human
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVES Diabetes self-management is a key element in the overall management of diabetes . Identifying barriers to disease self-management is a critical step in achieving optimal health outcomes . Our goal was to explore patients ' perceptions about barriers to self-management of diabetes that could possibly help explain poor health outcomes among minority patients . STUDY DESIGN Four focus groups were conducted among 31 predominately African American patients with diabetes who were enrolled in the Baltimore Cardiovascular Partnership Study , a NIH-funded multiyear prospect i ve partnership study . The topic guide consisted of a series of open-ended questions about knowledge of current health status , medication use , continuity of care , blood glucose level and nutrition . RESULTS The focus groups confirmed that previously reported barriers to self-management persisted and identified new concerns that could be associated with poor health outcomes among minority patients with diabetes .  Attitudes , perceptions and behaviors surrounding diabetes and self-management of the condition did vary across individuals , however , the variation appeared to reflect the individual 's knowledge and opinions rather than patient 's age , sex , or culture . The primary barrier to diabetes self-management result ed from lack of knowledge of target blood glucose and blood pressure . Several participants found some of the health information to be quite confusing . CONCLUSIONS Diabetes is a major public health concern and the lack of awareness of target blood glucose and blood pressure further complicates the problem . The limited health literacy seen in this study could help explain several of the barriers to self-management . The barriers to self-management identified in this qualitative study are amenable to intervention that could improve health outcomes OBJECTIVES Persons with concomitant heart failure ( HF ) and diabetes mellitus ( DM ) have complicated , often competing , self-care expectations and treatment regimens that may reduce quality of life ( QOL ) . This r and omized controlled trial tested an integrated self-care intervention on outcomes of HF and DM QOL , physical function , and physical activity ( PA ) . METHODS AND RESULTS Participants with HF and DM ( n = 134 ; mean age 57.4 ± 11 years , 66 % men , 69 % minority ) were r and omized to usual care ( control ) or intervention . The control group received st and ard HF and DM educational brochures with follow-up telephone contact . The intervention group received education and counseling on combined HF and DM self-care ( diet , medications , self-monitoring , symptoms , and PA ) with follow-up home visit and telephone counseling . Measures included question naires for HF- and DM-specific and overall QOL , PA frequency , and physical function ( 6-min walk test [ 6MWT ] ) and were obtained at baseline and 3 and 6 months . Analysis included mixed models with a priori post hoc tests . Adjusting for age , body mass index , and comorbidity , the intervention group improved in HF total ( P = .002 ) and physical ( P < .001 ) QOL scores at 3 months with retention of improvements at 6 months , improved in emotional QOL scores compared with control at 3 months ( P = .04 ) , and improved in health status ratings ( P = .04 ) at 6 months compared with baseline . The intervention group improved in 6MWT distance ( 924 ft to 952 ft ; P = .03 ) whereas the control group declined ( 834 ft to 775 ft ; F1,63 = 6.86 ; P = .01 ) . The intervention group increased self-reported PA between baseline and 6 months ( P = .01 ) . CONCLUSIONS An integrated HF and DM self-care  intervention improved perceived HF and general QOL but not DM QOL . Improved physical functioning and self-reported PA were also observed with the integrated self-care intervention . Further study of the HF and DM integrated self-care intervention on other outcomes , such as hospitalization and cost , is warranted Aim . This study compares the usefulness of Montreal Cognitive Assessment ( MoCA ) to St and ardized Mini-Mental Status Exam ( SMMSE ) for diagnosing  mild cognitive impairment  ( MCI ) in Type 2 diabetes mellitus ( DM ) population . Methods . This prospect i ve pilot study enrolled 30 community dwelling adults with Type 2 DM aged 50 years and above . Subjects were assessed using both the SMMSE and MoCA for MCI . In all subjects , depression and dementia were ruled out using the DSM IV criteria , and a functional assessment was done . MCI was diagnosed using the st and ard test , the European consortium criteria . Sensitivity and specificity analysis , positive and negative predictive values , likelihood ratios and Kappa statistic were calculated . Results . In comparison to consortium criteria , the sensitivity and specificity of MoCA were 67 % and 93 % in identifying individuals with MCI , and SMMSE were 13 % and 93 % , respectively . The positive and negative predictive values for MoCA were 84 % and 56 % , and for SMMSE were 66 % and 51 % , respectively . Kappa statistics showed moderate agreement between MoCA and consortium criteria ( kappa = 0.4 ) and a low agreement between SMMSE and consortium criteria ( kappa = 0.07 ) . Conclusion . In this pilot study , MoCA appears to be a better screening tool than SMMSE for MCI in the diabetic population OBJECTIVE To examine the prevalence and predictors of foot disease , self-care and clinical monitoring in adults with type 2 diabetes in Alberta , Canada . METHOD Baseline data from a prospect i ve cohort of adults with type 2 diabetes were used . Assessment of foot disease included self-reported peripheral neuropathy , peripheral vasculopathy , foot or leg ulcer/infection or gangrene/amputation . Foot self-care  was assessed using the Summary of Diabetes Self-Care Activities , and clinical monitoring using patients ' reports of having feet checked for lesions or sensory loss . RESULTS The mean age of respondents ( N=2040 ) was 64 ( SD 10.7 ) years ; 45 % were female , and 91 % were Caucasian . Peripheral neuropathy was reported by 18 % of the respondents , peripheral vasculopathy by 28 % , ulcer/infection by 6 % and gangrene/amputation by 1.4 % . Only 14 % of respondents performed foot self-care  behaviours ≥6 days per week , and only 41 % and 34 % had their feet clinical ly checked for lesions or sensory loss , respectively . Predictors of foot disease included longer duration of diabetes , smoking , depressive symptoms , low self-efficacy and a history of cardiovascular diseases . Predictors of good self-care included older age , female sex , longer duration of diabetes and no report of hyperlipidemia . Predictors of clinical monitoring included female sex , current smoking , residing in urban areas , longer duration of diabetes , and histories of heart disease or hyperlipidemia . CONCLUSIONS Peripheral neuropathy and vasculopathy were the most common reported foot problems in this population . Foot self-care is generally infrequent , and clinical monitoring is performed for less than half of these patients , with significant variations by patient demographics and clinical presentation OBJECTIVE —We examined the association between depression , measured as either a continuous symptom severity score or a clinical disorder variable , with self-care behaviors in type 2 diabetes . RESEARCH DESIGN AND METHODS —We surveyed 879 type 2 diabetic patients from two primary care clinics using the Harvard Department of Psychiatry/National Depression Screening Day Scale ( H AND S ) , the Summary of Diabetes Self-Care Activities , and self-reported medication adherence . RESULTS —Of the patients , 19 % met the criteria for probable major depression ( H AND S score ≥9 ) , and an additional 66.5 % reported at least some depressive symptoms . After controlling for covariates , patients with probable major depression reported significantly fewer days ' adherent to diet , exercise , and glucose self-monitoring regimens  ( P < 0.01 ) and 2.3-fold increased odds of missing medication doses in the previous week ( 95 % CI 1.5–3.6 , P < 0.001 ) compared with all other respondents . Continuous depressive symptom severity scores were better predictors of nonadherence to diet , exercise , and medications than categorically defined probable major depression . Major depression was a better predictor of glucose monitoring . Among the two-thirds of patients not meeting the criteria for major depression ( H AND S score < 9 , n = 709 ) , increasing H AND S scores were incrementally associated with poorer self-care behaviors ( P < 0.01 ) . CONCLUSIONS —These findings challenge the conceptualization of depression as a categorical risk factor for nonadherence and suggest that even low levels of depressive symptomatology are associated with nonadherence to important aspects of diabetes self-care . Interventions aim ed at alleviating depressive symptoms , which are quite common , could result in significant improvements in diabetes self-care The prevalence of type 2 diabetes is increasing in Malaysia , and people with diabetes have been reported to suffer from depression and diabetes distress which influences their self-efficacy in performing diabetes self-care practice s. This interviewer administered , cross sectional study , conducted in the district of Hulu Selangor , Malaysia , involving 371 r and omly selected patients with type 2 diabetes , recruited from 6 health clinics , aim ed to examine a conceptual model regarding the association between depression , diabetes distress and self-efficacy with diabetes self-care practice s using the partial least square approach of structural equation modeling . In this study , diabetes self-care practice s were similar regardless of sex , age group , ethnicity , education level , diabetes complications or type of diabetes medication . This study found that self-efficacy had a direct effect on diabetes self-care practice ( path coefficient = 0.438 , p<0.001 ) . Self-care was not directly affected by depression and diabetes distress , but indirectly by depression ( path coefficient = -0.115 , p<0.01 ) and diabetes distress ( path coefficient = -0.122 , p<0.001 ) via self-efficacy . In conclusion , to improve self-care practice s , effort must be focused on enhancing self-efficacy levels , while not forgetting to deal with depression and diabetes distress , especially among those with poorer levels of self-efficacy Objectives . Adherence to diabetes self care is poor for Hispanic American and African-American patients . This study examined the change in adherence over time and in response to a telemedicine intervention for elderly diabetes patients in these groups compared to white diabetes patients . We also examined whether adherence mediated the effect of the intervention on glycemic control ( A1c ) . Design . The Informatics for Diabetes Education and Telemedicine project r and omized medically underserved Medicare patients ( n=1665 ) to telemedicine case management ( televideo educator visits , individualized goal - setting /problem solving ) or usual care .  Hispanic and African-American educators delivered the intervention in Spanish if needed . Main outcome measures . Annual assessment included A1c and self-reported adherence ( Summary of Diabetes Self-Care Activities scale ) . A simple model ( only time and group terms ) and a model with covariates ( e.g. , age ) were examined for baseline and 5 years of follow-up . SAS PROC Mixed was used with non-linear terms to examine mediating effects of adherence on A1c , by performing tests of the mediating path coefficients . Results . Over time , self-reported adherence improved for the treatment group compared to usual care ( p<0.001 ) . There was no significant interaction with racial/ethnic group membership , i.e. , all groups improved . However , minority subjects were consistently less adherent than whites . Also , greater comorbidity and diabetes symptoms predicted poorer adherence , greater duration of diabetes and more years of education predicted better adherence . Adherence was a significant mediator of A1c ( p<0.001 ) . Conclusions . A unique , tailored telemedicine intervention was effective in achieving improved adherence to diabetes self care . However , African-American and Hispanic American participants were less adherent than white participants at all time points despite an individualized and accessible intervention . The finding that adherence did mediate glycemic control suggests that unique interventions for minority groups may be needed to overcome this disparity ABSTRACT Background : People with type 2 diabetes frequently have a variety of related and unrelated chronic conditions . These additional conditions have implication s for patient education , treatment burden and disease management . Objectives : The aim of this study was to examine the nature of multimorbidity , and its impact on GP visits , polypharmacy and glycaemic control as measured by HbA1c , in a cohort of patients with type 2 diabetes attending general practice in Irel and . Methods : A cohort of 424 patients with type 2 diabetes enrolled in a cluster r and omized controlled trial based in Irish general practice was examined . Patient data included : medical conditions , HbA1c , health service utilization , socio-economic status and number of prescribed medications . Results : 90 % of patients had at least one additional chronic condition and a quarter had four or more additional chronic conditions . 66 % of patients had hypertension ; 25 % had heart disease ; and 16 % had arthritis . General practitioner visits and polypharmacy increased significantly with increasing numbers of chronic conditions . When comparing patient self-report with medical records , patients who reported a higher proportion of their conditions had better glycaemic control with a significantly lower 
    Output:
    
agent
The most common concordant comorbidity was hypertension while depression was the most common discordant condition .
Adherence to medications was the most frequent diabetes self-care behavior reported and tended to be higher among concordant comorbidities .
The findings showed mixed results concerning the effect of some concordant comorbidities such as hypertension , hyperlipidemia , retinopathy , and heart failure on diabetes self-care behaviors .
But , there is agreement across studies that diabetes-discordant comorbidities have a more detrimental effect on self-care behaviors .
Conclusions : Concordant comorbidities may improve diabetes self-care , but the evidence is inconclusive .
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVES Diabetes self-management is a key element in the overall management of diabetes . Identifying barriers to disease self-management is a critical step in achieving optimal health outcomes . Our goal was to explore patients ' perceptions about barriers to self-management of diabetes that could possibly help explain poor health outcomes among minority patients . STUDY DESIGN Four focus groups were conducted among 31 predominately African American patients with diabetes who were enrolled in the Baltimore Cardiovascular Partnership Study , a NIH-funded multiyear prospect i ve partnership study . The topic guide consisted of a series of open-ended questions about knowledge of current health status , medication use , continuity of care , blood glucose level and nutrition . RESULTS The focus groups confirmed that previously reported barriers to self-management persisted and identified new concerns that could be associated with poor health outcomes among minority patients with diabetes .  Attitudes , perceptions and behaviors surrounding diabetes and self-management of the condition did vary across individuals , however , the variation appeared to reflect the individual 's knowledge and opinions rather than patient 's age , sex , or culture . The primary barrier to diabetes self-management result ed from lack of knowledge of target blood glucose and blood pressure . Several participants found some of the health information to be quite confusing . CONCLUSIONS Diabetes is a major public health concern and the lack of awareness of target blood glucose and blood pressure further complicates the problem . The limited health literacy seen in this study could help explain several of the barriers to self-management . The barriers to self-management identified in this qualitative study are amenable to intervention that could improve health outcomes OBJECTIVES Persons with concomitant heart failure ( HF ) and diabetes mellitus ( DM ) have complicated , often competing , self-care expectations and treatment regimens that may reduce quality of life ( QOL ) . This r and omized controlled trial tested an integrated self-care intervention on outcomes of HF and DM QOL , physical function , and physical activity ( PA ) . METHODS AND RESULTS Participants with HF and DM ( n = 134 ; mean age 57.4 ± 11 years , 66 % men , 69 % minority ) were r and omized to usual care ( control ) or intervention . The control group received st and ard HF and DM educational brochures with follow-up telephone contact . The intervention group received education and counseling on combined HF and DM self-care ( diet , medications , self-monitoring , symptoms , and PA ) with follow-up home visit and telephone counseling . Measures included question naires for HF- and DM-specific and overall QOL , PA frequency , and physical function ( 6-min walk test [ 6MWT ] ) and were obtained at baseline and 3 and 6 months . Analysis included mixed models with a priori post hoc tests . Adjusting for age , body mass index , and comorbidity , the intervention group improved in HF total ( P = .002 ) and physical ( P < .001 ) QOL scores at 3 months with retention of improvements at 6 months , improved in emotional QOL scores compared with control at 3 months ( P = .04 ) , and improved in health status ratings ( P = .04 ) at 6 months compared with baseline . The intervention group improved in 6MWT distance ( 924 ft to 952 ft ; P = .03 ) whereas the control group declined ( 834 ft to 775 ft ; F1,63 = 6.86 ; P = .01 ) . The intervention group increased self-reported PA between baseline and 6 months ( P = .01 ) . CONCLUSIONS An integrated HF and DM self-care  intervention improved perceived HF and general QOL but not DM QOL . Improved physical functioning and self-reported PA were also observed with the integrated self-care intervention . Further study of the HF and DM integrated self-care intervention on other outcomes , such as hospitalization and cost , is warranted Aim . This study compares the usefulness of Montreal Cognitive Assessment ( MoCA ) to St and ardized Mini-Mental Status Exam ( SMMSE ) for diagnosing  mild cognitive impairment  ( MCI ) in Type 2 diabetes mellitus ( DM ) population . Methods . This prospect i ve pilot study enrolled 30 community dwelling adults with Type 2 DM aged 50 years and above . Subjects were assessed using both the SMMSE and MoCA for MCI . In all subjects , depression and dementia were ruled out using the DSM IV criteria , and a functional assessment was done . MCI was diagnosed using the st and ard test , the European consortium criteria . Sensitivity and specificity analysis , positive and negative predictive values , likelihood ratios and Kappa statistic were calculated . Results . In comparison to consortium criteria , the sensitivity and specificity of MoCA were 67 % and 93 % in identifying individuals with MCI , and SMMSE were 13 % and 93 % , respectively . The positive and negative predictive values for MoCA were 84 % and 56 % , and for SMMSE were 66 % and 51 % , respectively . Kappa statistics showed moderate agreement between MoCA and consortium criteria ( kappa = 0.4 ) and a low agreement between SMMSE and consortium criteria ( kappa = 0.07 ) . Conclusion . In this pilot study , MoCA appears to be a better screening tool than SMMSE for MCI in the diabetic population OBJECTIVE To examine the prevalence and predictors of foot disease , self-care and clinical monitoring in adults with type 2 diabetes in Alberta , Canada . METHOD Baseline data from a prospect i ve cohort of adults with type 2 diabetes were used . Assessment of foot disease included self-reported peripheral neuropathy , peripheral vasculopathy , foot or leg ulcer/infection or gangrene/amputation . Foot self-care  was assessed using the Summary of Diabetes Self-Care Activities , and clinical monitoring using patients ' reports of having feet checked for lesions or sensory loss . RESULTS The mean age of respondents ( N=2040 ) was 64 ( SD 10.7 ) years ; 45 % were female , and 91 % were Caucasian . Peripheral neuropathy was reported by 18 % of the respondents , peripheral vasculopathy by 28 % , ulcer/infection by 6 % and gangrene/amputation by 1.4 % . Only 14 % of respondents performed foot self-care  behaviours ≥6 days per week , and only 41 % and 34 % had their feet clinical ly checked for lesions or sensory loss , respectively . Predictors of foot disease included longer duration of diabetes , smoking , depressive symptoms , low self-efficacy and a history of cardiovascular diseases . Predictors of good self-care included older age , female sex , longer duration of diabetes and no report of hyperlipidemia . Predictors of clinical monitoring included female sex , current smoking , residing in urban areas , longer duration of diabetes , and histories of heart disease or hyperlipidemia . CONCLUSIONS Peripheral neuropathy and vasculopathy were the most common reported foot problems in this population . Foot self-care is generally infrequent , and clinical monitoring is performed for less than half of these patients , with significant variations by patient demographics and clinical presentation OBJECTIVE —We examined the association between depression , measured as either a continuous symptom severity score or a clinical disorder variable , with self-care behaviors in type 2 diabetes . RESEARCH DESIGN AND METHODS —We surveyed 879 type 2 diabetic patients from two primary care clinics using the Harvard Department of Psychiatry/National Depression Screening Day Scale ( H AND S ) , the Summary of Diabetes Self-Care Activities , and self-reported medication adherence . RESULTS —Of the patients , 19 % met the criteria for probable major depression ( H AND S score ≥9 ) , and an additional 66.5 % reported at least some depressive symptoms . After controlling for covariates , patients with probable major depression reported significantly fewer days ' adherent to diet , exercise , and glucose self-monitoring regimens  ( P < 0.01 ) and 2.3-fold increased odds of missing medication doses in the previous week ( 95 % CI 1.5–3.6 , P < 0.001 ) compared with all other respondents . Continuous depressive symptom severity scores were better predictors of nonadherence to diet , exercise , and medications than categorically defined probable major depression . Major depression was a better predictor of glucose monitoring . Among the two-thirds of patients not meeting the criteria for major depression ( H AND S score < 9 , n = 709 ) , increasing H AND S scores were incrementally associated with poorer self-care behaviors ( P < 0.01 ) . CONCLUSIONS —These findings challenge the conceptualization of depression as a categorical risk factor for nonadherence and suggest that even low levels of depressive symptomatology are associated with nonadherence to important aspects of diabetes self-care . Interventions aim ed at alleviating depressive symptoms , which are quite common , could result in significant improvements in diabetes self-care The prevalence of type 2 diabetes is increasing in Malaysia , and people with diabetes have been reported to suffer from depression and diabetes distress which influences their self-efficacy in performing diabetes self-care practice s. This interviewer administered , cross sectional study , conducted in the district of Hulu Selangor , Malaysia , involving 371 r and omly selected patients with type 2 diabetes , recruited from 6 health clinics , aim ed to examine a conceptual model regarding the association between depression , diabetes distress and self-efficacy with diabetes self-care practice s using the partial least square approach of structural equation modeling . In this study , diabetes self-care practice s were similar regardless of sex , age group , ethnicity , education level , diabetes complications or type of diabetes medication . This study found that self-efficacy had a direct effect on diabetes self-care practice ( path coefficient = 0.438 , p<0.001 ) . Self-care was not directly affected by depression and diabetes distress , but indirectly by depression ( path coefficient = -0.115 , p<0.01 ) and diabetes distress ( path coefficient = -0.122 , p<0.001 ) via self-efficacy . In conclusion , to improve self-care practice s , effort must be focused on enhancing self-efficacy levels , while not forgetting to deal with depression and diabetes distress , especially among those with poorer levels of self-efficacy Objectives . Adherence to diabetes self care is poor for Hispanic American and African-American patients . This study examined the change in adherence over time and in response to a telemedicine intervention for elderly diabetes patients in these groups compared to white diabetes patients . We also examined whether adherence mediated the effect of the intervention on glycemic control ( A1c ) . Design . The Informatics for Diabetes Education and Telemedicine project r and omized medically underserved Medicare patients ( n=1665 ) to telemedicine case management ( televideo educator visits , individualized goal - setting /problem solving ) or usual care .  Hispanic and African-American educators delivered the intervention in Spanish if needed . Main outcome measures . Annual assessment included A1c and self-reported adherence ( Summary of Diabetes Self-Care Activities scale ) . A simple model ( only time and group terms ) and a model with covariates ( e.g. , age ) were examined for baseline and 5 years of follow-up . SAS PROC Mixed was used with non-linear terms to examine mediating effects of adherence on A1c , by performing tests of the mediating path coefficients . Results . Over time , self-reported adherence improved for the treatment group compared to usual care ( p<0.001 ) . There was no significant interaction with racial/ethnic group membership , i.e. , all groups improved . However , minority subjects were consistently less adherent than whites . Also , greater comorbidity and diabetes symptoms predicted poorer adherence , greater duration of diabetes and more years of education predicted better adherence . Adherence was a significant mediator of A1c ( p<0.001 ) . Conclusions . A unique , tailored telemedicine intervention was effective in achieving improved adherence to diabetes self care . However , African-American and Hispanic American participants were less adherent than white participants at all time points despite an individualized and accessible intervention . The finding that adherence did mediate glycemic control suggests that unique interventions for minority groups may be needed to overcome this disparity ABSTRACT Background : People with type 2 diabetes frequently have a variety of related and unrelated chronic conditions . These additional conditions have implication s for patient education , treatment burden and disease management . Objectives : The aim of this study was to examine the nature of multimorbidity , and its impact on GP visits , polypharmacy and glycaemic control as measured by HbA1c , in a cohort of patients with type 2 diabetes attending general practice in Irel and . Methods : A cohort of 424 patients with type 2 diabetes enrolled in a cluster r and omized controlled trial based in Irish general practice was examined . Patient data included : medical conditions , HbA1c , health service utilization , socio-economic status and number of prescribed medications . Results : 90 % of patients had at least one additional chronic condition and a quarter had four or more additional chronic conditions . 66 % of patients had hypertension ; 25 % had heart disease ; and 16 % had arthritis . General practitioner visits and polypharmacy increased significantly with increasing numbers of chronic conditions . When comparing patient self-report with medical records , patients who reported a higher proportion of their conditions had better glycaemic control with a significantly lower 
    Output:
    