Memory complaints moderate the concordance between self-report and electronically monitored adherence in adults with type 2 diabetes

AimsWe examined the impact of memory complaints on the concordance between self-report (SR) and electronically monitored (EM) medication adherence, independent of depression symptoms, among adults with type 2 diabetes (T2D).MethodsAdults (N = 104, age = 56.6 ± 9.2; 64% female) completed a prospective and retrospective memory questionnaire (PRMQ) and a depression symptom interview at baseline. EM was tracked over 3 months and participants rated adherence using SR. Multiple linear regression evaluated PRMQ as a moderator of the relationship between EM and SR, adjusting for depression and other covariates.ResultsPRMQ was correlated with lower SR (r = ?0.31, p = 0.001), but not with EM. PRMQ moderated the relationship between SR and EM, independent of depression symptoms. At low levels of PRMQ, SR and EM were closely related (β = 0.76, p < 0.001); at high levels of PRMQ the relationship was weaker (β = 0.28, p = 0.02). Participants who under-reported their adherence (SR < EM) had higher PRMQ scores than more concordant reporters (p = 0.016).ConclusionsSR and EM measures were less concordant among adults with T2D who endorsed higher PRMQ scores. Memory complaints may contribute to under-reporting of medication adherence in adults with T2D.     

Women-Focused Cardiovascular Rehabilitation: An International Council of Cardiovascular Prevention and Rehabilitation Clinical Practice Guideline

Women-focused cardiovascular rehabilitation (CR; phase II) aims to better engage women, and might result in better quality of life than traditional programs. This first clinical practice guideline by the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) provides guidance on how to deliver women-focused programming. The writing panel comprised experts with diverse geographic representation, including multidisciplinary health care providers, a policy-maker, and patient partners. The guideline was developed in accordance with Appraisal of Guidelines for Research and Evaluation (AGREE) II and the Reporting Items for practice Guidelines in HealTh care (RIGHT). Initial recommendations were on the basis of a meta-analysis. These were circulated to a Delphi panel (comprised of corresponding authors from review articles and of programs delivering women-focused CR identified through ICCPR’s audit; N = 76), who were asked to rate each on a 7-point Likert scale in terms of impact and implementability (higher scores positive). A Web call was convened to achieve consensus; 15 panelists confirmed strength of revised recommendations (Grading of Recommendations Assessment, Development, and Evaluation [GRADE]). The draft underwent external review from CR societies internationally and was posted for public comment. The 14 drafted recommendations related to referral (systematic, encouragement), setting (model choice, privacy, staffing), and delivery (exercise mode, psychosocial, education, self-management empowerment). Nineteen (25.0%) survey responses were received. For all but 1 recommendation, ≥ 75% voted to include; implementability ratings were < 5/7 for 4 recommendations, but only 1 for effect. Ultimately 1 recommendation was excluded, 1 separated into 2 and all revised (2 substantively); 1 recommendation was added. Overall, certainty of evidence for the final recommendations was low to moderate, and strength mostly strong. These recommendations and associated tools can support all programs to feasibly offer some women-focused programming.     

Do social support and community engagement act as mechanisms in the association between neighbourhood income inequality and the mental health of mothers in Calgary,Canada? A mediation analysis

PurposeAccording to the social determinants of health framework, income inequality is a potential risk factor for adverse mental health. However, few studies have explored the mechanisms suspected to mediate this relationship. The current study addresses this gap through a mediation analysis to determine if social support and community engagement act as mediators linking neighbourhood income inequality to maternal anxiety and depressive symptoms within a cohort of new mothers living in the City of Calgary, Canada.MethodsData collected at three years postpartum from mothers belonging to the All Our Families (AOF) cohort were used in the current study. Maternal data were collected between 2012 and 2015 and linked to neighbourhood socioeconomic data from the 2006 Canadian Census. Income inequality was measured using Gini coefficients derived from 2006 after-tax census data. Generalized structural equation models were used to quantify the associations between income inequality and mental health symptoms, and to assess the potential direct and indirect mediating effects of maternal social support and community engagement.ResultsIncome inequality was not significantly associated with higher depressive symptoms (β = 0.32, 95%CI = −0.067, 0.70), anxiety symptoms (β = 0.11, 95%CI = −0.39, 0.60), or lower social support. Income inequality was not associated with community engagement. For the depression models, higher social support was significantly associated with lower depressive symptoms (β = −0.13, 95%CI = −0.15, −0.097), while community engagement was not significantly associated with depressive symptoms (β = 0.059, 95%CI = −0.15, 0.27). Similarly, for the anxiety models, lower anxiety symptoms were significantly associated with higher levels of social support (β = −0.17, 95%CI = −0.20, −0.13) but not with higher levels of community engagement (β = 0.14, 95%CI = −0.14, 0.41).ConclusionThe current study did not find clear evidence for social support or community engagement mediating the relationship between neighbourhood income inequality and maternal mental health. Future investigations should employ a broader longitudinal approach to capture changes in income inequality, potential mediators, and mental health symptomatology over time.     

Skin3D: Detection and longitudinal tracking of pigmented skin lesions in 3D total-body textured meshes

We present an automated approach to detect and longitudinally track skin lesions on 3D total-body skin surface scans. The acquired 3D mesh of the subject is unwrapped to a 2D texture image, where a trained objected detection model, Faster R-CNN, localizes the lesions within the 2D domain. These detected skin lesions are mapped back to the 3D surface of the subject and, for subjects imaged multiple times, we construct a graph-based matching procedure to longitudinally track lesions that considers the anatomical correspondences among pairs of meshes and the geodesic proximity of corresponding lesions and the inter-lesion geodesic distances.We evaluated the proposed approach using 3DBodyTex, a publicly available dataset composed of 3D scans imaging the coloured skin (textured meshes) of 200 human subjects. We manually annotated locations that appeared to the human eye to contain a pigmented skin lesion as well as tracked a subset of lesions occurring on the same subject imaged in different poses. Our results, when compared to three human annotators, suggest that the trained Faster R-CNN detects lesions at a similar performance level as the human annotators. Our lesion tracking algorithm achieves an average matching accuracy of 88% on a set of detected corresponding pairs of prominent lesions of subjects imaged in different poses, and an average longitudinal accuracy of 71% when encompassing additional errors due to lesion detection. As there currently is no other large-scale publicly available dataset of 3D total-body skin lesions, we publicly release over 25,000 3DBodyTex manual annotations, which we hope will further research on total-body skin lesion analysis.     

Rationale for a Clinical Trial That Compares Acute Stroke Rehabilitation at Inpatient Rehabilitation Facilities to Skilled Nursing Facilities: Challenges and Opportunities

In the United States, approximately 400,000 patients with acute stroke are discharged annually to inpatient rehabilitation facilities (IRFs) or skilled nursing facilities (SNFs). Typically, IRFs provide time-intensive therapy for an average of 2-3 weeks, whereas SNFs provide more moderately intensive therapy for 4-5 weeks. The factors that influence discharge to an IRF or SNF are multifactorial and poorly understood. The complexity of these factors in combination with subjective clinical indications contributes to large variations in the use of IRFs and SNFs. This has significant financial implications for health care expenditure, given that stroke rehabilitation at IRFs costs approximately double that at SNFs. To control health care spending without compromising outcomes, the Institute of Medicine has stated that policy reforms that promote more efficient use of IRFs and SNFs are critically needed. A major barrier to the formulation of such policies is the highly variable and low-quality evidence for the comparative effectiveness of IRF- vs SNF-based stroke rehabilitation. The current evidence is limited by the inability of observational data to control for residual confounding, which contributes to substantial uncertainty around any magnitude of benefit for IRF- vs SNF-based care. Furthermore, it is unclear which specific patients would receive the most benefit from each setting. A randomized controlled trial addresses these issues, because random treatment allocation facilitates an equitable distribution of measured and unmeasured confounders. We discuss several measurement, practical, and ethical issues of a trial and provide our rationale for design suggestions that overcome some of these issues.     

Performance of risk prediction models for post-operative mortality in patients undergoing liver resection

BackgroundLiver resection is commonly performed for hepatic tumors, however preoperative risk stratification remains challenging. We evaluated the performance of contemporary prediction models for short-term mortality after liver resection in patients with and without cirrhosis.MethodsThis retrospective cohort study examined National Surgical Quality Improvement Program data. We included patients who underwent liver resections from 2014 to 2019. VOCAL-Penn, MELD, MELD-Na, ALBI, and Mayo risk scores were evaluated in terms of model discrimination and calibration for 30-day post-operative mortality.ResultsA total 15,198 patients underwent liver resection, of whom 249 (1.6%) experienced 30-day post-operative mortality. The VOCAL-Penn score had the highest discrimination (area under the ROC curve [AUC] 0.74) compared to all other models. The VOCAL-Penn score similarly outperformed other models in patients with (AUC 0.70) and without (AUC 0.74) cirrhosis.ConclusionThe VOCAL-Penn score demonstrated superior predictive performance for 30-day post-operative mortality after liver resection as compared to existing clinical standards.     

Evolving Trends in the Management of Low-Risk Prostate Cancer

IntroductionDeferred treatment is a growing management strategy for low-risk prostate cancer. However, it is unknown whether this growth is mediated by patient factors. In this study, we sought to evaluate factors associated with deferred treatment in patients with low-risk prostate cancer and shifts in these factors after recent incorporation of active surveillance into national guidelines.Materials and MethodsWe identified 137,915 men diagnosed with low-risk prostate cancer (prostate-specific antigen <10 ng/mL, Gleason score ≤6, stage cT1-cT2a) in the National Cancer Database from 2010 to 2017. Multivariate logistic regression models were used to determine factors associated with deferred treatment. Interaction variables were added to determine whether trends in use of deferred treatment over time depend on race, income, education, and insurance status.ResultsThe use of deferred treatment among men with low-risk prostate cancer increased from 14.7% in 2010-2011 to 46.3% in 2016-2017 (P < .001). On multivariate analysis, deferred treatment was associated with older age, more contemporary year of diagnosis, black race, lower income, higher educational attainment, government insurance, being uninsured, treatment at an academic/research facility, and treatment at a facility in New England (each P < .05). Incorporation of interaction variables showed that black race, belonging to the two lowest income quartiles, government insurance, and being uninsured became less associated with deferred treatment in recent years.ConclusionsThe use of deferred treatment among men with low-risk prostate cancer increased significantly from 2010 to 2017. However, patients who were black, low-income, and not privately insured experienced smaller increases in deferred treatment. Interventions to increase uptake in these groups present opportunities to improve quality of care.