Formal Diagnosis Research Articles

Socioeconomic and behavioral determinants of non-compliance with physician referrals following community screening for diabetes, hypertension and hyperlipidemia: a mixed-methods study

Early detection of undiagnosed diabetes, hypertension or hyperlipidemia through screening could reduce healthcare costs resulting from disease complications. To date, despite ample research on the factors linked to the uptake of community health screening programs, little attention has been directed at delayed or incomplete follow-up after positive outcomes are identified in community screening tests. This study aimed to investigate the socioeconomic and behavioral factors that influence non-compliance with recommendations for primary care physician referrals, following community-based screening for diabetes, hypertension and hyperlipidemia. A parallel mixed-methods study was conducted. For quantitative data, we performed multivariable analysis on community-based chronic disease screening data. The qualitative component involved semi-structured interviews with individuals with both non-compliance and compliance with referral recommendations. Thematic data analysis was undertaken using the Theoretical Domains Framework (TDF). The quantitative analysis showed that older age (OR = 0.92, 95%CI [0.89–0.96]), non-Chinese ethnicity (OR = 0.24; 95% CI [0.08–0.44]) and residing in 5-room public/ private housing (OR = 0.40; 95% CI [0.14–0.74]) were associated with lower odds of non-compliance with referral recommendations. Thematic analysis identified multiple behavioral-level determinants acting as enablers or barriers within 7 TDF domains: awareness of health risks after receiving screening results, self-management orientation and behavioral control, fear of formal diagnosis and concerns about healthcare cost, optimistic belief driven by the lack of symptoms, interpersonal relationship and social obligations, aversion to medication, communication at the result collection and sense of uncertainty regarding self-scheduling of appointment. Findings provide valuable implications for the development of interventions aimed at improving adherence to referral recommendation. Future endeavors should include culturally sensitive outreach, evidence-based information dissemination, family-centered education, positive public health messaging, brief counseling during result collection and an opt-out appointment system to enhance follow-up care.

A multi-dimensional assessment of financial hardship of cancer patients using existing health system data.

Existing financial hardship screening does not capture the multifaceted and dynamic nature of the problem. The use of existing health system data is a promising way to enable scalable and sustainable financial hardship screening. We used existing data from 303 adult patients with cancer at the University of Virginia Comprehensive Cancer Center (2016-2018). All received distress screening and had a valid financial assistance screening based solely on household size-adjusted income. We constructed a composite index that integrates multiple existing health system data (Epic, distress screening, and cancer registry) to assess comprehensive financial hardship (e.g., material conditions, psychological responses, and coping behaviors). We examined differences of at-risk patients identified by our composite index and by existing single-dimension criterion. Dynamics of financial hardship over time, by age, and cancer type, were examined by fractional probit models. At-risk patients identified by the composite index were generally younger, better educated, and had a higher annual household income, though they had lower health insurance coverage. Identified periods to intervene for most patients are before formal diagnosis, 2 years, and 6 years after diagnosis. Within 2 years of diagnosis and more than 4 years after diagnosis appear critical for subgroups of patients who may suffer from financial hardship disparities. Existing health system data provides opportunities to systematically measure and track financial hardship in a systematic, scalable and sustainable way. We find that the dimensions of financial hardship can exhibit different patterns over time and across patient subgroups, which can guide targeted interventions. The scalability of the algorithm is limited by existing data availability.

Neurodevelopmental Outcomes of Children Born to Women Who Traveled to a Zika Virus-Endemic Region During Pregnancy

Abstract Background Zika virus (ZIKV) exposure during pregnancy causes a wide range of congenital malformations and developmental deficits, but we do not know whether potential ZIKV exposure during pregnancy without a formal ZIKV diagnosis results in worse developmental outcomes. Pregnant women without symptoms are not recommended to be tested for ZIKV infection per CDC guidelines. However, ZIKV infections can be asymptomatic, which means that pregnant women may have unknowingly been infected with ZIKV during travel to an endemic region. Our study aims to determine whether neurodevelopmental outcomes of children born to women with a travel history to a ZIKV-endemic region at the height of the pandemic are worse than children without a maternal travel history. Methods We identified women who presented to a maternal-fetal medicine clinic within the University of Wisconsin Hospitals and Clinics system in Madison, WI, between 2015-2018 and recently traveled to a ZIKV-endemic region (n=175) and conducted a retrospective chart review. Children with no maternal travel history to a ZIKV-endemic region were identified by state registry data and matched based on month of birth and gestational age (n=189). Developmental outcomes were defined from regular screening tools obtained during well child visits, the Ages and Stages Questionnaire (ASQ-3), and the Modified Checklist for Autism in Toddlers (MCHAT). We compared the number of “No Concern”, “Borderline” and “Concern” ASQ scores between groups using a generalized linear mixed effects model with a logit link function. The number of Low, Medium or High MCHAT risk scores at 18 and 24 months were compared between groups using Fisher’s exact test. Birth weight, maternal age and maternal race were included as covariates. All reported p-values are two-sided and P<0.05 was used to define statistical significance. Results Cases had a significantly higher rate (13.9%) of borderline/concern scores in the ASQ screening tool compared to controls (7.7%) at 16-22 months (p=0.0288), which appeared to be driven by differences in the personal-social domain where more cases (16.1%) had borderline/concern scores than the controls (5.5%, p=0.0348). There were no differences seen at 9-15 months or at 23-36 months. We also found that cases had higher rates of moderate-high risk scores (10.3%) on the MCHAT compared to controls (2.2%) at 18 months (p=0.0240), but this difference wasn’t statistically significant at 24 months. There were no differences in birth weight, maternal age and gestational age between groups. Very few of the mothers (18.3%) reported 1 or more signs or symptoms consistent with a ZIKV infection, and of the 105 women with ZIKV testing, 103 were negative. Conclusions Our findings indicate that children born to mothers who traveled to a ZIKV-endemic region during pregnancy, regardless of the maternal ZIKV testing result, had worse developmental screening scores around 18 months of age. This suggests that children with maternal travel history to a ZIKA-endemic region should be regularly monitored and receive early formal developmental testing as needed.

German longitudinal prescription database (LRx): Description ofcharacteristics, use in pharmacoepidemiological research, and limitations .

Large databases have played a critical role in pharmacoepidemiological research in the last decade, with this role likely to gain further importance in the future. The aim of the present paper is to describe the characteristics, the recent use, and the limitations of the German longitudinal prescription (LRx) database. The LRx database contains patient-level data on prescriptions collected in retail pharmacies, corresponding to ~80% of prescriptions reimbursed by statutory health insurance funds in Germany. The LRx database includes a higher proportion of older adults and women compared to the overall German population with statutory health insurance. Coverage per family of drugs ranges from 71.8% for antiepileptics to 94.7% for urological agents. Multiple pharmacoepidemiological studies based on the data from the German LRx database have been published in the last years on topics such as patterns of prescription and treatment adherence and persistence. A large number of disorders have been investigated in this research (e.g., type 2 diabetes, inflammatory diseases, and psychiatric conditions). The major limitations of the LRx database are the lack of formal diagnoses and the absence of hospital data. In conclusion, the German LRx database could be a key source of data for future pharmacoepidemiological studies.

Explore the potential triggers to binge eating episode

Apart from the manifestation within the eating disorder framework, binge eating is also considered as a maladaptive eating behaviour that can occur to individuals without a formal diagnosis of eating disorder. By reviewing recent empirical literatures, negative emotions, body-image, perfectionism, and dieting seem to emerge as primary triggers to binge eating episode. Specially, negative emotions have been extensively discussed and believed to play a pivotal role in triggering the onset of binge eating. Body image and the trait perfectionism tend to be interrelated and mutually reinforced, increasing the risk for binge eating. Lastly, the effect of dieting seems to be relatively ambiguous, as it has been shown to be confounded by multiple factors, indicative of an indirect effect on binge eating. Although limitations were acknowledged, the findings of the present study still provided a comprehensive insight into the potential triggers to binge eating among the subgroup of people without eating disorders.

Development of a Novel Method of Assessing Potential Loss of Control in Internet Gaming Disorder.

As video game play has increased in popularity, so too have reports that a subset of individuals play games in a way that causes negative consequences to their lives, which has resulted in the proposed inclusion of Internet Gaming Disorder (IGD) as a formal mental health diagnosis. Given the mass popularity of video games, it is critical that screening materials for this proposed disorder are sufficiently sensitive to ensure that individuals who suffer harm are identified, while those who do not are not mislabeled as such. Here we examined the extent to which participants' responses to a typical IGD questionnaire predicted academic behaviors that could be associated with harm. We recruited 42 college students and tracked their gaming and studying habits weekly over the course of one semester, taking particular note of weeks in which participants did or did not have exams. We predicted that college students overall would spend less time engaging with video games and more time with academics when they had exams, but such modulations would be smaller among individuals with more initial IGD symptoms (i.e., the "more IGD symptoms" group, as compared to the "fewer IGD symptoms" group, would show loss of control). We did not find that college students overall spent less time engaging with video games and more time with academics when they had exams, but post-hoc effect size analyses indicated that our study was underpowered. Implications of potential results using this methodology are discussed and estimates of powerful sample sizes are provided.

Correlation between Peripheral Blood and Bone Marrow Somatic Mutations Among Patients with Suspected or Established Myelodysplastic Syndromes from the National MDS Study

INTRODUCTION: Myelodysplastic Syndromes (MDS) are caused by progressive clonal dominance of mutated hematopoietic stem cells. While assessment of mutations in peripheral blood (PB) is an established standard for monitoring patients with some diseases such as chronic myeloid leukemia, the sensitivity and precision of PB screening and monitoring for somatic mutations in patients with MDS and related conditions such as clonal cytopenias of undetermined significance (CCUS) is less certain. Multiple published guidelines require bone marrow (BM) evaluations for the above, an invasive procedure not often performed outside of clinical trials. We compared somatic mutations and variant allele frequencies (VAFs) in paired PB and BM samples to assess the utility of PB results as a surrogate for diagnosis and monitoring. METHODS: The National MDS Natural History Study (National MDS Study) is an observational longitudinal cohort study of cytopenic patients suspected of having a diagnosis of MDS. All patients have PB and BM sampled when entering the study, prior to formal diagnosis. For this study, paired PB and BM baseline DNA samples from 36 patients were assessed for somatic mutations. Only subjects with minimum of one variant detected in their BM were included in this study. DNA was extracted from PB using an automated FlexSTAR (AutoGen) and from BM cell pellets using a QIAamp DNA Mini Kit (QIAGEN). Targeted exon sequencing of 96 genes was performed using a NovaSeq 6000 at a mean coverage of >1,200X and a mean breadth (bases covered at ≥100X) of >99.9%. Reads were aligned against a patched version of the build GRCh38 using BWA-MEM. VarScan2 was used to detect single nucleotide variants and short insertions/deletions with a minimum VAF of 2% and 5%, respectively. Resulting variants from 53 genes were manually reviewed to retain likely disease-causing variants. Correlation analysis between PB and BM VAFs was performed using Pearson correlation and linear regression. To confirm paired samples were sourced from the same subject, the Somalier software using a set of highly polymorphic SNPs across different ancestries was utilized to ensure a high level of relatedness. RESULTS: The 36 patients included 10 (28%) with MDS, 2 (6%) with MDS/MPN, 1 (3%) with AML (<30% blasts), and 23 (64%) with CCUS. The median age was 73 years (Table 1). Five of 36 patients had circulating PB blasts. Among the 191 mutations identified, the most common were TET2 (27%), SRSF2 (13%), DNMT3A (9%), SF3B1 (8%), and ASXL1 (8%). Correlation analysis of mutations (n=180) shared between paired PB and BM samples indicated a linear relationship between VAFs detected in PB and BM (Pearson correlation r=0.95, Figure 1), with a slight increase in variance observed with increasing VAFs. The deviation from the perfect (grey line) to the observed (yellow line) linear fit indicated that PB VAFs underestimated VAFs in BM by approximately 23% overall (Figure 1). For example, a BM VAF of 0.20 translated to a mean PB VAF of 0.16 based on the regression fit. The lower sensitivity was confirmed when looking at the number of total missed variants (present in BM, absent in PB): 9 of 101 (9%). Two mutations were detected in PB, but not BM. These mutations and diagnoses were 1) ETNK1 (VAF 0.026) in a patient with MDS-EB-1; and 2) CBL (VAF 0.021) in a patient with MDS with isolated del5q. Next, we assessed the relationship between percent of detected mutations and minimum VAF that was detected using linear regression and found that the higher the minimum VAF, the lower the percent of missed mutations. For example, for a 0.1, 0.2, and 0.3 minimum VAF, 11%, 9%, and 8% of BM mutations were missed, respectively. There was no difference in concordance between MDS and CCUS. SUMMARY & CONCLUSIONS: PB can be used to reliably identify somatic mutations in patients with suspected or established MDS and related conditions. Linear correlation between PB and BM VAFs showed, unsurprisingly, that BM mutations with higher VAFs are more likely to be detected. If PB is positive, this method of variant detection may be used potentially to diagnose and monitor. However, if negative (or if VAF is less than 0.10), bone marrow genomics are still necessary to exclude detectable clonal mutations. For quantitative predictive tools that use VAFs, PB VAFs would need to be corrected to improve predictive results; our estimated linear regression equation could be used to guide this in a larger prospective study.

81 Autism Symptoms Reported and Observed During Neuropsychological Assessment of Children with Congenital Heart Disorder

Objective:Children with congenital heart disease (CHD) have increased likelihood for Autism Spectrum Disorder (AuSD; Sigmon, Kelleman, Susi, Nylung & Oster, 2020). Even those not meeting full criteria remain at greater risk for problems with social processing/communication (Cassidy et al, 2018). The current study examined what symptoms indicative of potential AuSD were qualitatively reported by parents, and what symptoms were noted behaviorally by clinicians. These behaviors may be targets for both further clinical inquiry and intervention.Participants and Methods:A retrospective chart review of CHD patients seen for neuropsychological assessment between the ages of 6-18 years and between 2016-2021 was conducted. The final sample included 88 patients (Ethnicity: 14% Hispanic; Race: 76% White, 17% Black/African American, 5% Asian, 1% Native American, 1% Unknown). A coding system for AuSD symptoms was derived by the authors, who are experienced in AuSD diagnosis and assessment, based on DSM-5 criteria. A comprehensive list of behaviors consistent with each symptom category was generated, and assessment reports were subsequently reviewed noting the presence, absence or “no mention” of each symptom. A second coding system was derived to assess for AuSD symptoms documented in each report’s behavioral observations. Three pediatric neuropsychologists, one post-doctoral fellow, and one psychometrist were coders, with very good reliability (k=.854 (95% CI, .827 to .881), p < .0001).Results:Twelve patients (14%) were diagnosed with AuSD. Age of diagnosis ranged from 3-14 years (M=7.82, SD=3.92). Main concerns parents expressed included difficulty with reciprocal conversation (75%), making friends (75%), initiating and maintaining social interactions (67%), and restrictive/intense interests (58%). During testing, providers noted variable eye contact (67%), appropriate responses to questions but minimal social conversation (67%), and exaggerated prosody (42%). Of those who did not have an AuSD diagnosis, the most frequent parent concerns included difficulty making friends (38%), difficulty initiating or maintaining social interactions (33%), atypical affect (25%), and restrictive/intense interests (18%). In this sample, providers noted concerns with answering questions but not maintaining conversation (26%), flat affect (16%), loud (17%) or soft (21%) speech volume, and socially immature behaviors (10%). Within this No Diagnosis group, general social concerns were highly correlated (point biserial) with more specific autism symptoms (e.g., intense interests, difficulty with transitions, sensory sensitivities r = .986 - .784), although most often the presence or absence of these concerns were not documented.Conclusions:We examined qualitative parent-reported and provider-observed behaviors indicative of potential AuSD as detailed in a comprehensive neuropsychological evaluation report. Behaviors in children with formal AuSD diagnoses were consistent with that diagnosis, based on both parent and provider description. Of note, in children without AuSD, though, both parents and providers reported AuSD-like concerns (e.g., social communication/interaction problems, atypical interests, atypical affect, atypical speech volume) in a large minority of children. It is important that if general social concerns are present, that providers follow-up on, and document, a broader constellation of AuSD symptoms. These behaviors deserve further exploration and study within the CHD population and are important areas of inquiry in any clinical evaluation, as they should directly inform intervention.

6 The Role of CPAP Treatment on Associations Between Obstructive Sleep Apnea and Cognition Among Black and White Older Adults

Objective:Obstructive sleep apnea (OSA) may be a modifiable risk factor for late-life cognitive impairment. We previously demonstrated that non-Hispanic Black older adults are less likely to be diagnosed with OSA despite having equal or greater health risk for OSA compared to non-Hispanic White older adults, and this disparity in diagnosis was strongest among individuals with lower education. Here, we aimed to determine 1) whether there are racial differences in continuous positive airway pressure (CPAP) treatment, 2) how CPAP treatment may influence OSA-cognition associations, and 3) whether CPAP differentially influences OSA-cognition associations across racial groups.Participants and Methods:Cross-sectional data were obtained from 424 socioeconomically diverse community-dwelling adults ages 55-83 (63.4±3.2 years, 41.7% male, 53.5% Black) from the Michigan Cognitive Aging Project. Physician-diagnosed OSA and current CPAP use were self-reported. Global cognition was operationalized as a composite of five factor scores derived from a comprehensive neuropsychological battery. Racial group differences were investigated with chi-square and Fisher’s exact tests with statistical significance set at the .05 level. Associations between OSA and cognition (adjusted for age, gender, race, and years of education) were investigated with linear regressions. Subsequent models isolated effects of uncontrolled OSA by excluding individuals using CPAP. Racial differences in OSA-cognition associations were investigated with race-stratified models.Results:Fewer Black participants (9.2%) reported diagnosed OSA compared to White participants (12.3%; x2 (1, N=424) =5.314, p=.021, cp=.112). In the whole sample, 47.3% of participants with diagnosed OSA reported CPAP use, and this proportion did not differ across race (x2 [1, N=86] =.048, p=.826). In the whole sample, OSA diagnosis was only associated with cognition when CPAP users were excluded (excluding CPAP users: ß=-.085, SE=.037, p=.024; including CPAP users: ß=-.067, SE=.036, p=.062). In race-stratified models, diagnosed OSA was only associated with cognition among Black participants, and this association was stronger when CPAP users were excluded (excluding CPAP users: ß=-.142, SE=.060, p=.018; including CPAP users: ß=-.126, SE=.058, p=.030). Diagnosed OSA was not associated with cognition among White participants, irrespective of whether CPAP users were included (excluding CPAP users: ß=-.084,SE=.068, p=.215; including CPAP users: ß=-.056, SE=.064, p=.378).Conclusions:Our findings support CPAP treatment as a potential intervention to mitigate late-life cognitive impairment among those with OSA. Despite being less likely to receive a diagnosis of OSA, Black older adults were equally likely to engage in CPAP treatment as White older adults when diagnosed. The detrimental impact of OSA on cognition may be more salient among Black older adults, which may reflect racial disparities in cardiovascular risk and/or resources that promote cognitive reserve. However, CPAP appears to be an effective treatment to reduce OSA-related cognitive impairment for Black older adults, highlighting the critical importance of diagnosis and treatment in this group. Intervention efforts that abate racial inequalities in access to quality healthcare in order to facilitate acquisition of a formal OSA diagnosis and CPAP treatment may help to reduce preventable cognitive health disparities among older adults.

University Student Perspectives Negotiating Positive and Negative Mental Health on Campus

This study explored university students’ perspectives on negotiating and navigating their fluctuating mental health on one specific campus, with particular interest in their experiences of campus-based mental health services. Given the dearth of evidence across paradigms that establishes a concerning prevalence of poor mental health among post-secondary students, this study sought to give voice to students with respect to what changes they felt were most pressing. Seven semi-structured interviews were completed with undergraduate students (second through fourth year) at a mid-sized Canadian institution. Data were analyzed thematically, integrating critical and recovery-oriented social theories. Findings, from the perspective of the students themselves, generated through this process included barriers to help seeking behaviours related to formal services included perceived and actual stigma, lack of confidence in the effectiveness of services, roundabout intake processes, and the perceived need for formal diagnosis as a prerequisite to access. Facilitators to help seeking behaviour related to formal services included quickly developing a positive relationship with a counsellor and access to knowledgeable gatekeepers of mental health services. And finally, informal supports included social support, being meaningfully included and involved in the university environment, recreation, and some forms of substance use.

Autism diagnosis experience and parental stress among Portuguese parents

PurposeThis study aims to examine the impact that diagnostic factors such as duration of diagnostic period, number of professionals consulted and perceived social support have on parental stress during the diagnostic process of autism spectrum disorder (ASD).Design/methodology/approachForty parents of 2–18 year-old children/adolescents with a formal ASD diagnosis recruited from five specialized private clinics in Lisbon completed a survey which included diagnostic questionnaire, parental stress scale and social support scale from April to December 2022.FindingsData analysis indicated that the mean age of the diagnosis was 5.6 years with a delay of 3.95 years from first concern until final diagnosis. On average, parents consulted a mean of 3.62 professionals. Other findings indicated that as age of parents increased, levels of parental stress decreased. Parents with higher levels of social support had lower levels of parental stress. Furthermore, higher age of child at first concern predicted higher affective social support.Originality/valueThis study reflects on the experience of obtaining the ASD diagnosis in Portugal, raising awareness on the importance of providing early detection and social support for distressed parents.

The imperative of collaboration: Lived experience perspectives on team approaches in outpatient eating disorder treatment.

Across healthcare broadly, team treatment approaches range from siloed multidisciplinary treatment to synergistic Interprofessional Collaborative Practice (IPCP), with IPCP increasingly favored. In eating disorders, clinical practice guidelines endorse team outpatient treatment, and these approaches are widely used in clinical practice. However, there is limited evidence to describe attitudes toward and experiences of team approaches, including IPCP, among individuals with a lived experience. Twenty-seven participants (aged 20-51 years) with a formal eating disorder diagnosis were recruited. Each had received outpatient eating disorder treatment from a team or teams comprising a mental health professional, dietitian, and general practitioner (GP) in the past 2 years. Qualitative data were collected via semi-structured interviews and analyzed using Braun and Clarke's reflexive thematic analysis. Four themes were derived from the qualitative analysis. Themes included: (1) working together is better; (2) the linchpin of teamwork is communication; (3) teams should foster autonomy with limit-setting; and (4) systemic failures negatively affect team treatment. Participants favored highly collaborative treatment from a team including a mental health professional, dietitian, and GP at a minimum, where the team engaged in high-quality communication and fostered autonomy with limit-setting. Systemic failures negatively affecting team treatment were reported across the care continuum. Findings endorse the application of IPCP to outpatient eating disorder treatment as a strategy to improve treatment satisfaction, engagement, and outcomes. Given the paucity of evidence exploring IPCP in this field, however, the development and evaluation of interprofessional education and treatment models is a foundational necessity. Team eating disorder treatment is widely used in clinical practice, although there is limited evidence to guide interventions. This study explores attitudes toward and experiences of team outpatient eating disorder treatment among individuals with a lived experience. Understanding preferred team treatment characteristics delivers important information to improve treatment satisfaction, engagement, and outcomes for individuals receiving outpatient eating disorder treatment.

Cross-sectional analysis of depressive symptom profiles and serum C-reactive protein levels: data from the Northern Finland 1966 birth cohort

Purpose Individuals with depression exhibit significantly higher levels of systemic inflammation than those without depression, particularly among those with atypical depression. However, this association has been less convincing at the population level among individuals without a formal depression diagnosis but with suggestive symptoms. Our aim was to clarify this association. Materials and methods In a large birth cohort sample of the Finnish general population, we examined the cross-sectional association between high-sensitivity C-reactive protein (hsCRP) levels in venous blood samples and atypical/non-atypical depressive symptoms using the Beck Depression Inventory-II to screen 5443 middle-aged participants. Results As expected, depressive symptoms associated to elevated hsCRP-levels compared to non-depressed. Participants with the atypical subtype of depressive symptoms (n = 84) had an odds ratio (OR) of 2.59 (95% CI 1.40–4.81) for elevated hsCRP levels compared to the non-depressed group. Similarly, our findings indicate that participants with non-atypical symptoms (n = 440) also showed an OR of 1.42 (95% CI 1.05–1.92) when compared to the non-depressed group (n = 4919). Conclusions These results provide additional support for previous research linking depression and inflammation and add to the field with a unique and sizeable study population. Furthermore, the current results support the notion that different types of depressive symptoms may be associated with inflammatory markers in slightly different ways.

Panniculitis; A Rare Cutaneous Mafestation of Sjögren’s Syndrome

Objective: Panniculitis, an inflammatory disorder primarily affecting subcutaneous adipose tissue, is frequently associated with inflammatory rheumatic diseases. Panniculitis is an uncommon cutaneous manifestation of Sjögren's syndrome (SS), an autoimmune disease primarily known for causing dry eyes and mouth. Case: We report the case of a 56-year-old female initially diagnosed with rheumatoid arthritis, who later met the 2016 ACR-EULAR criteria for primary Sjögren’s syndrome. Following several treatments, she developed nodular lesions in the interscapular area, which were later diagnosed as septal panniculitis associated with SS. Panniculitis can sometimes precede the formal diagnosis of systemic diseases, such as SS. Therefore, it is essential to consider conditions like Sjögren syndrome in the differential diagnosis of unexplained panniculitis. Conclusion: This case underscores the potential link between Sjögren's syndrome and panniculitis. Panniculitis may manifest before the formal diagnosis of Sjögren's syndrome. It is imperative to include connective tissue diseases, including not only the more common lupus erythematosus and dermatomyositis but also Sjögren's syndrome, in the differential diagnosis when confronted with unexplained cases of panniculitis

Predictors, mediators, and moderators of response to digital interventions for eating disorders: A systematic review.

Digital interventions show promise as an effective prevention or self-management option for eating disorders (EDs). However, it remains unclear how, for whom, and through what mechanisms they work in this population, as a synthesis of outcome predictors, moderators, and mediators is lacking. This systematic review synthesized empirical research investigating predictors, mediators, and moderators of response to digital interventions for EDs. Six databases were searched (PROSPERO CRD42022295565) for studies that assessed predictors, moderators, or mediators of response (i.e., uptake, drop-out, engagement, and symptom level change) to a digital prevention or treatment program for EDs. Variables were grouped into several overarching categories (demographic, symptom severity, psychological, etc.) and were synthesized qualitatively across samples without a formally diagnosed ED (typically prevention-focused) and samples with a formally diagnosed ED (typically treatment-focused). Eighty-six studies were included. For studies recruiting samples without a formal diagnosis (n = 70 studies), most predictors explored were statistically unrelated to outcome, although participant age, baseline symptom severity, confidence to change, motivation, and program engagement showed preliminary evidence of prognostic potential. No robust moderators or mediators were identified. Few studies recruiting samples with a formal diagnosis emerged (n = 16), of which no reliable predictors, moderators, or mediators were identified. It remains unclear how, for whom, and under what circumstances digital programs targeting EDs work. We offer several recommendations for future research with the aim of advancing understanding of client characteristics and intervention elements that signal success from this intervention modality. Digital interventions have shown potential as an effective, scalable, and accessible intervention option for EDs. However, responsiveness varies, so advancing understanding of predictors, mediators, and moderators of outcome to digital interventions for EDs is needed. Such knowledge is important for enabling safe and efficient treatment matching, and for informing future development of effective digital interventions.

Management Strategies for Borderline Personality Disorder and Bipolar Disorder Comorbidities in Adults with ADHD: A Narrative Review.

This narrative review examines two of the common comorbidities of attention-deficit/hyperactivity disorder, bipolar disorder (BD), and borderline personality disorder (BPD), which each share several common features with ADHD that can make assessment and diagnosis challenging. The review highlights some of the key symptomatic differences between adult ADHD and these disorders, allowing for more careful consideration before establishing a formal diagnosis. When the disorders are found to be comorbid, further complications may arise; thus, the review will also help to provide evidence-based treatment recommendations as well as suggestions on how to minimize adverse events. Incorporating evidence from systematic reviews, journal articles, randomized controlled trials, and case reports, this review highlights that the diagnosis of ADHD and some of its common comorbidities is challenging and requires full, in-depth assessment and management. The management strategies of these comorbidities will also be addressed, with emphasis on achieving mood stabilization for BD prior to initiating appropriate ADHD pharmacotherapy. Medications, specifically mood stabilizers, antipsychotics, and antidepressants, are fundamental in treating symptoms seen in BD and some cases of BPD, alongside psychotherapy and lifestyle modifications when appropriate. The review highlights the effectiveness of specific medications, including psychostimulants, atomoxetine, and bupropion, as add-on therapies to mood-stabilizing treatments for addressing ADHD symptoms in patients with these comorbidities. Despite limited research, the review will address various pharmacological and psychotherapeutic approaches for managing comorbid ADHD and BPD, emphasizing the need for further investigations to better understand the unique needs of this patient population.

Patient and caregiver experiences of living with dementia in Tanzania.

Introduction: Tanzania is a low-income country with an increasing prevalence of dementia, which provides challenges for the existing healthcare system. People with dementia often don't receive a formal diagnosis, and with a lack of formal healthcare, are often predominantly supported by family relatives. There are very few published data relating to lived experiences of people with dementia in Tanzania. This study aimed to understand people with dementia, and their caregivers' experiences of living with dementia in Tanzania and the perceived needs of people with dementia.Methods: Qualitative, semi-structured interviews were conducted with 14 people with dementia and 12 caregivers in Moshi, Tanzania. Interviews were audio-recorded, translated, transcribed and analysed using a Framework Analysis approach.Results: Three sub-themes were identified within data describing the experience of 'Living with Dementia in Tanzania': 'Deteriorations in Health', 'Challenges to living with Dementia in Tanzanian Culture', and 'Lack of Support': people with dementia faced challenges due to social isolation, stigmatisation, and lack of caregiver knowledge on how best to provide support. Collectively, these impacted on both the physical and mental health of people with dementia. Misconceptions about dementia aetiology related to age, stresses of daily life and other co-morbidities. People with dementia were motivated to access treatment, exhibiting pluralistic health-seeking behaviours. There was an overall preference for non-pharmacological interventions over medication, with high levels of trust in medical professional opinions.Conclusions: Living with dementia in Tanzania is influenced by both cultural and religious factors. More work is needed to target supplementary healthcare (with efforts to promote accessibility), support for caregivers and public health education about dementia to overcome existent misconceptions and stigma.

Exploring the Association of Male Sex With Adverse Outcomes in Severe Bronchopulmonary Dysplasia: A Retrospective, Multicenter Cohort Study

Background and ObjectiveBronchopulmonary dysplasia (BPD) is a significant contributor to morbidity and mortality in infants born premature. Male sex is an independent risk factor for the development of BPD. However, whether male sex is associated with adverse outcomes occurring after formal diagnosis of severe BPD prior to hospital discharge remains unclear. Research QuestionIs male sex associated with a higher risk of adverse outcomes in infants with established severe BPD? Study Design and MethodsA retrospective, multi-center cohort study of infants enrolled in the BPD Collaborative Registry from January 1, 2015, to June 29th, 2022 was performed. Demographics, clinical characteristics, and outcomes were stratified by sex (i.e., male vs. female). Regression modeling was used to estimate the association of sex with the primary composite outcome of death or tracheostomy at hospital discharge. ResultsWe identified 1156 infants with severe BPD, defined at 36 weeks’ postmenstrual age (PMA) by the National Institutes of Health 2001 consensus definition. The cohort was predominantly male (59% males, 41% females). However, rates of mechanical ventilation at 36 weeks’ PMA (i.e. type 2 severe BPD) did not differ by sex. Overall mortality within the cohort was low (5.3% males, 3.6 % females). The odds ratio of death or tracheostomy for males to females was 1.0 (95%CI: 0.7, 1.5). InterpretationOur results lead us to speculate that while sex is an important variable contributing to the development and pathogenesis of severe BPD, it does not appear to be associated with adverse outcomes in this cohort of infants with established disease. The surprising results raise important questions surrounding the temporal role of biological sex in developing severe BPD and its progression during the NICU stay. As we explore the phenotypes and endotypes of BPD, it is imperative to consider how sex modulates the disease from birth through hospital discharge.

Charcot arthropathy outcomes after early referral to a regional tertiary care foot clinic.

Community physicians may not encounter Charcot arthropathy frequently, and its symptoms and signs may be nonspecific. Patients often have a delay of several months before receiving a formal diagnosis and referral for specialty care. However, limited Canadian data are available. We evaluated the clinical history, treatment and outcomes of patients treated for Charcot arthropathy after prompt referral and diagnosis. We performed a retrospective chart review of 76 patients with diabetes (78 feet) who received nonoperative treatment for Charcot arthropathy in a specialty foot clinic between Jan. 20, 2009, and Mar. 26, 2018. Patients were referred to the foot clinic by community physicians for evaluation or were pre-existing patients at the foot clinic with new-onset Charcot arthropathy. Of the 78 feet included in our analyses, 52 feet (67%) were evaluated initially by a community physician and referred to the foot clinic, where they were seen within 3 ± 5 weeks. The remaining 26 feet (33%) were already being treated at the foot clinic. Most feet had swelling, erythema, warmth, a palpable pulse and loss of protective sensation. Ulcers were present initially in 23 feet (29%). Sixty-four feet (82%) with Charcot arthropathy were in Eichenholtz classification stage 1 and most had midfoot involvement. Nonoperative treatment included total contact casting (60 feet, 77%). Mean duration of nonoperative treatment until resolution for 55 feet (71%) was 6 ± 5 months. Surgery was performed on 20 feet (26%) for the treatment of infection and recurrent ulcer associated with deformity, including 6 (8%) lower limb amputations. Charcot arthropathy may resolve in most feet with early referral and nonoperative treatment, but remains a limb-threatening condition.

Psychological Symptoms and Service Utilization in Prepubertal and Pubertal Transgender and Gender-Diverse Patients

To describe the demographic characteristics and psychological symptoms of gender-diverse patients and to compare symptoms between prepubertal and pubertal subgroups METHODS: This was a retrospective chart review of all gender-diverse patients seen by at least 1 provider at the Nemours Gender Wellness Program from March 2015 to December 2020. The extracted data included demographic and psychosocial characteristics at baseline and 1-year follow-up visits. Pubertal status was determined by Tanner staging by a pediatric endocrinologist or gynecologist. Descriptive statistics were used to compare these variables between prepubertal and pubertal subgroups. Our sample included 177 individuals at baseline and 96 subjects at the 1-year follow-up visit. Most patients were White (83.0%), non-Hispanic (92.0%), transgender male (72.9%), and pubertal (90.4%). Compared with prepubertal patients, at the baseline visit, pubertal patients had significantly higher rates of current (68.1% vs 17.6%, P < .001) and lifetime (80.0% vs 23.5%, P < .001) depressive symptoms, current anxiety symptoms (70.0% vs 41.2%, P=.01), lifetime suicide attempts (12.5% vs 0%, P < .001), and a formal diagnosis of an eating disorder (5.0% vs 0%, P < .001). Symptoms did not change significantly over time from baseline to the 1-year follow-up visit. We found elevated rates of psychological symptoms and diagnoses in gender-diverse youth, with higher rates in pubertal compared with prepubertal patients. By elucidating how the psychosocial characteristics of gender-diverse children and adolescents differ based on pubertal status, these data can be used to improve current outreach and treatment strategies for transgender pediatric patients.