Publications by authors named "Jennifer Campbell"

226 Publications

A model-based framework for correcting inhomogeneity effects in magnetization transfer saturation and inhomogeneous magnetization transfer saturation maps.

Magn Reson Med 2021 May 6. Epub 2021 May 6.

McConnell Brain Imaging Centre, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada.

Purpose: In this work, we propose that Δ -induced errors in magnetization transfer (MT) saturation (MT ) maps can be corrected with use of an R and map and through numerical simulations of the sequence.

Theory And Methods: One healthy subject was scanned at 3.0T using a partial quantitative MT protocol to estimate the relationship between observed R (R ) and apparent bound pool size ( ) in the brain. MT values were simulated for a range of , R , and . An equation was fit to the simulated MT , then a linear relationship between R and was generated. These results were used to generate correction factor maps for the MT acquired from single-point data. The proposed correction was compared to an empirical correction factor with different MT-preparation schemes.

Results: was highly correlated with R (r > 0.96), permitting the use of R to estimate for correction. All corrected MT maps displayed a decreased correlation with compared to uncorrected MT and MT corrected with an empirical factor in the corpus callosum. There was good agreement between the proposed approach and the empirical correction with radiofrequency saturation at 2 kHz, with larger deviations seen when using saturation pulses further off-resonance and in inhomogeneous (ih) MT maps.

Conclusion: The proposed correction decreases the dependence of MT on inhomogeneities. Furthermore, this flexible framework permits the use of different saturation protocols, making it useful for correcting inhomogeneities in ihMT.
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http://dx.doi.org/10.1002/mrm.28831DOI Listing
May 2021

Truncating SRCAP variants outside the Floating-Harbor syndrome locus cause a distinct neurodevelopmental disorder with a specific DNA methylation signature.

Am J Hum Genet 2021 Apr 19. Epub 2021 Apr 19.

Institute of Human Genetics, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany.

Truncating variants in exons 33 and 34 of the SNF2-related CREBBP activator protein (SRCAP) gene cause the neurodevelopmental disorder (NDD) Floating-Harbor syndrome (FLHS), characterized by short stature, speech delay, and facial dysmorphism. Here, we present a cohort of 33 individuals with clinical features distinct from FLHS and truncating (mostly de novo) SRCAP variants either proximal (n = 28) or distal (n = 5) to the FLHS locus. Detailed clinical characterization of the proximal SRCAP individuals identified shared characteristics: developmental delay with or without intellectual disability, behavioral and psychiatric problems, non-specific facial features, musculoskeletal issues, and hypotonia. Because FLHS is known to be associated with a unique set of DNA methylation (DNAm) changes in blood, a DNAm signature, we investigated whether there was a distinct signature associated with our affected individuals. A machine-learning model, based on the FLHS DNAm signature, negatively classified all our tested subjects. Comparing proximal variants with typically developing controls, we identified a DNAm signature distinct from the FLHS signature. Based on the DNAm and clinical data, we refer to the condition as "non-FLHS SRCAP-related NDD." All five distal variants classified negatively using the FLHS DNAm model while two classified positively using the proximal model. This suggests divergent pathogenicity of these variants, though clinically the distal group presented with NDD, similar to the proximal SRCAP group. In summary, for SRCAP, there is a clear relationship between variant location, DNAm profile, and clinical phenotype. These results highlight the power of combined epigenetic, molecular, and clinical studies to identify and characterize genotype-epigenotype-phenotype correlations.
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http://dx.doi.org/10.1016/j.ajhg.2021.04.008DOI Listing
April 2021

Assessing How a Transplant Hospitality House for Patients and Families Can Promote Wellbeing.

Prog Transplant 2021 Apr 1:15269248211003561. Epub 2021 Apr 1.

Campbell-Collaboratives, LLC, Ardmore, PA, USA.

Patients and caregivers face increasingly complex and unique challenges when they travel to distant hospitals for transplant care. They can find themselves in a strange city managing hospital stays and outpatient appointments, requiring lodging, food, transportation, financial assistance, and emotional support. Those unable to overcome these logistical challenges may lose access to lifesaving treatment. Transplant specific hospitality houses have emerged to support patients who travel long distances from home to seek care, though little is known about the impact of such programs. Can a transplant hospitality house impact opportunities for family-centered care, perceptions of physiological and physical security, and perceptions of belonging and esteem? Can their contributions also be linked to perceived positive health outcomes and what aspects of a transplant hospitality house are most significant for a patient's and caregiver's health journey? One transplant hospitality house investigated these questions with 71 participating in focus groups or key stakeholder interviews: transplant patients and caregivers, transplant hospital social workers, volunteers, financial contributors, board members, and staff. The findings suggest that while patients and caregivers were dependent and deeply grateful for the lodging and amenities that met their basic needs, it was the contact and support from other patients and caregivers at the transplant hospitality house that had the most profound positive impact on patient and family attitudes, outlooks, and perceived well-being.
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http://dx.doi.org/10.1177/15269248211003561DOI Listing
April 2021

Efficient whole-brain tract-specific T mapping at 3T with slice-shuffled inversion-recovery diffusion-weighted imaging.

Magn Reson Med 2021 Aug 21;86(2):738-753. Epub 2021 Mar 21.

McConnell Brain Imaging Centre, Montreal Neurological Institute and Hospital, Montreal, Quebec, Canada.

Purpose: Most voxels in white matter contain multiple fiber populations with different orientations and levels of myelination. Conventional T mapping measures 1 T value per voxel, representing a weighted average of the multiple tract T times. Inversion-recovery diffusion-weighted imaging (IR-DWI) allows the T times of multiple tracts in a voxel to be disentangled, but the scan time is prohibitively long. Recently, slice-shuffled IR-DWI implementations have been proposed to significantly reduce scan time. In this work, we demonstrate that we can measure tract-specific T values in the whole brain using simultaneous multi-slice slice-shuffled IR-DWI at 3T.

Methods: We perform simulations to evaluate the accuracy and precision of our crossing fiber IR-DWI signal model for various fiber parameters. The proposed sequence and signal model are tested in a phantom consisting of crossing asparagus pieces doped with gadolinium to vary T , and in 2 human subjects.

Results: Our simulations show that tract-specific T times can be estimated within 5% of the nominal fiber T values. Tract-specific T values were resolved in subvoxel 2 fiber crossings in the asparagus phantom. Tract-specific T times were resolved in 2 different tract crossings in the human brain where myelination differences have previously been reported; the crossing of the cingulum and genu of the corpus callosum and the crossing of the corticospinal tract and pontine fibers.

Conclusion: Whole-brain tract-specific T mapping is feasible using slice-shuffled IR-DWI at 3T. This technique has the potential to improve the microstructural characterization of specific tracts implicated in neurodevelopment, aging, and demyelinating disorders.
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http://dx.doi.org/10.1002/mrm.28734DOI Listing
August 2021

Evaluation of the Addition of Pharmacist Management to a Medication Assistance Program in Patients with Hypertension and Diabetes Resistant to Usual Care.

J Pharm Pract 2021 Mar 19:8971900211002138. Epub 2021 Mar 19.

Regional One Health, Internal Medicine Clinic, Division of General Internal Medicine, University of Tennessee Health Science Center, Department of Medicine, Division of General Internal Medicine, Memphis, TN, USA.

Objective: To evaluate the effect of a medication assistance program and the addition of pharmacist management on clinical outcomes in patients with hypertension and diabetes through an Advanced Pharmaceutical Care program.

Methods: This was a prospective quality improvement study on patients with hypertension and/or diabetes resistant to usual care. The primary outcomes were change in A1C, blood glucose, and blood pressure between 3 phases: usual care, free medications, and free medications plus pharmacist management. Secondary outcomes included achievement of A1C, blood glucose, and blood pressure goals as well as pharmacist interventions.

Results: Seven patients were included in the study. The mean A1C decreased from 11.3% to 8.3% with free medications (p = 0.28) and from 8.3% to 6.4% with pharmacist management (p = 0.119). Mean blood pressure during usual care, free medications, and pharmacist intervention was 150/87 mm Hg, 148/85 mm Hg, and 125/78 mm Hg, respectively. After pharmacist management, 75% of patients with type 2 diabetes were able to achieve A1C and blood glucose goals, and 71% of patients with hypertension achieved blood pressure <130/80 mm Hg.

Conclusions: The Advanced Pharmaceutical Care program allowed pharmacists to identify and overcome patient-specific barriers to care, provide individualized disease state education, and optimize medication management. Medication assistance led to improvements in A1C and blood pressure, but did not affect achievement of disease state goals. Pharmacist involvement in hypertension and diabetes care led to clinically significant reductions in blood pressure and A1C and enabled patients to reach guideline-recommended blood pressure and glycemic goals.
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http://dx.doi.org/10.1177/08971900211002138DOI Listing
March 2021

Cost-effectiveness of financial incentives to improve glycemic control in adults with diabetes: A pilot randomized controlled trial.

PLoS One 2021 18;16(3):e0248762. Epub 2021 Mar 18.

Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America.

Purpose: Determine the cost-effectiveness of three financial incentive structures in obtaining a 1% within group drop in HbA1c among adults with diabetes.

Methods: 60 African Americans with type 2 diabetes were randomized to one of three financial incentive structures and followed for 3-months. Group 1 (low frequency) received a single incentive for absolute HbA1c reduction, Group 2 (moderate frequency) received a two-part incentive for home testing of glucose and absolute HbA1c reduction and Group 3 (high frequency) received a multiple component incentive for home testing, attendance of weekly telephone education classes and absolute HbA1c reduction. The primary clinical outcome was HbA1c reduction within each arm at 3-months. Cost for each arm was calculated based on the cost of the intervention, cost of health care visits during the 3-month time frame, and cost of workdays missed from illness. Incremental cost effectiveness ratios (ICER) were calculated based on achieving a 1% within group drop in HbA1c and were bootstrapped with 1,000 replications.

Results: The ICER to decrease HbA1c by 1% was $1,100 for all three arms, however, bootstrapped standard errors differed with Group 1 having twice the variation around the ICER coefficient as Groups 2 and 3. ICERs were statistically significant for Groups 2 and 3 (p<0.001) indicating they are cost effective interventions.

Conclusions: Given ICERs of prior diabetes interventions range from $1,000-$4,000, a cost of $1,100 per 1% within group decrease in HbA1c is a promising intervention. Multi-component incentive structures seem to have the least variation in cost-effectiveness.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0248762PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7971847PMC
March 2021

Stress that Endures: Influence of Adverse Childhood Experiences on Daily Life Stress and Physical Health in Adulthood.

J Affect Disord 2021 04 5;284:38-43. Epub 2021 Feb 5.

Department of Medicine, Division of General Internal Medicine, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226 USA; Center for Advancing Population Science (CAPS), Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226 USA. Electronic address:

Background: Understanding the influence of ACEs on reported daily stress is needed to further address the role of ACEs on adult health and well-being.

Methods: Data from 3,235 adults in the Midlife in the US (MIDUS) (Wave 1 (1995-1996) and Wave II (2004-2006)) were used. ACEs included emotional and physical abuse, household dysfunction, and financial strain. Daily stress was assessed using the National Study of Daily Experiences survey. Generalized Estimating Equations were used to examine the relationship between ACEs and Daily Stress.

Results: ACE exposure was associated with higher number of reported stressors per day (p<.05), stressor severity (p<.05), number of physical symptoms reported (p<.05), and negative affect (p<.05). ACE count was significantly associated with multiple stressor types (OR=1.73, 95% 1.05-2.82) and number of days reported with stressor (RR=1.14, 95% 1.00-1.30). Abuse specifically was associated with a higher number of days reported with a stressor (RR=1.23, 95% CI 1.16 - 1.30).

Limitations: Assessment of ACEs is retrospective and self-reported. Secondly, this data is limited by ACE category. Specifically, sexual abuse and other forms of family dysfunction were not included in this dataset.

Conclusions: ACEs are associated with increased report of daily stress as an adult, reported physical symptoms as a result of stress, and reports of poor negative affect in adulthood. These findings highlight the role that ACEs play in the occurrence of reported daily stress during adulthood. Further investigation is needed to establish treatment and interventions for individuals who have experienced ACEs to avoid worsening health conditions and promote positive coping skills.
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http://dx.doi.org/10.1016/j.jad.2021.02.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8040325PMC
April 2021

Examining the Relationship Between Delay Discounting, Delay Aversion, Diabetes Self-care Behaviors, and Diabetes Outcomes in U.S. Adults With Type 2 Diabetes.

Diabetes Care 2021 Apr 10;44(4):893-900. Epub 2021 Feb 10.

Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI

Objective: Delay discounting and delay aversion are emerging areas for understanding diabetes management; however, few data exist on their relationship with multiple diabetes self-care behaviors and diabetes outcomes.

Research Design And Methods: This cross-sectional study included 356 adults with type 2 diabetes across three racial/ethnic groups receiving care from two primary care clinics. The primary predictors were delay discounting and delay aversion. Outcomes included self-care behaviors, quality of life (QOL; mental health component score [MCS], physical component score), and A1C. Multiple linear regression models were run to examine the association between predictors and the outcomes, A1C, QOL, and each self-care behavior.

Results: Higher delay discounting was associated with lower engagement in self-care behaviors for general diet (B = -0.06; 95% CI -0.12; -0.01), specific diet (B = -0.07; 95% CI -0.12; -0.03), and foot care (B = -0.10; 95% CI -0.17; -0.02). Higher delay aversion was associated with lower engagement in self-care behaviors for general diet (B = -0.06; 95% CI -0.10; -0.01), specific diet (B = -0.03; 95% CI -0.07; -0.01), foot care (B = -0.11; 95% CI -0.17; -0.05), and lower MCS (B = -0.38; 95% CI -0.71; -0.06).

Conclusions: In a diverse sample of adults with type 2 diabetes, higher delay discounting and higher delay aversion were significantly related to lower engagement in self-care behaviors. High delay aversion was specifically related to lower QOL. These findings offer new knowledge by highlighting the role that delay-related behaviors may have in the performance of self-care behaviors and the impact on QOL. Work is needed to further elucidate these relationships. Specifically, these results highlight the importance of targeting value and decision-making for diabetes self-management.
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http://dx.doi.org/10.2337/dc20-2620DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7985422PMC
April 2021

Relationship between physical and mental health comorbidities and COVID-19 positivity, hospitalization, and mortality.

J Affect Disord 2021 03 25;283:94-100. Epub 2021 Jan 25.

Center for Advancing Population Science, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226, USA; Department of Medicine, Division of General Internal Medicine, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI 53226, USA. Electronic address:

Background: Understanding the association between separate and combined mental and physical health diagnoses and COVID-19 outcomes is greatly needed to address the severity of illness.

Methods: Data on 24,034 patients screened for COVID-19 as of July 2020 were extracted from the Froedtert/Medical College of Wisconsin Epic medical record. COVID-19 outcomes were defined as positive screens, proportion hospitalized among positive screens, and proportion that died among positive and hospitalized population. The primary independent variable was a 3-category variable: physical health diagnosis alone, mental health diagnosis alone, and combined mental and physical health diagnoses. Logistic regression and Cox proportional hazard models were used to examine the independent relationship between separate and combined diagnoses and COVID-19 outcomes.

Results: Compared to physical health diagnosis alone, mental health diagnosis alone had lower odds of screening positive (OR=0.68, CI=0.51;0.92) and was not associated with hospitalization or mortality among positive screens. Combined had lower odds of screening positive (OR=0.78, CI=0.69;0.88) and higher odds of hospitalization among positive screens after adjusting for demographics (OR=1.58, CI=1.20;2.08) but lost significance in the fully adjusted model. No category of diagnoses was associated with mortality.

Limitations: Analysis is cross-sectional and cannot speak to any causal relationships.

Conclusions: Overall, compared to physical health diagnosis alone, mental health diagnosis and combined had lower odds of positive screens. However, individuals with combined were more likely to be hospitalized, after adjusting for demographics only. These findings add new evidence for risk of COVID-19 and related hospitalization in individuals who have a physical and mental health diagnosis.
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http://dx.doi.org/10.1016/j.jad.2021.01.048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7830241PMC
March 2021

Team Science, Population Health, and COVID-19: Lessons Learned Adapting a Population Health Research Team to COVID-19.

J Gen Intern Med 2021 Jan 22. Epub 2021 Jan 22.

Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA.

Our multidisciplinary research team is composed of 6 faculty with expertise in internal medicine, nephrology, maternal/fetal medicine, health services research, statistics, and community-based research, and 36 program staff including biostatisticians, nurses, program coordinators, program assistants, and medical assistants/phlebotomists. With the emergence of the COVID-19 pandemic and the impact it was having on our community, especially the ethnic minority population in inner-city Milwaukee, we felt it was critical to stay engaged and figure out how to ask meaningful research questions that are important to the community, are relevant to the times, and will lead to lasting change. While navigating this unprecedented challenge, our research team made difficult decisions but were able to engage our staff and respond to community needs. We organized our lessons learned to serve as a perspective on how to effectively remain committed to vision and serve our communities, while collecting evidence that can inform policy in difficult times.
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http://dx.doi.org/10.1007/s11606-020-06455-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7822580PMC
January 2021

Financial incentives to improve glycemic control in African American adults with type 2 diabetes: a pilot randomized controlled trial.

BMC Health Serv Res 2021 Jan 13;21(1):57. Epub 2021 Jan 13.

Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, 701 Watertown Plank Rd, Milwaukee, WI, 53226-3596, USA.

Background: Financial incentives is emerging as a viable strategy for improving clinical outcomes for adults with type 2 diabetes. However, there is limited data on optimal structure for financial incentives and whether financial incentives are effective in African Americans with type 2 diabetes. This pilot study evaluated impact of three financial incentive structures on glycemic control in this population.

Methods: Sixty adults with type 2 diabetes were randomized to one of three financial incentive structures: 1) single incentive (Group 1) at 3 months for Hemoglobin A1c (HbA1c) reduction, 2) two-part equal incentive (Group 2) for home testing of glucose and HbA1c reduction at 3 months, and 3) three-part equal incentive (Group 3) for home testing, attendance of weekly telephone education classes and HbA1c reduction at 3 months. The primary outcome was HbA1c reduction within each group at 3 months post-randomization. Paired t-tests were used to test differences between baseline and 3-month HbA1c within each group.

Results: The mean age for the sample was 57.9 years and 71.9% were women. Each incentive structure led to significant reductions in HbA1c at 3 months with the greatest reduction from baseline in the group with incentives for multiple components: Group 1 mean reduction = 1.25, Group 2 mean reduction = 1.73, Group 3 mean reduction = 1.74.

Conclusion: Financial incentives led to significant reductions in HbA1c from baseline within each group. Incentives for multiple components led to the greatest reductions from baseline. Structured financial incentives that reward home monitoring, attendance of telephone education sessions, and lifestyle modification to lower HbA1c are viable options for glycemic control in African Americans with type 2 diabetes.

Trial Registration: Trial registration: NCT02722499 . Registered 23 March 2016, url.
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http://dx.doi.org/10.1186/s12913-020-06029-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7803385PMC
January 2021

Financial Incentives and Nurse Coaching to Enhance Diabetes Outcomes (FINANCE-DM): a trial protocol.

BMJ Open 2020 12 22;10(12):e043760. Epub 2020 Dec 22.

Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.

Introduction: Given the burden of diabetes in ethnic minorities and emerging data on the efficacy of financial incentives in type 2 diabetes mellitus (T2DM), it is critical to examine the efficacy of financial incentives across and within racial/ethnic groups.

Methods And Analysis: This trial is an ongoing 5-year, randomised clinical trial designed to test the efficacy of a inancial centives nd urse oaching to nhance Diabetes Outcomes (FINANCE-DM) intervention composed of (1) nurse education, (2) home telemonitoring and (3) structured financial incentives; compared with an active control group (nurse education and home telemonitoring alone). The study also will evaluate whether intervention effects are sustained 6 months after the financial incentives are withdrawn (ie, 18 months post-randomisation) and whether the intervention is differentially efficacious across racial/ethnic groups. Participants will include 450 adults with a clinical diagnosis of T2DM and HbA1c of 8% or higher who self-identify as White, African American or Hispanic. Participants will be randomised to one of two groups: the FINANCE intervention or Active Control. The location and setting of this study include primary care clinics at the Medical College of Wisconsin (MCW) in Milwaukee, WI and community partner sites affiliated with the Center for Advancing Population Science at MCW.

Ethics And Dissemination: This trial was approved by IRB at MCW under PRO00033788.

Trial Registration Number: Registration for this trial on the United States National Institute of Health Clinical Trials Registry can be found under ID: NCT04203173 and online (https://clinicaltrials.gov/ct2/show/NCT04203173?id=NCT04203173&draw=2&rank=1).
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http://dx.doi.org/10.1136/bmjopen-2020-043760DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7757449PMC
December 2020

Community-Based Participatory Research Interventions to Improve Diabetes Outcomes: A Systematic Review.

Diabetes Educ 2020 12 14;46(6):527-539. Epub 2020 Oct 14.

Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.

Purpose: The purpose of this study was to conduct a systematic evaluation of community-based participatory research (CBPR) interventions on diabetes outcomes. Understanding of effective CBPR interventions on diabetes outcomes is limited, and findings remain unclear.

Methods: A reproducible search strategy was used to identify studies testing CBPR interventions to improve diabetes outcomes, including A1C, fasting glucose, blood pressure, lipids, and quality of life. Pubmed, PsychInfo, and CINAHL were searched for articles published between 2010 and 2020. Using a CBPR continuum framework, studies were classified based on outreach, consulting, involving, collaborating, and shared leadership.

Results: A total of 172 were screened, and a title search was conducted to determine eligibility. A total of 16 articles were included for synthesis. Twelve out of the 16 studies using CBPR approaches for diabetes interventions demonstrated statistically significant differences in 1 or more diabetes outcomes measured at a postintervention time point. Studies across the spectrum of CBPR demonstrated statistically significant improvements in diabetes outcomes.

Conclusions: Of the 16 studies included for synthesis, 14 demonstrated statistically significant changes in A1C, fasting glucose, blood pressure, lipids, and quality of life. The majority of studies used community health workers (CHWs) to deliver interventions across group and individual settings and demonstrated significant reductions in diabetes outcomes. The evidence summarized in this review shows the pivotal role that CHWs and diabetes care and education specialists play in not only intervention delivery but also in the development of outward-facing diabetes care approaches that are person- and community-centered.
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http://dx.doi.org/10.1177/0145721720962969DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901040PMC
December 2020

Use of a healthy volunteer imaging program to optimize clinical implementation of stereotactic MR-guided adaptive radiotherapy.

Tech Innov Patient Support Radiat Oncol 2020 Dec 29;16:70-76. Epub 2020 Nov 29.

Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA.

Purpose: MR-linacs (MRLs) have enabled the use of stereotactic magnetic resonance (MR) guided online adaptive radiotherapy (SMART) across many cancers. As data emerges to support SMART, uncertainty remains regarding optimal technical parameters, such as optimal patient positioning, immobilization, image quality, and contouring protocols. Prior to clinical implementation of SMART, we conducted a prospective study in healthy volunteers (HVs) to determine optimal technical parameters and to develop and practice a multidisciplinary SMART workflow.

Methods: HVs 18 years or older were eligible to participate in this IRB-approved study. Using a 0.35 T MRL, simulated adaptive treatments were performed by a multi-disciplinary treatment team in HVs. For each scan, image quality parameters were assessed on a 5-point scale (5 = extremely high, 1 = extremely poor). Adaptive recontouring times were compared between HVs and subsequent clinical cases with a -test.

Results: 18 simulated treatments were performed in HVs on MRL. Mean parameters for visibility of target, visibility of nearby organs, and overall image quality were 4.58, 4.62, and 4.62, respectively (range of 4-5 for all measures). In HVs, mean ART was 15.7 min (range 4-35), comparable to mean of 16.1 (range 7-33) in the clinical cases (p = 0.8963). Using HV cases, optimal simulation and contouring guidelines were developed across a range of disease sites and have since been implemented clinically.

Conclusions: Prior to clinical implementation of SMART, scans of HVs on an MRL resulted in acceptable image quality and target visibility across a range of organs with similar ARTs to clinical SMART. We continue to utilize HV scans prior to clinical implementation of SMART in new disease sites and to further optimize target tracking and immobilization. Further study is needed to determine the optimal duration of HV scanning prior to clinical implementation.
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http://dx.doi.org/10.1016/j.tipsro.2020.10.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7710639PMC
December 2020

A Scoping Review of the Relationship between Running and Mental Health.

Int J Environ Res Public Health 2020 11 1;17(21). Epub 2020 Nov 1.

Physical Activity for Health Research Centre (PAHRC), University of Edinburgh, Edinburgh EH8 8AQ, UK.

Poor mental health contributes significantly to global morbidity. The evidence regarding physical benefits of running are well-established. However, the mental health impacts of running remain unclear. An overview of the relationship between running and mental health has not been published in the last 30 years. The purpose of this study was to review the literature on the relationship between running and mental health. Our scoping review used combinations of running terms (e.g., Run* and Jog*) and mental health terms (general and condition specific). Databases used were Ovid(Medline), Ovid(Embase), ProQuest and SportDiscus. Quantitative study types reporting on the relationships between running and mental health were included. Database searches identified 16,401 studies; 273 full-texts were analysed with 116 studies included. Overall, studies suggest that running bouts of variable lengths and intensities, and running interventions can improve mood and mental health and that the type of running can lead to differential effects. However, lack of controls and diversity in participant demographics are limitations that need to be addressed. Cross-sectional evidence shows not only a range of associations with mental health but also some associations with adverse mental health (such as exercise addiction). This review identified extensive literature on the relationship between running and mental health.
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http://dx.doi.org/10.3390/ijerph17218059DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7663387PMC
November 2020

Genetics for paediatric radiologists.

Pediatr Radiol 2020 11 2;50(12):1680-1690. Epub 2020 Nov 2.

Yorkshire Regional Genetics Service, Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust, Chapeltown Rd., Leeds, LS7 4SA, UK.

An understanding of genetics and genomics is increasingly important for all clinicians. Next-generation genomic sequencing technologies enable sequencing of the entire human genome in short timescales, and are increasingly being implemented in health care systems. Clinicians across all medical specialties will increasingly use results generated from genomic testing to inform their clinical practice and provide the best quality of care for patients. These innovations are already transforming the diagnostic pathways for rare genetic diseases, including skeletal dysplasias, with an inevitable impact on the traditional roles of diagnosticians. This article covers the fundamentals of human genetics, mechanisms of genetic variation and the technologies used to investigate the genetic basis of disease, with a specific focus on skeletal dysplasias and the potential impact of genomics on paediatric radiology.
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http://dx.doi.org/10.1007/s00247-020-04837-4DOI Listing
November 2020

Increasing browse and social complexity can improve zoo elephant welfare.

Zoo Biol 2021 Jan 11;40(1):9-19. Epub 2020 Oct 11.

Department of Conservation, Science, and Education, North Carolina Zoo, Asheboro, North Carolina, USA.

While recent work has assessed how environmental and managerial changes influence elephant welfare across multiple zoos, few studies have addressed the effects of management changes within a single institution. In this paper, we examine how management changes related to social structure and diet affect the behavior of a group of zoo elephants over a 23-month period while also considering underlying factors, such as time of day, hormonal cycle, and individual differences. We recorded individual behaviors using 2-min scan samples during 60-min sessions. We analyzed behavioral changes across several study variables using generalized linear mixed models. We found that increasing browse can improve opportunities for foraging throughout the day but may not be sufficient to reduce repetitive behaviors. We observed that increasing group size and integration of bulls with cows can lead to increased social interaction in African elephants. Our results highlight the importance of using multiple management alterations to address elephant welfare, and considering environmental factors, when making management decisions.
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http://dx.doi.org/10.1002/zoo.21575DOI Listing
January 2021

A New Paradigm for Addressing Health Disparities in Inner-City Environments: Adopting a Disaster Zone Approach.

J Racial Ethn Health Disparities 2021 Jun 12;8(3):690-697. Epub 2020 Aug 12.

Medical University of South Carolina, 171 Ashley Ave, Charleston, SC, 29425, USA.

Inner cities are characterized by intergenerational poverty, limited educational opportunities, poor health, and high levels of segregation. Human capital, defined as the intangible, yet integral economically productive aspects of individuals, is limited by factors influencing inner-city populations. Inner-city environments are consistent with definitions of disasters causing a level of suffering that exceeds the capacity of the affected community. This article presents a framework for improving health among inner-city populations using a multidisciplinary approach drawn from medicine, economics, and disaster response. Results from focus groups and photovoice conducted in Milwaukee, WI are used as a case study for a perspective on using this approach to address health disparities. A disaster approach provides a long-term focus on improving overall health and decreasing health disparities in the inner city, instead of a short-term focus on immediate relief of a single symptom. Adopting a disaster approach to inner-city environments is an innovative way to address the needs of those living in some of the most marginalized communities in the country.
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http://dx.doi.org/10.1007/s40615-020-00828-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7878568PMC
June 2021

Association Between Dissatisfaction With Care and Diabetes Self-Care Behaviors, Glycemic Management, and Quality of Life of Adults With Type 2 Diabetes Mellitus.

Diabetes Educ 2020 08;46(4):370-377

Department of Medicine, Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.

Purpose: The purpose of the study was to examine the associations between patient dissatisfaction and diabetes outcomes among patients with type 2 diabetes.

Methods: Primary data from 615 adults with type 2 diabetes from 2 adult primary care clinics completed validated questionnaires. Patient dissatisfaction was measured by asking participants to what degree over the past 12 months were they very dissatisfied with the care they received from their primary care provider. Diabetes outcomes included self-care behaviors, quality of life, and A1C. A1C was abstracted from the medical record. Multiple linear regression models were used to assess associations between patient dissatisfaction, self-care, blood glucose, and quality of life.

Results: After adjusting for covariates, this study demonstrated that higher patient dissatisfaction was significantly associated with poor general diet, worse blood glucose levels, and lower mental component score for quality of life.

Conclusions: In patients with type 2 diabetes, patient dissatisfaction had a significant association with higher blood glucose levels, poor general diet, and low quality of life. Demographic factors driving patient dissatisfaction included young age, low income, and low health literacy. Future studies should investigate how to address patient satisfaction in an effort to improve health outcomes.
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http://dx.doi.org/10.1177/0145721720922953DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7556702PMC
August 2020

Adverse Childhood Experiences and Decreased Renal Function: Impact on All-Cause Mortality in U.S. Adults.

Am J Prev Med 2020 08;59(2):e49-e57

Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of General Internal Medicine, Department of Medicine, The Medical College of Wisconsin, Milwaukee, Wisconsin.

Introduction: Evidence suggests that individuals with a history of adverse childhood experiences have higher odds of developing kidney disease than individuals with no adverse childhood experiences. However, no study has examined the influence of coexisting adverse childhood experiences and kidney disease on mortality risk. This study uses a longitudinal survey of adults to examine the influence of coexisting adverse childhood experiences and decreased renal function on all-cause mortality in a sample of U.S. adults.

Methods: A total of 1,205 adults participating in the Midlife Development in the United States series between 1995 and 2014 were used for this analysis performed in 2019. A total of 6 types of adverse childhood experiences were available in the data set, which were combined to create a dichotomous variable with any adverse experience counted as yes. Decreased renal function was defined as an estimated glomerular filtration rate <60 milliliter/minute/1.73 m. The main outcome was all-cause mortality. Cox proportional hazards models were performed to examine 4 combinations of adverse childhood experiences and decreased renal function associated with overall survival (neither, adverse childhood experiences only, decreased renal function only, or both) controlling for covariables.

Results: In fully adjusted models, adverse childhood experiences and decreased renal function were associated with increased all-cause mortality relative to neither (hazard ratio=2.85, 95% CI=1.30, 6.25). Decreased renal function only and adverse childhood experiences only were not significantly associated with all-cause mortality (hazard ratio=1.14, 95% CI=0.64, 2.04 and hazard ratio=1.55, 95% CI=0.44, 5.41, respectively). When using decreased renal function as the reference group, coexisting adverse childhood experiences and decreased renal function was associated with a 64% increased risk of all-cause mortality, though this relationship was not statistically significant.

Conclusions: Coexistence of adverse childhood experiences and decreased renal function is associated with higher all-cause mortality than seen in individuals with neither adverse childhood experiences nor decreased renal function and may be associated with higher all-cause mortality than seen in individuals with decreased renal function alone. Future research is needed to better understand this potential association.
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http://dx.doi.org/10.1016/j.amepre.2020.04.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7378887PMC
August 2020

Telehealth and indigenous populations around the world: a systematic review on current modalities for physical and mental health.

Mhealth 2020 5;6:30. Epub 2020 Jul 5.

Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.

Approximately 370-500 million Indigenous people live worldwide. While Indigenous peoples make up only 5% of the world's population, they account for 15% of the extreme poor and have life expectancy that is 20 years shorter than that of non-Indigenous people. Access to healthcare has been identified as an important social determinant of health and key driver of health outcomes. Indigenous populations often face barriers to accessing healthcare including living in remote areas, lacking financial resources, and having cultural differences. Telehealth, the utililzation of any synchronous modality, including phone, video, or teleconferencing technology used to support the provision of long-distance health care and health education, is a feasible and cost-effective treatment delivery mechanism that has successfully addressed access barriers faced by vulnerable populations globally, however, few studies have included indigenous populations and the application of this technology to improve physical and mental health outcomes. This systematic review aims to identify trials that were conducted among Indigenous adults, and to summarize the components of interventions that have been found to effectively improve the health of Indigenous peoples. The PRISMA guidelines for reporting of systematic reviews were followed in preparing this manuscript. Studies were identified by searching PubMed, Scopus, and PsychInfo databases for clinical trial articles on Indigenous peoples and mental and physical health, published between January 1, 1998 and December 31, 2018. Eligibility criteria for determining studies to include in the analysis were as follows: (I) ≥18 years of age; (II) indigenous peoples; (III) any technology-based intervention; (IV) studies included at least one of the following mental health (depression, post-traumatic stress disorder, suicide) and physical health (mortality, blood pressure, hemoglobin A1C, cholesterol, quality of life) outcomes; (V) clinical trials. A total of 2,662 articles were identified and six were included in the final review based on pre-specified eligibility criteria. Three were conducted in the United States, one study was conducted in Canada, and two were conducted in New Zealand. Study sample sizes ranged from 20 to 762, intervention delivery times ranged from three to 20 months and utilized telephone, internet and SMS messaging as the type of technology. There is a paucity of evidence on the use of telehealth programs to increase access to chronic disease programs in Indigenous populations. This review highlights the importance of culturally tailoring programs despite the modality in which they are delivered, and recommends telephone-based delivery facilitated by a trained health professional. Telehealth has great promise for meeting the health needs of highly marginalized Indigenous populations around the world, however, at this point more research is needed to understand how best to structure and deliver these programs for maximum effect.
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http://dx.doi.org/10.21037/mhealth.2019.12.03DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7327286PMC
July 2020

Relative Contribution of Individual, Community, and Health System Factors on Glycemic Control Among Inner-City African Americans with Type 2 Diabetes.

J Racial Ethn Health Disparities 2021 Apr 25;8(2):402-414. Epub 2020 Jun 25.

Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, 53226, USA.

Background: Health disparities disproportionately impact inner-city African Americans; however, limited information exists on the contribution of individual, community, and health system barriers on diabetes outcomes in this population.

Methods: A cross-sectional study collected primary data from 241 inner-city African Americans with type 2 diabetes. A conceptual framework was used to specify measurements across the individual level, such as age and comorbidities; community level, such as neighborhood factors and support; and health system level such as access, trust, and provider communication. Based on current best practices, four regression approaches were used: sequential, stepwise with forward selection, stepwise with backward selection, and all possible subsets. Variables were entered in blocks based on the theoretical framework in the order of individual, community, and health system factors and regressed against HbA1c.

Results: In the final adjusted model across all four approaches, individual-level factors like age (β = - 0.05; p < 0.001); having 1-3 comorbidities (β = - 2.03; p < 0.05), and having 4-9 comorbidities (β = - 2.49; p = 0.001) were associated with poorer glycemic control. Similarly, male sex (β = 0.58; p < 0.05), being married (β = 1.16; p = 0.001), and being overweight/obese (β = 1.25; p < 0.01) were associated with better glycemic control. Community and health system-level factors were not significantly associated with glycemic control.

Conclusion: Individual-level factors are key drivers of glycemic control among inner-city African Americans. These factors should be the key targets for interventions to improve glycemic control in this population. However, community and health system factors may have indirect pathways to glycemic control that should be examined in future studies.
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http://dx.doi.org/10.1007/s40615-020-00795-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7759592PMC
April 2021

High acceptability and viral suppression of patients on Dolutegravir-based first-line regimens in pilot sites in Uganda: A mixed-methods prospective cohort study.

PLoS One 2020 27;15(5):e0232419. Epub 2020 May 27.

Ministry of Health, Kampala, Uganda.

Uganda adopted the integrase inhibitor dolutegravir (DTG) as part its preferred first-line HIV treatment regimen in 2018. Prior to the national rollout, the Uganda Ministry of Health and Clinton Health Access Initiative (CHAI) launched a pilot study in July 2017 aimed at better understanding patients' and prescribers' experience and acceptability of DTG. Patients were enrolled in the study if they were newly initiating treatment or switched from an NNRTI regimen due to intolerance. Patients were followed up for 6 months after initiation onto DTG and acceptability and experiences were assessed through questionnaires at one-month and six-month follow-up visits. In addition to acceptability side effects of patients on DTG regimens were assessed. Analysis was conducted using MS Excel and SAS 9.4 and confidence intervals were adjusted for facility level clustering. A total of 365 patients from 6 study sites were enrolled in the study, of whom 50% were treatment-experienced and 50% treatment naïve. 325 patients completed the 6 months of follow-up. Survey results showed a high level of acceptability (more than 90%) of DTG-containing regimens for both categories of patients during the from one-month and six-months interviews. The rate of self-reported side effects amongst patients was 33% overall and higher for experienced (37%) than naïve (29%) patients at 6 months. Although frequencies declined between month-1 and month-6, the changes were not statistically significant. Almost all patients (94%) were virally suppressed at 6 months. Overall, the study findings showed a very high level of acceptability of Dolutegravir-based regimens across both experienced and naïve patients. The overall viral suppression rate in this cohort was 94% at six months of taking DTG-based regimen.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0232419PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7252626PMC
July 2020

Genomic Epidemiology of Invasive Methicillin-Resistant Staphylococcus aureus Infections Among Hospitalized Individuals in Ontario, Canada.

J Infect Dis 2020 11;222(12):2071-2081

Public Health Ontario, Toronto Laboratory, Toronto, Ontario, Canada.

Background: Prevention and control of methicillin-resistant Staphylococcus aureus (MRSA) infections remain challenging. In-depth surveillance integrating patient and isolate data can provide evidence to better inform infection control and public health practice.

Methods: We analyzed MRSA cases diagnosed in 2010 (n = 212) and 2016 (n = 214) by hospitals in Ontario, Canada. Case-level clinical and demographic data were integrated with isolate characteristics, including antimicrobial resistance (AMR), classic genotyping, and whole-genome sequencing results.

Results: Community-associated MRSA (epidemiologically defined) increased significantly from 23.6% in 2010 to 43.0% in 2016 (P < .001). The MRSA population structure changed over time, with a 1.5× increase in clonal complex (CC)8 strains and a concomitant decrease in CC5. The clonal shift was reflected in AMR patterns, with a decrease in erythromycin (86.7% to 78.4%, P = .036) and clindamycin resistance (84.3% to 47.9%, P < .001) and a >2-fold increase in fusidic acid resistance (9.0% to 22.5%, P < .001). Isolates within both CC5 and CC8 were relatively genetically diverse. We identified 6 small genomic clusters-3 potentially related to transmission in healthcare settings.

Conclusions: Community-associated MRSA is increasing among hospitalized individuals in Ontario. Clonal shifting from CC5 to CC8 has impacted AMR. We identified a relatively high genetic diversity and limited genomic clustering within these dominant CCs.
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http://dx.doi.org/10.1093/infdis/jiaa147DOI Listing
November 2020

Seronegative Coeliac Disease Masquerading as Irritable Bowel Syndrome type Symptoms.

J Gastrointestin Liver Dis 2020 Mar 13;29(1):111-113. Epub 2020 Mar 13.

Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom.

Coeliac disease affects 1% of the population but internationally delays in diagnosis are frequent. A relationship between irritable bowel syndrome type symptoms and coeliac disease is well established and most IBS guidelines recommend that patients presenting with IBS type symptoms should be tested serologically for coeliac disease. Seronegative coeliac disease accounts for 3-5% of all cases of coeliac disease and it is a diagnostic challenge which requires a high level of clinical suspicion and consideration of duodenal biopsies prior to confidently excluding this diagnosis. We report the first case of seronegative coeliac disease masquerading as IBS type symptoms. We suggest that if patients have evidence of haematinic deficiency, subsequent weight loss, features of malabsorption or a family history of coeliac disease, then a duodenal biopsy should be considered irrespective of negative serology.
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http://dx.doi.org/10.15403/jgld-718DOI Listing
March 2020

Relationship Between Multiple Measures of Financial Hardship and Glycemic Control in Older Adults With Diabetes.

J Appl Gerontol 2021 Feb 13;40(2):162-169. Epub 2020 Mar 13.

Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, USA.

To examine the relationship between multiple measures of financial hardship and glycemic control in older adults with diabetes. Using data from Health and Retirement Study (HRS), we investigated four measures of financial hardship: difficulty paying bills, ongoing financial strain, decreasing food intake due to money, and taking less medication due to cost. Using linear regression models, we investigated the relationship between each measure, and a cumulative score of hardships per person, on glycemic control (HbA1c). After adjustment, a significant relationship existed with each increasing number of hardships associated with increasing HbA1c (0.09, [95%CI 0.04, 0.14]). Difficulty paying bills (0.25, [95%CI 0.14, 0.35]) and decreased medication usage due to cost (0.17, [95%CI 0.03, 0.31]) remained significantly associated with HbA1c. In older adults, difficulty paying bills and cost-related medication nonadherence is associated with glycemic control, and every additional financial hardship was associated with an increased HbA1c by nearly 0.1%.
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http://dx.doi.org/10.1177/0733464820911545DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7487017PMC
February 2021

Secondary syphilis with atypical rash and hemoptysis in a man with HIV co-infection.

CMAJ 2019 Dec;191(50):E1383

Department of Internal Medicine (Richert, Keynan), Max Rady College of Medicine, University of Manitoba; Nine Circles Community Health Centre (Campbell); Manitoba HIV Program (Campbell, Keynan); Section of Medical Microbiology and Infectious Diseases (Keynan), Max Rady College of Medicine, University of Manitoba, Winnipeg, Man.

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http://dx.doi.org/10.1503/cmaj.190495DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7015446PMC
December 2019

Individual-, Community-, and Health System-Level Barriers to Optimal Type 2 Diabetes Care for Inner-City African Americans: An Integrative Review and Model Development.

Diabetes Educ 2020 02 5;46(1):11-27. Epub 2019 Dec 5.

Medical College of Wisconsin, Department of Medicine, Division of General Internal Medicine, Center for Advancing Population Science, Milwaukee, Wisconsin.

Purpose: The purpose of this integrative review is (1) to elucidate the unique barriers faced by inner-city African Americans for type 2 diabetes (T2DM) care; (2) to identify effective interventions/programs for optimal T2DM care at the individual, community, and health systems levels; and (3) to integrate 2 behavioral models and 1 social ecological model for framing interventions for inner-city African American to optimize T2DM care.

Methods: PRISMA guidelines were followed to systematically search PubMed, PsychInfo, and CINAHL. Integration of models was based on underlying principles of social ecological models.

Results: The search returned 1183 articles. Forty-six articles were synthesized after applying inclusion criteria. Multiple barriers for the individual level, community level, and health system level were identified. Major barriers include lack of knowledge, lack of social support, and self-management support. Interventions identified in this review show that among inner-city African Americans with T2DM, the focus is placed at the health systems level, with very limited focus toward addressing individual- and community-level barriers. Final synthesis includes development of a new integrated model that explains barriers to care across multiple levels.

Conclusions: These findings highlight the fragmentation that may be occurring between policy, research, and practice for achieving health equity and addressing health disparities for T2DM care among inner-city African Americans. The new model is an important step in the pursuit of equity in T2DM by specifying the complex barriers that occur across multiple levels. The application of this model using the 2017 National Standards for Diabetes-Self Management Education and Support are discussed.
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http://dx.doi.org/10.1177/0145721719889338DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7853305PMC
February 2020

Differential Impact of Food Insecurity, Distress, and Stress on Self-care Behaviors and Glycemic Control Using Path Analysis.

J Gen Intern Med 2019 12 16;34(12):2779-2785. Epub 2019 Oct 16.

Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, 53226-3596, USA.

Background: The aim of this study was to investigate the direct and indirect pathways through which food insecurity influences glycemic control and self-care behaviors.

Methods: Using data collected from 615 adults with type 2 diabetes, we investigated pathways between food insecurity and diabetes outcomes using path analysis. We included measures of perceived stress, diabetes distress, diabetes fatalism, and depression as psychosocial factors in the pathway. Self-care behaviors included general diet, specific diet, exercise, blood sugar testing, foot care, and medication adherence. Analyses were conducted using Stata v14, to include both direct and indirect effects, with standardized estimates to allow comparison of paths.

Results: Food insecurity was directly associated with stress (r = 0.43, p < 0.001), depression (r = 0.34, p < 0.001), fatalism (r = 0.09, p = 0.03), and distress (r = 0.36, p < 0.001). The type of stress, however, was differentially associated with outcomes, with distress associated with HbA1c (r = 0.25, p < 0.001), general and specific diet (r = - 0.28 and - 0.17, respectively, p = 0.001), and medication adherence (r = - 0.26, p < 0.001), while stress was associated with specific diet (r = - 0.14, p = 0.005) and medication adherence (r = - 0.15, p < 0.001) and depression was associated with exercise (r = - 0.06, p = 0.007). Food insecurity was indirectly associated with HbA1c (r = 0.08, p = 0.001), and four self-care behaviors (general diet, specific diet, exercise, and medication adherence).

Conclusions: Food insecurity influences self-care behaviors indirectly via multiple psychosocial factors, and glycemic control indirectly through diabetes distress, supporting the hypothesis that stress is an important mechanism. Programs to improve access to resources and manage psychosocial concerns should be combined with food-based programs for food insecure populations with diabetes.
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http://dx.doi.org/10.1007/s11606-019-05427-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6854195PMC
December 2019