The mediating/moderating role of cultural context factors on self-care practices among those living with diabetes in rural Appalachia.

BACKGROUND: The aim of this study was to examine whether cultural factors, such as religiosity and social support, mediate/moderate the relationship between personal/psychosocial factors and T2DM self-care in a rural Appalachian community. METHODS: Regression models were utilized to assess for mediation and moderation. Multilevel linear mixed effects models and GEE-type logistic regression models were fit for continuous (social support, self-care) and binary (religiosity) outcomes, respectively. RESULTS: The results indicated that cultural context factors (religiosity and social support) can mediate/moderate the relationship between psychosocial factors and T2DM self-care. Specifically, after adjusting for demographic variables, the findings suggested that social support may moderate the effect of depressive symptoms and stress on self-care. Religiosity may moderate the effect of distress on self-care, and empowerment was a predictor of self-care but was not mediated/moderated by the assessed cultural context factors. When considering health status, religiosity was a moderately significant predictor of self-care and may mediate the relationship between perceived health status and T2DM self-care. CONCLUSIONS: This study represents the first known research to examine cultural assets and diabetes self-care practices among a community-based sample of Appalachian adults. We echo calls to increase the evidence on social support and religiosity and other contextual factors among this highly affected population. TRIAL REGISTRATION: US National Library of Science identifier NCT03474731. Registered March 23, 2018, www.clinicaltrials.gov .

Evaluating the Association Between Depressive Symptoms and Glycemic Control Among Residents of Rural Appalachia.

Introduction: Type 2 diabetes mellitus (T2DM) is associated with a range of co-morbid physical and psychological conditions, including depression. Yet there is a dearth of evidence regarding the prevalence of depression among those in Appalachia living with T2DM; this gap persists despite the higher regional prevalence of T2DM and challenging social determinants of health. Purpose: This study aimed to provide greater detail about the relationships between T2DM and depressive symptoms in adults living in Appalachia Kentucky. Methods: The present study was a cross-sectional analysis of baseline data derived from an ongoing study of Appalachia Kentucky adults living with T2DM. Outcome data included demographics, Center for Epidemiologic Studies Depression Scale, point-of-care HbA1c, and the Summary of Diabetes Self-Care Activities. Bivariate analysis was conducted using Pearson's correlation to determine the statistically significant relationships between variables which were then included in a multiple regression model. Results: The sample (N=365), consisted primarily of women (n=230, 64.6%) of mean age 64 years (±10.6); almost all (98%) were non-Hispanic White (n=349), and most were married (n=208, 59.1%). The majority (47.2%) reported having two comorbid conditions (n=161), including T2DM, and the mean HbA1c was 7.7% (1.7). Nearly 90% were nonsmokers (n=319). Depressive symptoms were reported in 25% (n=90) of participants. A higher number of comorbid conditions, increased age, Medicaid insurance, tobacco use, lower financial status, female sex, and disability compared to fully employed status all were correlated with a higher rate of depressive symptoms (r ≤ 0.2). The regression indicated that depressive symptoms were associated with age (ß = -0.010, p = 0.001); full-time employment status compared to those who are disabled (ß = -.0209, p = 0.18); men compared to women (ß = -0.122, p = 0.042), and those who smoke compared to nonsmokers (ß = 0.175, p = 0.038). Implications: Depressive symptoms were correlated with T2DM among this sample of Appalachian residents with poorly controlled T2DM, especially among women. Given the vast number of social determinants (e.g., poverty, food insecurity, and rurality) affecting this population, healthcare providers must assess for depression and consider its negative influence on the patient's ability to achieve glycemic control.

Rare But Fatal: Hemophagocytic Lymphohistiocytosis (HLH) With Acute Acalculous Cholecystitis.

Acalculous cholecystitis is an acute inflammatory disease of the gall bladder with high morbidity and mortality rate. It can be seen in trauma, burns, sepsis, total parenteral nutrition, prolonged fasting, and autoimmune diseases. However, there are very few reports of acalculous cholecystitis with macrophage activation syndrome (MAS) and hemophagocytic lymphohistiocytosis (HLH) in patients with underlying rheumatic/autoimmune disorders. Here we report a 23-year-old male with a past medical history of granulomatosis with polyangiitis who presented with fever, weight loss, and pancytopenia. A comprehensive infectious evaluation was done including bacterial cultures and viral and fungal serologies. Repeat abdominal imaging obtained later due to developing abdominal pain raised concerns for acute acalculous cholecystitis. Despite aggressive management of sepsis, the patient continued to decline clinically. HLH was suspected when the patient was found to meet the clinical criteria with fever, splenomegaly, cytopenia, hypertriglyceridemia, elevated liver function tests, hypofibrinogenemia, and ferritin of 22K ng/mL, absent NK cell activity, and elevated soluble CD25 receptor levels. Bone marrow biopsy did not reveal hemophagocytosis. Intravenous methylprednisolone was started and the patient showed remarkable clinical improvement with a decrease in all inflammatory markers and did not require any surgical intervention. On the review of the literature, we were able to identify four female patients with underlying adult-onset Still's disease and Kikuchi disease who presented with HLH along with acalculous cholecystitis likely triggered by flare. Our male patient presented with HLH and acute acalculous cholecystitis. He had a history of granulomatosis polyangiitis (GPA) that remained in remission. Hypersecretion of pro-inflammatory cytokines and cytotoxic cells in HLH promotes ischemia of the gall bladder wall. Early initiation of immunosuppressive therapy under careful observation can prevent surgical intervention and mortality in these patients.