated with persistent, relapsing, or new symptoms or other health effects occurring after acute infection, termed postacute sequelae of SARS-CoV-2 infection (PASC), also known as long COVID. Characterizing PASC requires analysis of prospectively and uniformly collected data from diverse uninfected and infected individuals., Objective: To develop a definition of PASC using self-reported symptoms and describe PASC frequencies across cohorts, vaccination status, and number of infections., Design, Setting, and Participants: Prospective observational cohort study of adults with and without SARS-CoV-2 infection at 85 enrolling sites (hospitals, health centers, community organizations) located in 33 states plus Washington, DC, and Puerto Rico. Participants who were enrolled in the RECOVER adult cohort before April 10, 2023, completed a symptom survey 6 months or more after acute symptom onset or test date. Selection included population-based, volunteer, and convenience sampling., Exposure: SARS-CoV-2 infection., Main Outcomes and Measures: PASC and 44 participant-reported symptoms (with severity thresholds)., Results: A total of 9764 participants (89% SARS-CoV-2 infected; 71% female; 16% Hispanic/Latino; 15% non-Hispanic Black; median age, 47 years [IQR, 35-60]) met selection criteria. Adjusted odds ratios were 1.5 or greater (infected vs uninfected participants) for 37 symptoms. Symptoms contributing to PASC score included postexertional malaise, fatigue, brain fog, dizziness, gastrointestinal symptoms, palpitations, changes in sexual desire or capacity, loss of or change in smell or taste, thirst, chronic cough, chest pain, and abnormal movements. Among 2231 participants first infected on or after December 1, 2021, and enrolled within 30 days of infection, 224 (10% [95% CI, 8.8%-11%]) were PASC positive at 6 months., Conclusions and Relevance: A definition of PASC was developed based on symptoms in a prospective cohort study. As a first step to providing a framework for other investigations, iterative refinement that further incorporates other clinical features is needed to support actionable definitions of PASC.

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., (©Jessica M Allan, Amber K Brooks, Cindy Crusto, Lauren D Feld, Amy S Oxentenko, Nancy D Spector, Monica Verduzco-Gutierrez, Julie K Silver. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 13.06.2023.)

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., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Multiple national studies suggest that, among physicians, physiatrists are at increased risk for occupational burnout., Objective: To identify characteristics of the work environment associated with professional fulfillment and burnout among U.S. physiatrists., Design: Between May and December 2021, a mixed qualitative and quantitative approach was used to identify factors contributing to professional fulfillment and burnout in physiatrists., Setting: Online interviews, focus groups, and survey., Participants: Physiatrists in the AAPM&R Membership Masterfile., Main Outcome Measures: Burnout and professional fulfillment assessed using the Stanford Professional Fulfillment Index., Results: Individual interviews with 21 physiatrists were conducted to identify domains that contributed to professional fulfillment followed by focus groups for further definition. Based on themes identified, scales were identified or developed to evaluate: control over schedule (6 items; Cronbach's alpha = 0.86); integration of physiatry into patient care (3 items; Cronbach's alpha = 0.71); personal-organizational values alignment (3 items; Cronbach's alpha = 0.90); meaningfulness of physiatrist clinical work (6 items; Cronbach's alpha = 0.90); teamwork and collaboration (3 items; Cronbach's alpha = 0.89). Of 5760 physiatrists contacted in the subsequent national survey, 882 (15.4%) returned surveys (median age 52 years; 46.1% women). Overall, 42.6% (336 of 788) experienced burnout and 30.6% (244 of 798) had high levels of professional fulfillment. In multivariable analysis, each one-point improvement in control over schedule (odds ratio [OR] = 1.96; 95% confidence interval [CI] = 1.45-2.69), integration of physiatry into patient care (OR = 1.77; 95% CI = 1.32-2.38), personal-organizational values alignment (OR = 1.92; 95% CI = 1.48-2.52), meaningfulness of physiatrist clinical work (OR = 2.79; 95% CI = 1.71-4.71) and teamwork and collaboration score (OR = 2.11; 95% CI = 1.48-3.03) was independently associated with higher likelihood of professional fulfillment., Conclusions: Control over schedule, optimal integration of physiatry into clinical care, personal-organizational values alignment, teamwork, and meaningfulness of physiatrist clinical work are strong and independent drivers of occupational well-being in U.S. physiatrists. Variation in these domains by practice setting and subspecialty suggests tailored approaches are needed to promote professional fulfillment and reduce burnout among U.S. physiatrists., (© American Academy of Physical Medicine and Rehabilitation and Wolters Kluwer Health, Inc.)

Abstract: This study aimed to report the training characteristics, academic accomplishments, and motivation of current US academic physical medicine and rehabilitation program directors.A 22-question survey was developed and disseminated via email in May 2020 to 91 current residency program directors who are members of the Association of Academic Physiatrists Residency Fellowship Program Director Committee. Follow-up emails were sent 2 and 4 wks after initial distribution, and the survey was closed after 6 wks in June 2020. Data collected were deidentified. Descriptive analysis was performed.Response rate was 49.5% (45/91); 64.4% of program directors were men, and 35.6% were women. Of the respondents, 75.4% were White/Caucasian, 6.7% were Hispanic/Latinx, 15.6% were Asian, and 2.2% were Black/African American. Moreover, 56% (9/16) of female program directors vs. 0% (0/29) of male program directors reported experiencing sex discrimination in the workplace.Four percent of program directors were full professors in physical medicine and rehabilitation when first appointed, 17% were associate professors, and 72% were assistant professors. Thirty-four percent of program directors had at least six peer-reviewed publications when first appointed.This survey provides insight to the training characteristics, accomplishments, and motivation of current program directors for physiatrists aspiring to enter these ranks and highlights the underrepresentation of women/minorities among leadership positions in physical medicine and rehabilitation., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: Environmental scans determine trends in an organization's or field's internal and external environment. The results can help shape goals, inform strategic decision making, and direct future actions. The Association of Academic Physiatrists convened a strategic planning group in 2020, composed of physiatrists representing a diversity of professional roles, career stages, race and ethnicity, gender, disability status, and geographic areas of practice. This strategic planning group performed an environmental scan to assess the forces, trends, challenges, and opportunities affecting both the Association of Academic Physiatrists and the entire field of academic physiatry (also known as physical medicine and rehabilitation, physical and rehabilitation medicine, and rehabilitation medicine). This article presents aspects of the environmental scan thought to be most pertinent to the field of academic physiatry organized within the following five themes: (1) Macro/Societal Trends, (2) Technological Advancements, (3) Diversity and Global Outreach, (4) Economy, and (5) Education/Learning Environment. The challenges and opportunities presented here can provide a roadmap for the field to thrive within the complex and evolving healthcare systems in the United States and globally., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

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., (© 2022. The Author(s), under exclusive licence to Society of General Internal Medicine.)

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.

Despite efforts to improve parity in the biomedical workforce, gender bias persists related to equitable pay, promotion, speaking opportunities, journal editorial positions, research funding, and leadership positions. This bias becomes more prominent for women of color and women with other intersectional identities who come from underrepresented groups. It is critical to understand the barriers that women face and why the pathway is especially challenging for women of color. In this commentary, the authors cite research related to the effects of institutional gender bias in academic medicine, including research on bias against women of color. As academic leaders who come from underrepresented groups, the authors are aware that traditional approaches to reducing this bias have not worked well, and they instead highlight promising strategies aimed at filling the pathway to leadership with women of color who are qualified and ready to take the helm. They address solutions to ensure the academic pathway is supportive. They also provide several recommendations, including: offering more opportunities for mentorship and sponsorship, improving access to formal leadership programming, modeling successful upstander initiatives, recognizing the growing role of minority-based medical societies, implementing early-career education, increasing journal editorial board representation, and expanding promotion criteria. Appropriate training, education, and partnership with internal and external stakeholders are necessary to advance leadership equity for women of color in academic medicine., (Copyright © 2022 by the Association of American Medical Colleges.)

Background: Symptoms of burnout are highly prevalent among physiatrists, and prior studies have helped identify key contributors to this epidemic of burnout. Little is known about the physician stressors unique to those providing care in inpatient rehabilitation facilities (IRFs) and what strategies such facilities have used to help mitigate burnout among inpatient physiatrists., Objective: To identify what IRF leaders perceive as stress points contributing to burnout among inpatient rehabilitation physicians and what, if any, interventions their programs have implemented to help mitigate physician burnout., Design: 10 item cross-sectional survey study of IRF physician and nonphysician leaders in the United States., Participants: 104 physicians serving in the roles of IRF medical director, director of rehabilitation, and/or executive leadership and 19 nonphysician IRF leaders., Results: Regulatory demands, late admissions, understaffing, and on-call responsibilities were the major stress points most identified as contributing to physician burnout among both the physician and nonphysician respondents. The use of advanced practice providers and hospitalists were the most common system changes reportedly used to help mitigate physician burnout. Although 57.8% of physician leaders felt late admissions were a major stress point for physicians, only 18.2% of those responding reported having implemented admission cutoff times., Conclusions: There are stressors unique to the practice of inpatient rehabilitation that are likely contributing to physiatrist burnout, including late admissions and on-call responsibilities. Many IRFs have begun to implement system changes to help mitigate burnout among inpatient physiatrists. The use of nonphysiatrist providers is a commonly reported strategy. Future studies are needed to determine the effectiveness of such a strategy on reducing symptoms of burnout among IRF physicians as well as its effect on IRF patient outcomes., (© 2022 American Academy of Physical Medicine and Rehabilitation.)

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., Competing Interests: Declaration of interests The authors declare no competing interests., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Abstract: The objectives were to assess US medical students' awareness about physical medicine and rehabilitation, their career goals that may align with physical medicine and rehabilitation, and their exposure to physical medicine and rehabilitation and to compare the demographics of those applying to, interested, or not interested in physical medicine and rehabilitation residency. This was a descriptive cross-sectional study. An online survey was distributed to 76 medical schools, and 2067 students responded. First-generation and Hispanic/Latino students are less likely to know about physical medicine and rehabilitation. Medical students who heard about physical medicine and rehabilitation before or during college or who are first-generation students to attend medical school are more likely to be interested in physical medicine and rehabilitation. Medical students identified as female, Black or African American, and more advanced in medical training have lesser interest. Rotating in physical medicine and rehabilitation at their home institution and shadowing a physical medicine and rehabilitation physician also increase the likelihood of respondents to apply to physical medicine and rehabilitation residency. This study highlights that female students and underrepresented minorities in medicine are less likely to know about physical medicine and rehabilitation or be interested in physical medicine and rehabilitation. First-generation medical students know less about the field but the ones who do have increased interest in physical medicine and rehabilitation. These findings support the need for pipeline programs to improve exposure, recruitment, development, promotion, and retention of first-generation minorities and women into physical medicine and rehabilitation., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The aim of the study was to report the training characteristics, academic accomplishments, and motivation of current United States academic physical medicine and rehabilitation chairs., Design: The authors developed a 23-question survey that was disseminated via e-mail to 86 current chairs who were members of the Chairs Council from the Association of Academic Physiatrists in May 2020. Follow-up e-mails were sent 2 and 4 wks after the initial distribution, and the survey closed after 6 wks in June 2020. The data collected were deidentified. Descriptive analysis was performed., Results: Forty-nine chair responses were received, which had a response rate of 60%. A total of 69.4% of the chairs (32 of 49) were men and 30.6% (17 of 49) were women. A total of 75.5% (37 of 49) were White/Caucasian, 12.2% (6 of 49) Hispanic/Latinx, 10.2% (5 of 49) Asian, and 2% (1 of 49) were Black/African American. A total of 8.2% of the chairs (4 of 49) reported having a disability. Sixty-seven percent of the female chairs (10 of 15) reported experiencing gender discrimination in the workplace versus 3% of male chairs (1 of 34). Twenty-nine percent of the chairs were full professors in physical medicine and rehabilitation when first appointed, 57.1% associate professors, and 6% assistant professors. A total of 73.5% of the chairs had served as a reviewer for a peer-reviewed publication. Fifty-two percent of the chairs had a leadership role in a national physical medicine and rehabilitation organization. Fifty-eight percent of the chairs had at least 16 peer-reviewed publications when first appointed., Conclusions: This survey provides insight to the training characteristics, accomplishments, and motivation of current chairs for physiatrists aspiring to enter these ranks. It also highlights the underrepresentation of women and minorities among leadership positions in physical medicine and rehabilitation., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)