Effect of Cardiorespiratory Fitness Level on Physiological Responses and Task Performance During a High-Rise Firefighting Task.

OBJECTIVES: To determine the impact of cardiorespiratory fitness (CRF) on physiological and performance outcomes during a 120-m vertical high-rise ascent in firefighters with CRF levels at or above (higher-fit) and below (lower-fit [LF]) the national recommended minimum physical employment standard (V˙O 2 max 42.3 mL·kg -1 ·min -1 ). METHODS: Twenty-eight firefighters completed two high-rise firefighting trials (continuous and discontinuous ascent with predetermined 1-minute rest breaks). Task time, heart rate, ratings of perceived exertion, core body temperature, and thermal comfort were recorded at predetermined elevations. RESULTS: Task time was significantly longer in both trials for the LF group. Ratings of perceived exertion and thermal comfort were also significantly higher in the LF group, with three times more LF firefighters being unable to complete the ascent without sounding their low-air alarm. CONCLUSIONS: Higher CRF improves performance and efficiency during stair-climbing in simulated high-rise firefighting tasks.

Testosterone Treatment, Weight Loss, and Health-related Quality of Life and Psychosocial Function in Men: A 2-year Randomized Controlled Trial.

OBJECTIVE: To determine the effect of testosterone vs placebo treatment on health-related quality of life (HR-QOL) and psychosocial function in men without pathologic hypogonadism in the context of a lifestyle intervention. DESIGN, SETTING, PARTICIPANTS: Secondary analysis of a 2-year randomized controlled testosterone therapy trial for prevention or reversal of newly diagnosed type 2 diabetes, enrolling men ≥ 50 years at high risk for type 2 diabetes from 6 Australian centers. INTERVENTIONS: Injectable testosterone undecanoate or matching placebo on the background of a community-based lifestyle program. MAIN OUTCOMES: Self-reported measures of HR-QOL/psychosocial function. RESULTS: Of 1007 participants randomized into the Testosterone for Type 2 Diabetes Mellitus (T4DM) trial, 648 (64%) had complete data available for all HR-QOL/psychosocial function assessments at baseline and 2 years. Over 24 months, while most measures were not different between treatment arms, testosterone treatment, compared with placebo, improved subjective social status and sense of coherence. Baseline HR-QOL/psychosocial function measures did not predict the effect of testosterone treatment on glycemic outcomes, primary endpoints of T4DM. Irrespective of treatment allocation, larger decreases in body weight were associated with improved mental quality of life, mastery, and subjective social status. Men with better baseline physical function, greater sense of coherence, and fewer depressive symptoms experienced greater associated decreases in body weight, with similar effects on waist circumference. CONCLUSION: In this diabetes prevention trial, weight loss induced by a lifestyle intervention improved HR-QOL and psychosocial function in more domains than testosterone treatment. The magnitude of weight and waist circumference reduction were predicted by baseline physical function, depressive symptomology, and sense of coherence.

Physiological Responses and Performance of Simulated High-Rise Firefighting.

OBJECTIVE: The aim of the study is to determine the physiological effects of breathing apparatus and ascent strategies during a simulated 120-m vertical high-rise firefighting ascent. METHODS: Twenty-eight firefighters completed four high-rise firefighting trials wearing standard- or extended-duration breathing apparatus with continuous ascent (SDBA-C/EDBA-C) or with breaks (SDBA-B/EDBA-B). Task time, heart rate, ratings of perceived exertion, core body temperature, and thermal comfort were recorded at predetermined elevations. RESULTS: Task time took significantly longer during the EDBA-C compared with SDBA-C trial. Heart rate (at 40, 80, and 100 m) was significantly lower in trials following breaks compared with the continuous trials. Core body temperature rose by 0.11°C every 10 m of ascent. During the SDBA trials, 89% to 96% of firefighters activated their low air alarm compared with only 7% in EDBA. CONCLUSIONS: Firefighters should wear EDBA beyond 80 m of ascent and are encouraged to take regular breaks.

Fistula development after anal abscess drainage-a multicentre retrospective cohort study.

PURPOSE: Anal abscesses are common and, despite correct treatment with surgical drainage, carry the risk of developing fistulas. Studies identifying risk factors for the development of anal fistulas are sparse. This study aimed to identify the risk factors for anal fistulas after anal abscess surgery. METHODS: This was a multicentre, retrospective cohort study of patients undergoing acute surgery for anal abscesses in the Capital Region of Denmark between 2018 and 2019. The patients were identified using ICD-10 codes for anal abscesses. Predefined clinicopathological factors and postoperative courses were extracted from patient records. RESULTS: A total of 475 patients were included. At a median follow-up time of 1108 days (IQR 946-1320 days) following surgery, 164 (33.7%) patients were diagnosed with an anal fistula. Risk factors for developing fistulas were low intersphincteric (OR 2.77, 95CI 1.50-5.06) and ischioanal (OR 2.48, 95CI 1.36-4.47) abscesses, Crohn's disease (OR 5.96, 95CI 2.33-17.2), a history of recurrent anal abscesses (OR 4.14, 95CI 2.47-7.01) or repeat surgery (OR 5.96, 95CI 2.33-17.2), E. coli-positive pus cultures (OR 4.06, 1.56-11.4) or preoperative C-reactive protein (CRP) of more than 100 mg/L (OR 3.21, 95CI 1.57-6.71). CONCLUSION: Several significant clinical risk factors were associated with fistula development following anal abscess surgery. These findings are clinically relevant and could influence the selection of patients for specialised follow-up, facilitate expedited diagnosis, and potentially prevent unnecessarily long treatment courses.

Socioeconomic differences in associations between living in a 20-min neighbourhood and diet, physical activity and self-rated health: Cross-sectional findings from ProjectPLAN.

The 20-min neighbourhood (20MN) concept aims to enable residents to meet daily needs using resources within a 20-min trip from home noting that there is no single definition of what services and amenities are required for daily needs nor what modes of transport constitute a 20 min trip. Whether 20MNs promote better health and whether associations differ by socio-economic status (SES) is unknown. Using cross-sectional data from adults randomly sampled in 2018-19 from Melbourne or Adelaide, Australia, we examined whether associations between neighbourhood type (20MN/non-20MN) and diet, physical activity or self-rated health vary according to individual- or area-level SES. We found no consistent patterns of interactions. The results do not consistently support the often assumed belief that 20MNs support more healthful behaviour and that these relationships vary by SES.

A Review of the Aquatic Environmental Transformations of Engineered Nanomaterials.

Once released into the environment, engineered nanomaterials (ENMs) undergo complex interactions and transformations that determine their fate, exposure concentration, form, and likely impact on biota. Transformations are physical, chemical, or biological changes that occur to the ENM or the ENM coating. Over time, these transformations have an impact on their behaviour and properties. The interactions and transformations of ENMs in the environment depend on their pristine physical and chemical characteristics and the environmental or biological compartment into which they are released. The uniqueness of each ENM property or lifecycle results in a great deal of complexity. Even small changes may have a significant impact on their potential transformations. This review outlines the key influences and outcomes of ENM evolution pathways in aquatic environments and provides an assessment of potential environmental transformations, focusing on key chemical, physical, and biological processes. By obtaining a comprehensive understanding of the potential environmental transformations that nanomaterials can undergo, more realistic models of their probable environmental behaviour and potential impact can be developed. This will, in turn, be crucial in supporting regulatory bodies in their efforts to develop environmental policy in the field of nanotechnology.

The Occurrence of Oxidative Stress Induced by Silver Nanoparticles in Chlorella vulgaris Depends on the Surface-Stabilizing Agent.

Silver nanoparticles (AgNPs) are of great interest due to their antimicrobial properties, but their reactivity and toxicity pose a significant risk to aquatic ecosystems. In biological systems, AgNPs tend to aggregate and dissolve, so they are often stabilized by agents that affect their physicochemical properties. In this study, microalga Chlorella vulgaris was used as a model organism to evaluate the effects of AgNPs in aquatic habitats. Algae were exposed to AgNPs stabilized with citrate and cetyltrimethylammonium bromide (CTAB) agents and to AgNO3 at concentrations that allowed 75% cell survival after 72 h. To investigate algal response, silver accumulation, ROS content, damage to biomolecules (lipids, proteins, and DNA), activity of antioxidant enzymes (APX, PPX, CAT, SOD), content of non-enzymatic antioxidants (proline and GSH), and changes in ultrastructure were analyzed. The results showed that all treatments induced oxidative stress and adversely affected algal cells. AgNO3 resulted in the fastest death of algae compared to both AgNPs, but the extent of oxidative damage and antioxidant enzymatic defense was similar to AgNP-citrate. Furthermore, AgNP-CTAB showed the least toxic effect and caused the least oxidative damage. These results highlight the importance of surface-stabilizing agents in determining the phytotoxicity of AgNPs and the underlying mechanisms affecting aquatic organisms.

Programmable synthetic biomolecular condensates for cellular control.

The formation of biomolecular condensates mediated by a coupling of associative and segregative phase transitions plays a critical role in controlling diverse cellular functions in nature. This has inspired the use of phase transitions to design synthetic systems. While design rules of phase transitions have been established for many synthetic intrinsically disordered proteins, most efforts have focused on investigating their phase behaviors in a test tube. Here, we present a rational engineering approach to program the formation and physical properties of synthetic condensates to achieve intended cellular functions. We demonstrate this approach through targeted plasmid sequestration and transcription regulation in bacteria and modulation of a protein circuit in mammalian cells. Our approach lays the foundation for engineering designer condensates for synthetic biology applications.

Particle Size Modulates Silver Nanoparticle Toxicity during Embryogenesis of Urchins Arbacia lixula and Paracentrotus lividus.

Silver nanoparticles represent a threat to biota and have been shown to cause harm through a number of mechanisms, using a wide range of bioassay endpoints. While nanoparticle concentration has been primarily considered, comparison of studies that have used differently sized nanoparticles indicate that nanoparticle diameter may be an important factor that impacts negative outcomes. In considering this, the aim of the present study was to determine if different sizes of silver nanoparticles (AgNPs; 10, 20, 40, 60 and 100 nm) give rise to similar effects during embryogenesis of Mediterranean sea urchins Arbacia lixula and Paracentrotus lividus, or if nanoparticle size is a parameter that can modulate embryotoxicity and spermiotoxicity in these species. Fertilised embryos were exposed to a range of AgNP concentrations (1−1000 µg L−1) and after 48 h larvae were scored. Embryos exposed to 1 and 10 µg L−1 AgNPs (for all tested sizes) showed no negative effect in both sea urchins. The smaller AgNPs (size 10 and 20 nm) caused a decrease in the percentage of normally developed A. lixula larvae at concentrations ≥50 µg L−1 (EC50: 49 and 75 µg L−1, respectively) and at ≥100 µg L−1 (EC50: 67 and 91 µg L−1, respectively) for P. lividus. AgNPs of 40 nm diameter was less harmful in both species ((EC50: 322 and 486 µg L−1, for P. lividus and A. lixula, respectively)). The largest AgNPs (60 and 100 nm) showed a dose-dependent response, with little effect at lower concentrations, while more than 50% of larvae were developmentally delayed at the highest tested concentrations of 500 and 1000 µg L−1 (EC50(100 nm); 662 and 529 µg L−1, for P. lividus and A. lixula, respectively. While AgNPs showed no effect on the fertilisation success of treated sperm, an increase in offspring developmental defects and arrested development was observed in A. lixula larvae for 10 nm AgNPs at concentrations ≥50 µg L−1, and for 20 and 40 nm AgNPs at concentrations >100 µg L−1. Overall, toxicity was mostly ascribed to more rapid oxidative dissolution of smaller nanoparticles, although, in cases, Ag+ ion concentrations alone could not explain high toxicity, indicating a nanoparticle-size effect.

Comparison of spatial approaches to assess the effect of residing in a 20-minute neighbourhood on body mass index.

Beliefs that neighbourhood environments influence body mass index (BMI) assume people residing proximally have similar outcomes. However, spatial relationships are rarely examined. We considered spatial autocorrelation when estimating associations between neighbourhood environments and BMI in two Australian cities. Using cross-sectional data from 1329 participants (Melbourne = 637, Adelaide = 692), spatial autocorrelation in BMI was examined for different spatial weights definitions. Spatial and ordinary least squares regression were compared to assess how accounting for spatial autocorrelation influenced model findings. Geocoded household addresses were used to generate matrices based on distances between addresses. We found low positive spatial autocorrelation in BMI; magnitudes differed by matrix choice, highlighting the need for careful consideration of appropriate spatial weighting. Results indicated statistical evidence of spatial autocorrelation in Adelaide but not Melbourne. Model findings were comparable, with no residual spatial autocorrelation after adjustment for confounders. Future neighbourhoods and BMI research should examine spatial autocorrelation, accounting for this where necessary.

Team IHMC at the 2020 Cybathlon: a user-centered approach towards personal mobility exoskeletons.

BACKGROUND: The past few decades have seen rapid advancements in exoskeleton technology, with a considerable shift towards applications involving users with gait pathologies. Commercial devices from ReWalk, Ekso Bionics, and Indego, mainly designed for rehabilitation purposes, have inspired the development of many research platforms aimed at extending capabilities for use as safe and effective personal mobility devices. The 2016 Cybathlon featured an impressive demonstration of exoskeletons designed to enable mobility for individuals with spinal cord injury, however, not a single team completed every task and only two completed the stairs. Major improvements were showcased at the 2020 Cybathlon, with seven of the nine teams completing a similar set of tasks. Team IHMC built upon its silver-medal success from 2016 with an upgraded device, Quix. METHODS: Quix features several notable improvements including an additional powered degree of freedom for hip ab/adduction to laterally shift the device and reduce user effort while walking, custom-tailored cuffs and soft goods based on 3D body scans to optimize user comfort, and a streamlined testing pipeline for online tuning of gait parameters. RESULTS: Team IHMC finished in fourth place behind the teams from EPFL and Angel Robotics. Although we suffered from a considerably slower flat-ground walking speed, our pilot reported marked improvements in overall effort, comfort, and ease-of-use compared to our previous device. CONCLUSIONS: Clear progress in exoskeleton development has been exhibited since the inaugural Cybathlon, with tasks involving rough terrain, stairs, and ramps now posing little threat to most of the competitors. As a result, the layout of the powered exoskeleton course will likely undergo significant modifications to further push the devices towards suitability for personal everyday use. The current tasks do not address the issue of donning and doffing, nor do they simulate a scenario similar to maneuvering a kitchen to prepare a meal, for example. An additional limitation that may be more difficult to test in a competition setting is the required upper-body effort to manipulate the device in an effective manner.

Real-Time Patient Portal Use Among Emergency Department Patients: An Open Results Study.

OBJECTIVES: We characterized real-time patient portal test result viewing among emergency department (ED) patients and described patient characteristics overall and among those not enrolled in the portal at ED arrival. METHODS: Our observational study at an academic ED used portal log data to trend the proportion of adult patients who viewed results during their visit from May 04, 2021 to April 04, 2022. Correlation was assessed visually and with Kendall's τ. Covariate analysis using binary logistic regression assessed result(s) viewed as a function of time accounting for age, sex, ethnicity, race, language, insurance status, disposition, and social vulnerability index (SVI). A second model only included patients not enrolled in the portal at arrival. We used random forest imputation to account for missingness and Huber-White heteroskedasticity-robust standard errors for patients with multiple encounters (α = 0.05). RESULTS: There were 60,314 ED encounters (31,164 unique patients). In 7,377 (12.2%) encounters, patients viewed results while still in the ED. Patients were not enrolled for portal use at arrival in 21,158 (35.2%) encounters, and 927 (4.4% of not enrolled, 1.5% overall) subsequently enrolled and viewed results in the ED. Visual inspection suggests an increasing proportion of patients who viewed results from roughly 5 to 15% over the study (Kendall's τ = 0.61 [p <0.0001]). Overall and not-enrolled models yielded concordance indices (C) of 0.68 and 0.72, respectively, with significant overall likelihood ratio χ 2 (p <0.0001). Time was independently associated with viewing results in both models after adjustment. Models revealed disparate use between age, race, ethnicity, SVI, sex, insurance status, and disposition groups. CONCLUSION: We observed increased portal-based test result viewing among ED patients over the year since the 21st Century Cures act went into effect, even among those not enrolled at arrival. We observed disparities in those who viewed results.

Changing Primary School Children's Engagement in Active School Travel Using Safe Routes to School Interventions: A Rapid Realist Review.

Safe Routes to School (SR2S) interventions have been implemented in many economically developed countries to improve children's engagement in Active School Travel (AST). Evaluations have highlighted inconsistencies in SR2S intervention outcomes, raising questions as to how, why, and under what contextual conditions these interventions work. This review used a Rapid Realist Review (RRR) methodology to build, test, and refine an overarching program theory that unpicks the contextual factors and underlying mechanisms influencing children's engagement in AST. From the 45 included documents, 16 refined Context-Mechanism-Outcome Configurations (CMOCs) were developed and clustered into three partial program theories (i.e., implementor/implementation, child, and parent), with the associated mechanisms of: (1) School Reliance; (2) School Priority; (3) Fun; (4) Pride; (5) Perceived Safety; (6) Distrust; (7) Convenience; (8) Perceived Capabilities; and (9) Reassurance. The overarching program theory delineates the pathways between intervention implementation, children's motivation, parental decision-making, and children's engagement in AST. The findings suggest SR2S interventions can motivate children to engage in AST, but whether this motivation is translated into engagement is determined by parental decision-making. This review is novel for highlighting that many of the factors influencing parental decision-making are contextually driven and appear to be unaddressed by the current suite of SR2S intervention strategies. The review additionally highlights the complexity of parental perceptions of safety, with the traffic and the road environment shaping only part of this multidimensional mechanism. Practitioners and policymakers need to tailor SR2S interventions to local contexts to better influence parental decision-making for children's engagement in AST.

Built Environment Features and Cardiometabolic Mortality and Morbidity in Remote Indigenous Communities in the Northern Territory, Australia.

Indigenous Australians experience poorer health than non-Indigenous Australians, with cardiometabolic diseases (CMD) being the leading causes of morbidity and mortality. Built environmental (BE) features are known to shape cardiometabolic health in urban contexts, yet little research has assessed such relationships for remote-dwelling Indigenous Australians. This study assessed associations between BE features and CMD-related morbidity and mortality in a large sample of remote Indigenous Australian communities in the Northern Territory (NT). CMD-related morbidity and mortality data were extracted from NT government health databases for 120 remote Indigenous Australian communities for the period 1 January 2010 to 31 December 2015. BE features were extracted from Serviced Land Availability Programme (SLAP) maps. Associations were estimated using negative binomial regression analysis. Univariable analysis revealed protective effects on all-cause mortality for the BE features of Education, Health, Disused Buildings, and Oval, and on CMD-related emergency department admissions for the BE feature Accommodation. Incidence rate ratios (IRR's) were greater, however, for the BE features Infrastructure Transport and Infrastructure Shelter. Geographic Isolation was associated with elevated mortality-related IRR's. Multivariable regression did not yield consistent associations between BE features and CMD outcomes, other than negative relationships for Indigenous Location-level median age and Geographic Isolation. This study indicates that relationships between BE features and health outcomes in urban populations do not extend to remote Indigenous Australian communities. This may reflect an overwhelming impact of broader social inequity, limited correspondence of BE measures with remote-dwelling Indigenous contexts, or a 'tipping point' of collective BE influences affecting health more than singular BE features.

Do residents with a 20-min neighbourhood walk more? Findings from ProjectPLAN.

BACKGROUND: The 20-min neighbourhood (20 MN) concept aims to provide people the ability to meet their daily needs within a 20-min non-motorised trip from home. Evidence as to whether the 20 MN encourages more walking for transport or recreation is currently absent. METHODS: This cross-sectional study used self-reported data from the Places and Locations for Activity and Nutrition study (ProjectPLAN) targeting adults (n = 843) residing in Melbourne or Adelaide, Australia. Multiple services and amenities were used to represent access to five service domains (healthy food, community resources, recreational resources, public open space, public transport). Address points meeting the access criteria for each of the five domains were defined as having a 20 MN. Non-20 MNs were defined as having five or fewer individual services and amenities. This study examined if those residing in a 20 MN compared with a non-20MN undertook more walking for transport or for recreation. The analysis considered separately each of the cities to support the estimation of effects specific to each local context. RESULTS: Respondents residing in a 20 MN relative to a non-20MN had higher odds of walking for transport in Melbourne (OR = 4.24, 95% CI = 2.38, 7.56), whilst in Adelaide there was no evidence of a difference (OR = 1.31, 95% CI = 0.80, 2.13). In Melbourne, the mean time spent walking for transport was greater for 20 MNs (82.5 min/week, 95% CI = 65.3, 99.7) compared to non-20MNs (41.2 min/week, 95% CI = 32.7, 49.7). Whilst minutes spent walking for recreation was higher than minutes spent walking for transport, no differences were found between neighbourhood types and walking for recreation in either city. CONCLUSION: 20 MNs appeared to promote walking for transport in the higher density setting of Melbourne, but no association was observed in the lower density city of Adelaide. Further investigation is required to determine other factors beyond service provision that can promote walking for transport in Adelaide (e.g. pedestrian safety). Recreational walking did not differ across neighbourhood types highlighting that service provision and thus the 20 MN is not related to walking for exercise/recreation purposes.

[Transanal endoscopic microsurgery for excision of a symptomatic tailgut cyst].

A tailgut cyst is a rare tumour originating from the embryonic remnant of the retrorectal space. The cyst is often asymptomatic, but it can cause abdominal or rectal pain and urogenital symptoms. When diagnosed, resection is the choice of treatment, and traditionally open surgery has been preferred. In this case report, we present a 30-year-old female patient with a painful tailgut cyst. She was found to be candidate for transanal endoscopic microsurgery, which was successfully performed.

Metabolically Healthy and Unhealthy Obese Phenotypes among Arabs and South Asians: Prevalence and Relationship with Cardiometabolic Indicators.

Obesity is a public health crisis in Kuwait. However, not all obese individuals are metabolically unhealthy (MuHO) given the link between obesity and future cardiovascular events. We assessed the prevalence of the metabolically healthy obese (MHO) phenotype and its relationship with high sensitivity C-reactive protein (hs-CRP), serum alanine aminotransferase (ALT), and insulin resistance (HOMA-IR) in Arab and South Asian ethnic groups in Kuwait. The national cross-sectional survey of diabetes and obesity in Kuwait adults aged 18-60 years were analysed. The harmonised definition of metabolic syndrome was used to classify metabolic health. Multinomial logistic regression analysis was used to model the relationship between the MHO and MuHO phenotypes and hs-CRP, ALT and HOMA-IR levels. Overall, the prevalence of MHO for body mass index (BMI)- and waist circumference (WC)-defined obesity was 30.8% and 56.0%, respectively; it was greater in women (60.4% and 61.8%, respectively) than men (39.6% and 38.2%, respectively). Prevalence rates were also lower for South Asians than for Arabs. The MHO phenotype had hs-CRP values above 3 µg/mL for each age group category. Men compared to women, and South Asians compared to Arabs had a lower relative risk for the MHO group relative to the MuHO group. This study shows there is high prevalence of MHO in Kuwait.

Operationalising the 20-minute neighbourhood.

BACKGROUND: Recent rapid growth in urban areas and the desire to create liveable neighbourhoods has brought about a renewed interest in planning for compact cities, with concepts like the 20-minute neighbourhood (20MN) becoming more popular. A 20MN broadly reflects a neighbourhood that allows residents to meet their daily (non-work) needs within a short, non-motorised, trip from home. The 20MN concept underpins the key planning strategy of Australia's second largest city, Melbourne, however the 20MN definition has not been operationalised. This study aimed to develop and operationalise a practical definition of the 20MN and apply this to two Australian state capital cities: Melbourne (Victoria) and Adelaide (South Australia). METHODS: Using the metropolitan boundaries for Melbourne and Adelaide, data were sourced for several layers related to five domains: 1) healthy food; 2) recreational resources; 3) community resources; 4) public open space; and 5) public transport. The number of layers and the access measures required for each domain differed. For example, the recreational resources domain only required a sport and fitness centre (gym) within a 1.5-km network path distance, whereas the public open space domain required a public open space within a 400-m distance along a pedestrian network and 8 ha of public open space area within a 1-km radius. Locations that met the access requirements for each of the five domains were defined as 20MNs. RESULTS: In Melbourne 5.5% and in Adelaide 7.6% of the population were considered to reside in a 20MN. Within areas classified as residential, the median number of people per square kilometre with a 20MN in Melbourne was 6429 and the median number of dwellings per square kilometre was 3211. In Adelaide's 20MNs, both population density (3062) and dwelling density (1440) were lower than in Melbourne. CONCLUSIONS: The challenge of operationalising a practical definition of the 20MN has been addressed by this study and applied to two Australian cities. The approach can be adapted to other contexts as a first step to assessing the presence of existing 20MNs and monitoring further implementation of this concept.

Geographic variation in and contextual factors related to biguanide adherence amongst medicaid enrolees with type 2 Diabetes Mellitus.

Much is known about the adverse impacts on diabetes outcomes of non-adherence to diabetes medication. Less is known about how adherence to diabetes medication varies geographically, and the correspondence of this variation to social and contextual factors. Using pharmacy claims data over a two-year period, this study analysed non-adherence to biguanide medication for N=24,387 adult Medicaid enrolees diagnosed with Type 2 Diabetes Mellitus (T2DM) and residing in Ohio. Spatial analysis was used to detect clusters of census tract level rates of non-adherence, defined as the proportion of patients below the Proportion Days Covered (PDC) threshold of 80%, the level at which patients have a reasonable likelihood of achieving most clinical benefit from their medication. Multilevel models were used to understand associations between medication non-adherence and contextual factors including social vulnerability, urbanicity and distance to utilised pharmacy, with adjustment for individual-level covariates. These findings indicate that contextual factors are associated with medication non-adherence in Medicaid clients with T2DM. They suggest a need for spatially specific, multifaceted intervention programmes that target and/or account for the features of residential settings beyond individual and health system-level factors alone. While "environmental" considerations are often acknowledged, few intervention initiatives are predicated on explicit knowledge of spatially variable influences that can be targeted to enable and support medication adherence.