Researchers purposively recruited participants from a nursing rehabilitation clinic at Hubei Cancer Hospital in China between May and September 2024. They conducted semistructured interviews and analyzed the transcripts using combined deductive and inductive content analysis. Data collection continued until both code saturation and meaning saturation were achieved, and agreement for 20% of transcripts assessed by two coders was substantial, with a Cohen’s kappa of 0.79.

The analysis identified seven themes. Exercise experience, habitual exercise cues and routines, and emotional support were classified primarily as system 1 processes. Reflective appraisal of dysphagia, consideration of medical-service resources, weighing benefits and risks, and the gap between expectations and effects were classified primarily as system 2 processes.

The findings therefore linked adherence to both immediate patterns of behavior and patients’ conscious assessment of their condition, resources, and possible outcomes. Cross-system interactions added a dynamic element to the findings. The study reported that immediate bodily and emotional responses were continually reshaped by reflective appraisal, contextual resources, and perceived progress.

In other words, patients’ assessments could affect how they interpreted immediate experiences, while situational conditions and perceptions of progress could influence reflective judgment. Adherence was thus understood as a changing product of interacting automatic and reflective processes. Emotional support was one of the themes associated with system 1 processes, indicating that support from other people formed part of the context in which exercises were performed.

The study also identified the consideration of medical-service resources as a reflective factor, showing that patients evaluated the services surrounding their care when thinking about exercise adherence. These findings should not be interpreted as evidence that any particular support strategy improves swallowing outcomes, because the study did not test such an intervention. The authors’ clinical-relevance section proposed combining habit-supportive cues and affective support with education, expectation management, accessible follow-up, and individualized goal setting.

They suggested that clinicians could anchor exercises to stable daily cues, involve family members as proximal habit coaches, offer flexible or abbreviated protocols for working patients, and provide motivational interviewing and tele-rehabilitation support to reduce uncertainty and sustain adherence. These are recommendations derived from the qualitative findings rather than results from a clinical trial of the proposed approaches. The study’s scope was limited by its design and setting.

It included 18 patients from one rehabilitation clinic in China, all of whom had experience with swallowing exercises. The findings describe reported processes behind adherence; they do not establish that the same patterns hold for every person with head and neck cancer or measure changes in swallowing function, treatment response, or survival. The research was also intended to explore mechanisms, not to demonstrate that swallowing exercises produce clinical benefits.

Overall, the study presents swallowing-exercise adherence as a context-sensitive process shaped by routines, emotional support, conscious appraisal, service resources, expectations, and perceived effects. For rehabilitation teams, that distinction points to a broader view of support, one that considers both the conditions surrounding daily exercise and the judgments patients make about their difficulties and progress.

Subject of Research: Factors influencing swallowing-exercise adherence among patients with head and neck cancer

Article Title: Swallowing exercise adherence in patients with head and neck cancer based on the dual-process model: a qualitative study

Article References: Liu, Y., Liu, S., Hu, L., Jia, J., Wang, Y., Lin, H., Zou, L., & Shi, L. (2026). Swallowing exercise adherence in patients with head and neck cancer based on the dual-process model: a qualitative study. Supportive Care in Cancer, 34(11), Article 1134. https://doi.org/10.1007/s00520-026-11360-z

Image Credits: AI Generated

DOI: 10.1007/s00520-026-11360-z

Keywords: head and neck cancer, swallowing exercises, exercise adherence, dual-process model, qualitative research, rehabilitation, health behavior, patient support, Swallowing, exercise, adherence, patients

Congenital pulmonary airway malformation, abbreviated CPAM, is a rare developmental anomaly of the lung in which parts of the bronchial tree fail to mature normally and instead form cystic, maldeveloped airspaces. Many affected children are asymptomatic, with the lesion discovered incidentally on chest imaging, yet the malformation carries risks of recurrent infection, pneumothorax and, over the long term, malignant transformation, so surgical resection is often recommended. Thoracoscopic resection, performed through small incisions with camera-assisted instruments, has become the standard approach, sparing children the large incisions of open thoracotomy.

The traditional midnight fasting rule was designed to reduce the risk of pulmonary aspiration, in which gastric contents regurgitate under anesthesia and are inhaled into the lungs. But prolonged fasting, particularly in young children, carries its own physiological costs: hypoglycemia, dehydration, irritability, hunger distress and metabolic stress that can complicate the perioperative course. Enhanced recovery protocols in adult surgery have largely abandoned prolonged fasting in favor of clear carbohydrate drinks up to two hours before anesthesia, on the principle that clear liquids empty rapidly from the stomach and that a modest carbohydrate load improves insulin sensitivity and patient comfort. Translating that principle to pediatric thoracic surgery, however, requires evidence that children will actually drink the prescribed solution and that doing so is safe.

The West China team enrolled 110 consecutive pediatric patients diagnosed with CPAM who received a standardized preoperative oral carbohydrate protocol as part of routine clinical practice. Because the supplementation protocol was already embedded in standard care and no additional intervention was assigned, the study was conducted as an observational analysis rather than a randomized trial, and it was not registered as a clinical trial. The researchers calculated adherence using a straightforward formula: the actual consumed volume divided by the prescribed volume, multiplied by 100 percent. This metric allowed them to quantify, for each child, how much of the intended carbohydrate load actually made it into the stomach before the fasting window closed.

The headline finding was one of good tolerance and reasonable but imperfect adherence. Carbohydrate-associated adverse events were documented in only 3.6 percent of enrolled patients, four of the 110 children, indicating that the clear carbohydrate solution was well tolerated across the cohort. The median adherence rate reached 80 percent, meaning that most children consumed most of the prescribed volume. Yet when the team applied a predefined exploratory cutoff of adherence at or above 80 percent, only about half of the participants met that threshold. In other words, the protocol was feasible and safe, but a substantial fraction of children fell short of the intended carbohydrate load, and understanding why became the central analytical question of the study.

To identify the drivers of adherence, the researchers applied multivariable linear regression models, a statistical technique that screens multiple candidate variables simultaneously while adjusting for the influence of the others. Three independent positive predictors emerged. Children whose operations were scheduled later in the surgical sequence adhered better, a finding that makes intuitive sense: a later start time gives families more hours in the morning to complete the drinking protocol without rushing, whereas an early first case compresses the entire supplementation window into the pre-dawn hours when both children and parents are least cooperative. Children with a low nutritional risk screening score also adhered better; the team used the Screening Tool for the Assessment of Malnutrition in Pediatrics, known as STAMP, and children at elevated nutritional risk presumably faced greater difficulty tolerating or completing the oral load. And active parental care was the third independent predictor, underscoring that the protocol’s success depends not on the child alone but on the engagement of the caregiver administering the drink.

The second analytical phase tested whether adherence levels correlated with short-term postoperative outcomes. Using Spearman’s rank correlation and multiple linear regression, the team found that higher adherence presented a positive linear correlation with elevated caregiver satisfaction scores and with fewer episodes of postoperative hunger-induced crying. These outcomes are not the dramatic endpoints of adult enhanced recovery literature, such as length of stay or complication rates, but they are the outcomes that matter most to families in the immediate postoperative period. A child who is less hungry and less distressed is a child who recovers more comfortably, and a caregiver who observes that comfort reports higher satisfaction with the entire perioperative experience.

The authors conclude that preoperative oral carbohydrate supplementation may optimize the perioperative experience for pediatric patients with CPAM and showed acceptable feasibility within this study cohort. The practical implications are concrete. Adjusting surgical schedules to arrange operations at later time points would give families the morning hours needed to complete the protocol without the pressure of an early first case. Implementing targeted interventions for patients at elevated nutritional risk, identified through tools such as STAMP, would direct support to the children least likely to complete the oral load on their own. And strengthening parent-guided care strategies, including structured education and engagement of caregivers in the supplementation process, would address the third independent predictor directly.

The study carries the hallmarks of careful observational methodology. Written informed consent was obtained from all surveyed caregivers, and the research was reviewed and approved by the Biomedical Ethics Review Committee of West China Hospital, Sichuan University. The authors declare no competing interests and received no specific funding for the work. Because the supplementation protocol was part of routine clinical practice, the findings reflect real-world implementation rather than the idealized conditions of a controlled trial, which strengthens their external validity but also means that adherence rates could differ in centers with different protocols, patient populations or surgical scheduling practices.

For the broader pediatric surgery community, the study adds to a growing body of evidence that the midnight fasting rule, long treated as inviolable, deserves to be replaced by evidence-based clear liquid and carbohydrate protocols tailored to children. The finding that only about half of children reached the exploratory adherence cutoff is a reminder that protocols on paper are not protocols in practice, and that the determinants of adherence, surgical timing, nutritional risk and parental engagement, are as important as the biochemical rationale for the drink itself. As enhanced recovery principles continue to spread from adult to pediatric thoracic surgery, studies like this one provide the granular, real-world data needed to design protocols that children will actually follow and that families will actually benefit from.

Subject of Research: Health

Article Title: Determinants of adherence to preoperative oral carbohydrates and short-term outcomes in pediatric congenital pulmonary airway malformation

Article References: Hou, S., Liu, J., An, T., Feng, L., Yuan, M., & Gong, Y. (2026). Determinants of adherence to preoperative oral carbohydrates and short-term outcomes in pediatric congenital pulmonary airway malformation. Scientific Reports. https://doi.org/10.1038/s41598-026-69477-4

Image Credits: AI Generated

DOI: 10.1038/s41598-026-69477-4

Keywords: pediatrics, preoperative carbohydrate supplementation, CPAM, fasting, treatment adherence, anesthesia, enhanced recovery, caregiver satisfaction, Determinants, adherence, preoperative, oral

The findings, published in Neurology, the medical journal of the American Academy of Neurology, arrive at a pivotal moment. Anti-amyloid therapies represent the first approved drugs that modify the underlying biology of Alzheimer’s disease rather than merely managing its symptoms, and their use is expected to expand steadily as diagnostic tools improve and clinical experience grows. But the study’s numbers reveal a stark pattern in who is actually reaching the infusion chair. Black adults had 86 percent lower odds of receiving an anti-amyloid medication compared with non-Hispanic white adults, while Hispanic adults had 79 percent lower odds, after the researchers accounted for other clinical and demographic factors.

“The association we found between race/ethnicity and anti-amyloid medication use raises important questions about how patients are identified, evaluated and ultimately selected for treatment,” said Melissa Elafros, M.D., Ph.D., co-first author of the study and the Andrea and Lawrence A. Wolfe Research Professor at University of Michigan Medical School. “It’s critical that we understand and address the disparities we are seeing today so that as many patients as possible receive benefits.”

To conduct the analysis, the research team drew on a database of more than one million adults diagnosed with mild cognitive impairment or dementia. From that population, they identified 2,427 patients who had received an anti-amyloid medication and compared them with a closely matched group of untreated patients. Because the study was observational, it captures associations rather than proving cause and effect, but the scale of the dataset allowed the investigators to examine how race, ethnicity, comorbid health conditions and social circumstances all intersected with the likelihood of treatment.

Beyond race and ethnicity, the researchers found that social and economic disadvantage played a powerful role. Participants who faced greater disadvantages, measured through factors including income, education, and access to housing and neighborhood resources, were nearly half as likely to receive the latest therapies as their less vulnerable counterparts. Health comorbidities were also strongly associated with whether patients were treated, suggesting that clinicians and health systems may be weighing a complex mix of medical and social considerations when deciding who is a candidate for drugs that require regular infusions, repeated brain imaging and careful monitoring for side effects such as amyloid-related imaging abnormalities.

What the study did not find may be just as consequential as what it did. Once patients began anti-amyloid therapy, adherence was similar across racial and ethnic groups, meaning that the disparities concentrate at the front door of treatment rather than in the day-to-day management of it. “Although race, ethnicity and overall vulnerability are associated with whether patients receive an anti-amyloid medication, we found no differences in initial adherence among those who start treatment,” said Brian C. Callaghan, M.D., M.S., senior author of the study and the Eva L. Feldman, MD, PhD Professor at U-M Medical School. “This suggests that interventions should focus on helping eligible patients start therapy, rather than on adherence after treatment begins.”

That distinction carries significant implications for how the field responds. If patients who begin therapy take the drugs as prescribed at comparable rates, then the bottleneck lies upstream, in the processes that determine who is referred, who undergoes amyloid testing, who is evaluated at specialized memory centers and who is ultimately offered treatment. Anti-amyloid drugs are typically reserved for people with early-stage disease confirmed by biomarkers, a requirement that depends on access to specialists, advanced imaging, lumbar punctures or other diagnostic resources that are unevenly distributed across the health care landscape. Communities that have historically faced barriers to neurologic care may therefore be systematically underrepresented among treatment candidates before any prescribing decision is even made.

The study was funded through a research contract with the American Academy of Neurology, and the authors note that its observational design means unmeasured factors could contribute to the observed differences. Even so, the consistency of the signal across more than two thousand treated patients and a comparable untreated comparison group strengthens the case that the disparities reflect structural patterns rather than random variation. Additional authors on the paper include Lavanya Muthukumar, M.S., and Samuel Terman, M.D., both of the University of Michigan, with further contributors listed in the published article.

For clinicians and policymakers, the message from the Michigan team is that the window for shaping equitable access is open now, while anti-amyloid therapies are still early in their real-world rollout. The researchers argue that understanding and addressing the disparities observed today is essential so that the benefits of a new generation of Alzheimer’s treatments reach as many eligible patients as possible, rather than reproducing the inequities that have long characterized dementia care. As these drugs move from specialized centers into broader clinical practice, the study offers a baseline measurement of who is being left behind, and a warning that without deliberate intervention, the first disease-modifying era of Alzheimer’s medicine could widen existing gaps in brain health.

Subject of Research: Racial, ethnic and socioeconomic disparities in access to anti-amyloid Alzheimer's disease therapies

Article Title: Who gets Alzheimer’s drugs? Race, vulnerability and health status shape access

Article References: Who gets Alzheimer’s drugs? Race, vulnerability and health status shape access. Original publication (Bibliographic details unavailable.)

Image Credits: AI Generated

DOI: Not provided

Keywords: Alzheimer's disease, anti-amyloid therapy, health disparities, mild cognitive impairment, dementia, Neurology, Michigan Medicine, adherence, social determinants of health, race and ethnicity, amyloid plaques, disease-modifying treatment

The logic behind differentiated service delivery is straightforward but powerful. Traditional antiretroviral therapy programs require patients to visit a health facility frequently, often monthly, for refills and check-ups. For stable clients, this is inefficient for the health system and burdensome for the patient, particularly in rural areas where a single clinic visit can consume an entire day and significant transport money. DSD models reorganize care around the needs of distinct patient groups, allowing clinically stable clients to receive their medication through less intensive channels, such as community distribution points, while reserving intensive facility-based care for those who need closer monitoring. The approach was established with the explicit aim of improving patient outcomes while simultaneously increasing the efficiency of the health system itself.

To evaluate how these models are actually working on the ground, the research team adopted a case study design. They conducted in-depth interviews with individuals receiving antiretroviral therapy through a DSD model, and key informant interviews with program implementers across multiple administrative levels. All interviews were guided by semi-structured interview guides, audio recorded, and transcribed verbatim. Participants were selected through purposive sampling, a technique that deliberately identifies information-rich cases—in this case, people with direct, varied experience of the models. The team then applied thematic analysis, organizing the findings according to the five dimensions of the RE-AIM framework: Reach, Effectiveness, Adoption, Implementation, and Maintenance. This structure allowed the researchers to assess not just whether the models work, but who they serve, how they are adopted, and whether they can endure.

On the question of reach, the study delivered a sobering but important finding: the overall reach of the DSD models is shaped significantly by cost and distance to the health facility. In other words, the very barriers that differentiated care is designed to reduce can also determine who manages to access it in the first place. For patients living far from distribution points or unable to afford transport, the theoretical benefits of a more flexible model may remain out of reach. This finding underscores a persistent tension in implementation science: an intervention that looks equitable on paper can reproduce existing inequalities in access unless geography and economics are explicitly engineered into its design.

Effectiveness, by contrast, emerged as a clear strength. The researchers found that the DSD models improved adherence to antiretroviral therapy, a critical outcome given that consistent medication-taking suppresses viral load and prevents both disease progression and onward transmission. The models also produced an unexpected systems benefit: they allowed health facility staff to plan client visits systematically. Rather than contending with unpredictable daily surges of patients, facilities could anticipate demand, allocate staff more rationally, and devote scarce clinician time to complex cases. In this sense, differentiated service delivery functions as a kind of demand-management technology for the health system, redistributing routine tasks so that human resources can be deployed where they matter most.

Adoption—the willingness of facilities and communities to take up the models—was strengthened by deliberate local adaptations. The study documented modifications that facilitated adoption, including the use of information, education, and communication materials to explain the models to clients and communities, and the active participation of traditional and community leaders. These local champions play a crucial role in contexts where trust in formal health institutions may be uneven and where stigma around HIV remains a barrier to engagement. By involving leaders who command community credibility, program implementers helped legitimize the new care pathways and encourage uptake among people who might otherwise have stayed away from clinic-based services.

The implementation dimension of the framework asked whether the models were delivered as intended, and here the findings were encouraging. The DSD models were successfully implemented as planned, supported by regular monitoring and ongoing training. This fidelity between design and execution is notable in large public health programs, where drift between policy and practice is common. Yet the study also surfaced a forward-looking concern: implementers recommended capacity building and expansion of human resources to maintain the models over time. Without a pipeline of trained staff and adequate workforce numbers, the systematic visit planning and monitoring that make the models work could erode, threatening the durability of the gains.

One of the most striking recommendations from the study concerns inclusion. The researchers proposed that future models should be created with a specific focus on meeting the needs of people with disabilities. This is a dimension of differentiated HIV care that is often overlooked, and it highlights how reach and equity must be considered together. A model that reduces visits for the general population of stable clients may inadvertently exclude clients who face physical, sensory, or cognitive barriers to accessing community distribution points or who require accommodations that the current designs do not anticipate. Building disability-inclusive features into the architecture of DSD models from the outset, rather than retrofitting them later, would be a significant step toward genuinely universal access to therapy.

Taken together, the RE-AIM analysis suggests that differentiated service delivery in Zambia is a promising strategy for improving the delivery of antiretroviral services, and the authors conclude that the findings highlight the importance of rolling out these models to cater to more people throughout the country. But the study is equally clear-eyed about what national scale-up will require. The models will only extend their reach if the financial and geographic barriers identified by patients are addressed, if community engagement through local leaders and communication materials continues, if the health workforce grows to sustain systematic planning and monitoring, and if future designs explicitly incorporate the needs of people with disabilities. In a country where so many people depend on lifelong therapy, the lesson of this research is that the next phase of the HIV response depends as much on implementation science—on understanding how programs actually behave in the world—as on the medicines themselves.

Subject of Research: Implementation of Differentiated Service Delivery models for antiretroviral therapy in Zambian health facilities, evaluated using the RE-AIM framework

Article Title: Implementation of DSD models in selected health facilities in Zambia: a RE-AIM framework analysis

Article References: Mulavu, M., Mulawa, M. J., Sitali, D., Jacobs, C., Zulu, J. M., Hamoonga, T. E., Chavula, M. P., Zyambo, C., Matenga, T. F. L., Kaonga, P., Musukuma, M., Sampa, M., Phiri, H., Hikabasa, H., & Mweemba, O. (2026). Implementation of DSD models in selected health facilities in Zambia: a RE-AIM framework analysis. BMC Public Health. https://doi.org/10.1186/s12889-026-28789-w

Image Credits: AI Generated

DOI: 10.1186/s12889-026-28789-w

Keywords: HIV, antiretroviral therapy, Differentiated Service Delivery, Zambia, RE-AIM framework, implementation science, public health, health systems, adherence, health facilities, community health, task shifting

PrEP works by maintaining antiretroviral drugs in the bloodstream and mucosal tissues before any exposure to HIV occurs. When taken consistently, oral tenofovir-based regimens reduce the risk of sexual HIV acquisition by well over ninety percent, and the principle has been extended to injectable and ring formulations. The pharmacology is straightforward: steady drug concentrations prevent the virus from establishing infection after it enters the body. The clinical challenge, as the new review makes clear, is everything that happens before and after the prescription is written.

The research team, led by Abdulmuminu Isah and Ifunanya Mary-Ann Onyia of the Person-Centered HIV Research Team at the University of Nigeria, Nsukka, conducted the review under a pre-registered PROSPERO protocol. They searched PubMed, Scopus, Web of Science and Google Scholar for English-language studies published between 2012 and 2024, focusing on adolescents and young people aged ten to twenty-four years, a range extended to twenty-five in three studies whose populations overlapped with the target group. From 16,339 records screened, only sixteen studies met the inclusion criteria, a number that itself reveals how thin the evidence base remains for this age group despite the scale of the epidemic among them.

The sixteen studies spanned North America, Latin America and sub-Saharan Africa, giving the synthesis a genuinely global reach. Because the review included populations at risk of HIV acquisition across three continents, the barriers identified are not artifacts of any single health system or culture. Instead, they recur with striking consistency, from university clinics in the United States to community health posts in eastern and southern Africa, wherever young people weigh whether a daily pill is worth the social and practical costs of taking it.

For PrEP uptake, the first decision point, the review identified stigma as the dominant barrier. Young people reported fearing that being seen collecting or taking the pills would mark them as promiscuous, HIV-positive, or sexually active in ways their families and communities would condemn. This fear operates through what social scientists call anticipated stigma, the internalized expectation of judgment before any actual encounter with it. It can stop a young person from even entering a clinic, and it interacts with low awareness of PrEP, since many eligible adolescents had never heard that prevention medication existed at all.

Mistrust of healthcare providers emerged as a second uptake barrier with deep roots. Adolescents described suspicion that clinics would disclose their sexual behavior to parents, judge their choices, or push moralizing advice rather than confidential care. Concerns about side effects, particularly nausea and other gastrointestinal symptoms associated with tenofovir-based regimens, added a biomedical dimension to the hesitancy. Financial constraints and practical access problems, including clinic distances, opening hours that conflict with school, and the cost of transport, completed the picture of a prevention tool that is free on paper but expensive in practice.

Sustained adherence proved even harder than initial uptake, and the barriers here were more granular. Pill fatigue, the weariness of taking a daily medication for a risk that has not yet materialized, was repeatedly reported. This is a pharmacologically rational complaint: maintaining protective drug concentrations requires consistent dosing, yet the perceived benefit is abstract while the daily burden is concrete. Side effects that fade for most users within weeks can nonetheless drive discontinuation during the critical early period when adherence habits form.

Structural barriers dominated the adherence findings. Transportation challenges made repeat clinic visits difficult, particularly for rural adolescents. Parental consent requirements in some jurisdictions meant that young people could not start or continue PrEP without involving a parent, a condition many avoided because it risked disclosure of sexual activity. Negative healthcare provider attitudes, including judgmental or dismissive treatment, eroded the trust that adherence depends upon. The review’s multilevel framework, spanning individual, interpersonal and structural domains, shows how these barriers reinforce one another: a judgmental provider confirms a young person’s mistrust, which deepens anticipated stigma, which makes the next clinic visit less likely.

The authors argue that addressing these barriers requires interventions matched to adolescents’ developmental and socio-cultural contexts, not simply scaled-down versions of adult programs. They call for stigma reduction campaigns, strengthened provider training in adolescent-friendly and nonjudgmental care, reform of consent policies that currently exclude minors from confidential prevention services, and expansion of youth-centred service models, including flexible hours, community-based delivery and digital support. The review’s conclusions carry particular weight because they are grounded in a systematic synthesis rather than single-site experience, and because the sixteen included studies, though few, consistently converge on the same barrier domains across three continents.

The implications extend beyond PrEP itself. As long-acting injectable prevention and the dapivirine ring enter adolescent populations, the same structural barriers, consent rules, stigma, mistrust and access constraints, will determine whether these innovations reach the people who need them. The review suggests that the technology of HIV prevention has outpaced the sociology of its delivery, and that closing the gap for adolescents and young people is now among the most urgent tasks in the global response to the epidemic.

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Subject of Research: Barriers to the uptake and sustained adherence to pre-exposure prophylaxis among adolescents and young people at risk of HIV acquisition: a systematic review of available evidence

Article Title: Barriers to the uptake and sustained adherence to pre-exposure prophylaxis among adolescents and young people at risk of HIV acquisition: a systematic review of available evidence

Article References: Isah, A., Onyia, I. M.-A., Ezike, C. B., Eze, C. C., Sospeter, S. B., Orok, E., Onyehalu, J. C., & Ezenri, G. (2026). Barriers to the uptake and sustained adherence to pre-exposure prophylaxis among adolescents and young people at risk of HIV acquisition: a systematic review of available evidence. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15650-4

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15650-4

Keywords: Barriers, uptake, sustained, adherence, pre-exposure, prophylaxis, adolescents, young, people, risk, acquisition, systematic

A new cross-sectional study conducted at three provincial public hospitals in An Giang and Ca Mau, Vietnam, between January and March 2026, offers a systematic answer to why patients with diabetes fail to adhere. The researchers recruited 644 eligible patients aged 18 or older with a confirmed diabetes diagnosis who were using at least one antidiabetic medication, using a convenience-based consecutive sampling approach that enrolled the first five eligible patients per day at each hospital over 57 working days. Participants completed a structured self-administered questionnaire during outpatient visits, administered by trained research assistants who were not involved in their clinical care. The mean age of participants was 57.59 years, most were female (54.5 percent) and married (79.3 percent), 95.5 percent had health insurance, and 22.5 percent were on polypharmacy, defined as five or more prescribed medications.

The questionnaire’s centerpiece was a Vietnamese adaptation of the Identification of Medication Adherence Barriers Questionnaire, or IMAB-Q, a tool built on evidence about modifiable factors associated with treatment adherence and mapped to the Theoretical Domains Framework. Each item was rated on a 5-point Likert scale, with reverse coding applied so that higher scores always indicated greater barriers. Medication adherence itself was measured with the Brief Adherence Rating Scale, whose final item is a visual analog scale from 0 to 100 percent that served as the continuous outcome. Quality of life was assessed with the EQ-5D-5L questionnaire covering mobility, self-care, usual activities, pain or discomfort, and anxiety or depression. The English instruments were translated using a standardized forward-backward procedure, reviewed by a panel of three experts including a clinician, a clinical pharmacist, and a public health specialist, and pilot-tested among 30 patients with no further modifications required.

For psychometric validation, the full sample was randomly split into two equal subsamples of 322 each. Exploratory factor analysis in the first subsample, using principal axis factoring and Promax rotation, initially identified seven factors with eigenvalues greater than 1. Several two-item factors and weakly loading items were removed, yielding a stable three-factor solution that explained 56.3 percent of the total variance. The retained domains were labeled medication management barriers, psychosocial barriers, and motivational barriers, with Cronbach’s alpha coefficients of 0.91, 0.84, and 0.89 respectively. Confirmatory factor analysis in the second subsample supported the structure, with a comparative fit index of 0.913, RMSEA of 0.076, and McDonald’s omega coefficients all exceeding 0.70. Discriminant validity was well established, with all heterotrait-monotrait ratios below the 0.85 threshold.

The structural equation modeling results delivered the study’s most striking finding. When all three barrier domains were considered simultaneously, only motivational barriers (unstandardized coefficient of –0.297, standardized coefficient of –0.261, p < 0.001) and psychosocial barriers (–0.194 and –0.156, p < 0.001) were significantly associated with medication adherence. Medication management barriers, by contrast, showed no independent association (p = 0.637). Bootstrap analysis with 1,000 resamples confirmed the robustness of these paths: the confidence intervals for motivational and psychosocial barriers excluded zero, while the interval for medication management barriers included it. Correlation analysis echoed the pattern, with motivational barriers showing the strongest negative correlation with adherence (r = –0.270, p < 0.001), and only psychosocial barriers correlating significantly with quality of life (r = –0.180, p < 0.001).

Why would motivation outweigh practical medication know-how? The researchers argue that motivational barriers reflect patients’ cognitive processes, emotional appraisal, and decision-making. Adherence is shaped by patients’ perceived need for treatment and their concerns about potential adverse consequences: when patients do not see medication as necessary, or harbor substantial worries about it, they are less likely to take it as prescribed. Motivation may improve when patients understand the necessity of medication and perceive its contribution to positive health outcomes. Notably, traditional sociodemographic and clinical variables failed to explain motivational barriers, as the regression model for this domain was not statistically significant (p = 0.259), suggesting that motivational barriers are shaped by more complex intrapersonal and contextual factors such as treatment beliefs, family support, or health literacy, which the current model did not capture.

Psychosocial barriers, reflected mainly in emotional burden, social influence, and lifestyle-related conflict, tell a story familiar from qualitative research on type 2 diabetes. After a prolonged treatment process and repeated life difficulties, patients may become exhausted with their lives and stop pursuing treatment and self-care. Fear of negative community reactions to the disease is a potent barrier: many patients conceal their condition, avoid taking medication in the presence of others, and even refuse monitoring by treatment supervisors. Family responsibilities, lifestyle preferences, and financial difficulties can also tip the decision against taking medication, while adhering to a strict regimen can disrupt daily life and make it hard to maintain important social roles with family and friends.

The regression models did identify predictors for the other two domains. Polypharmacy was associated with higher psychosocial barrier scores (p = 0.008), consistent with evidence that complex medication regimens are linked to poorer glycemic control, lower adherence, and reduced health-related quality of life, and that patients taking multiple medications experience psychological stress from frequent hospital visits, financial burden, and a reduced sense of independence. For medication management barriers, participants with health insurance had significantly lower barrier scores (p = 0.001), while a higher number of chronic comorbidities was associated with higher barrier scores (p = 0.009). Multimorbidity, the authors note, creates a persistent imbalance between illness and treatment burden and the patient’s capacity to manage that burden, complicating care coordination, self-care, and medication organization.

The authors caution that the three-factor structure should be viewed as a context-specific organization of the original IMAB-Q barriers rather than a direct replication of a fixed structure, since the original UK validation produced four scales whose associations did not follow the hypothesized Theoretical Domains Framework domains. They also acknowledge the limits of the cross-sectional design, the susceptibility of self-reported measures to recall and social desirability bias, and the potential selection bias from excluding 24.7 percent of returned questionnaires that were more than half blank, mainly due to questionnaire fatigue among older outpatients. Still, the policy implications are clear: diabetes management programs should go beyond medication provision and counseling, prioritizing individualized psychosocial support, patient-centered communication, and strategies that strengthen treatment motivation, with patients on polypharmacy singled out for targeted interventions. Motivational and psychosocial barriers, the study concludes, are the most promising targets for future adherence-improving interventions in diabetes care.

Subject of Research: Medication adherence barriers among patients with diabetes mellitus: barrier domains, associated factors, and associations with medication adherence

Article Title: Medication adherence barriers among patients with diabetes mellitus: barrier domains, associated factors, and associations with medication adherence

Article References: Le, M. H., Hang, Q. D., Trieu, T. B., Nguyen, M. C., Lam, Q. V., Tran, T. D., & Huynh, M. C. (2026). Medication adherence barriers among patients with diabetes mellitus: barrier domains, associated factors, and associations with medication adherence. Pharmacia, 73, Article e205741. https://doi.org/10.3897/pharmacia.73.e205741

Image Credits: AI Generated

DOI: 10.3897/pharmacia.73.e205741

Keywords: diabetes, medication adherence, Vietnam, psychosocial barriers, motivation, public health, Medication, adherence, barriers, patients, mellitus, barrier

The problem the study tackles is one of the most stubborn in cardiovascular medicine. Cardiac rehabilitation, which combines structured exercise, education, and psychosocial support, carries a Class IA recommendation in international guidelines for patients recovering from bypass surgery, and its benefits are well documented: better exercise capacity, improved cardiac function, and stronger psychological well-being. Yet participation remains dismal. Fewer than half of eligible patients in developed countries attend a program, and in developing nations the figure drops below 10 percent. The barriers are mundane but powerful: distance to the hospital, transportation costs, work schedules, and family obligations. Home-based telerehabilitation, delivered through wearable heart rate monitors, mobile applications, and periodic video or telephone consultations, has been proposed as a way around these obstacles, but rigorous real-world comparisons with careful confounding control have been scarce.

The research team screened the electronic health records of 288 adults aged 30 to 75 who underwent isolated CABG between February 2024 and February 2025, ultimately identifying 195 potentially eligible patients. After excluding 28 whose rehabilitation exposure could not be clearly documented, 167 patients formed the propensity-score estimation cohort: 56 who enrolled in home-based telerehabilitation, 54 in center-based rehabilitation, and 57 who received usual care without any formal program. The primary complete-case analysis then focused on the 105 patients, 35 per group, who completed full 12-week assessments. Because patients were not randomized, the investigators used generalized propensity scores and overlap weighting to adjust for 25 baseline covariates, ranging from age, sex, and body mass index to digital literacy, family support, distance to the rehabilitation center, and baseline fitness measures.

The home program itself was a carefully structured prescription rather than a casual suggestion to stay active. Patients received a wearable Polar H10 heart rate monitor paired with a dedicated mobile application and were asked to complete three aerobic sessions per week for 12 weeks, 36 sessions in total, each targeting 30 to 60 minutes of exercise at 60 to 80 percent of heart rate reserve, plus two weekly resistance training sessions. Intensity was progressed every two weeks based on heart rate response and perceived exertion on the Borg scale. Crucially, the researchers defined a session as completed only when at least 30 minutes of prescribed exercise at target intensity were objectively documented by the wearable device; app entries without valid sensor data did not count. Center-based patients attended the hospital’s outpatient program with the same prescription but under direct supervision with continuous ECG telemetry, and their adherence was verified through physiotherapist-signed attendance records and telemetry logs.

The headline result concerns adherence, the study’s primary implementation outcome. Patients in the home-based arm completed a mean of 87.7 percent of their prescribed sessions, compared with 78.5 percent in the center-based arm, an overlap-weighted difference of 9.1 percentage points with a 95 percent confidence interval of 4.4 to 13.7 and a P value below 0.001. The gap widened at the high end of the distribution: 78.6 percent of home-based patients achieved at least 80 percent completion, versus 44.4 percent of center-based patients, and 46.4 percent of the home group reached 90 percent or more, compared with just 13.0 percent of the center group. Home patients also logged more objectively verified exercise minutes overall, 1,578 versus 1,413, and more minutes at target intensity. Technical failures, such as lost or invalid wearable recordings, affected only 1.7 percent of prescribed home sessions.

On the key clinical outcome, the two delivery models proved remarkably close. Peak oxygen uptake, or VO2peak, measured by symptom-limited cardiopulmonary exercise testing on a cycle ergometer, rose from a baseline of roughly 18.3 to 18.4 mL/kg/min to about 23.1 to 23.6 mL/kg/min at 12 weeks in both rehabilitation groups. The adjusted difference between the home and center arms was a mere 0.17 mL/kg/min, with a confidence interval spanning −0.50 to 0.84 and a P value of 0.616, statistically indistinguishable from zero. Both active groups, however, dramatically outperformed usual care, which saw VO2peak inch up from 18.5 to 19.1 mL/kg/min; the adjusted advantages over control exceeded 4.0 mL/kg/min for both rehabilitation modalities. Given that lower VO2peak is strongly associated with increased mortality in cardiac populations, gains of that magnitude are clinically noteworthy.

Secondary outcomes told a consistent story. Six-minute walk distance improved by roughly 75 meters in both rehabilitation groups compared with control, with no meaningful difference between them. Left ventricular ejection fraction, measured by blinded readers using the biplane Simpson method, rose by about 4 to 5 percentage points in both active arms. Psychological measures moved in parallel: scores on the Hamilton Anxiety and Depression scales fell by 6 to 8 points in both rehabilitation groups while barely changing in usual care, and quality-of-life scores on the SF-36 physical and mental component summaries climbed by 16 to 22 points. Safety findings were reassuring in absolute terms: no major adverse cardiovascular events occurred in either rehabilitation group during the 12-week window, while two occurred among usual-care patients, though the small event counts precluded formal comparative safety inference. Exercise-related adverse events were uncommon and similar in character across both programs, including occasional chest pain, arrhythmia, and musculoskeletal complaints.

The investigators were careful about what their design can and cannot show. Because patients self-selected into each modality, unmeasured differences in motivation and preference may persist despite the extensive covariate adjustment, and the study was not powered or designed to formally test equivalence or non-inferiority between the two delivery models. Selection is a real concern: of the 195 potentially eligible patients, 46.2 percent were excluded from the complete-case analysis, and those excluded patients had fewer years of education, more frailty, lower employment rates, and markedly lower family support scores. The authors also note that the two delivery models differed not only in setting but in supervision intensity, with home patients exercising independently and receiving roughly 12 scheduled tele-consultations, so residual differences in how adherence was ascertained, device verification at home versus direct observation in center, cannot be fully excluded. Sensitivity analyses, including unweighted models, multiple imputation, restriction to a strict 11-to-13-week assessment window, and exclusion of crossovers, all produced directionally consistent estimates for the VO2peak comparison.

An exploratory analysis probing whether higher adherence drove better functional outcomes found a positive but non-significant association: each 10-percentage-point increase in adherence was associated with roughly 0.62 mL/kg/min greater VO2peak gain, with a confidence interval that just crossed zero. The authors explicitly caution against a causal reading, since healthier, more motivated, or faster-recovering patients may both complete more sessions and improve more, a classic healthy-adherer effect that observational data cannot untangle. The adherence-by-modality interaction was also non-significant, suggesting the adherence-outcome relationship did not differ meaningfully between the home and center programs.

What the study does establish is feasibility in routine practice. Among post-CABG patients who chose between the two options in a real clinical setting, home-based telerehabilitation delivered objectively verified adherence that exceeded center-based care and functional recovery that looked essentially identical at 12 weeks. For patients juggling work, travel, or caregiving obligations, the findings support offering a monitored home program as a legitimate alternative rather than a second-best compromise. The authors call for future work on clinical meaningfulness and cost-effectiveness, and longer follow-up will be needed to see whether early fitness gains translate into durable outcomes. But the message for the millions of bypass patients each year who cannot reach a hospital gym is clear: with a chest strap, a smartphone, and a structured prescription, the road to recovery may run straight through their living room.

Subject of Research: Home-based versus center-based cardiac rehabilitation adherence and functional outcomes after coronary artery bypass grafting

Article Title: Home-based telerehabilitation after CABG: higher objectively verified adherence and 12-week functional outcomes in a single-center observational cohort

Article References: Liu, Y., Wang, X., Wang, C., Zhang, M., Kong, M., Wang, M., Ma, J., & Liu, H. (2026). Home-based telerehabilitation after CABG: higher objectively verified adherence and 12-week functional outcomes in a single-center observational cohort. Frontiers in Cardiovascular Medicine, 13, Article 1947232. https://doi.org/10.3389/fcvm.2026.1947232

Image Credits: AI Generated

DOI: 10.3389/fcvm.2026.1947232

Keywords: cardiac rehabilitation, coronary artery bypass grafting, telerehabilitation, wearable sensors, adherence, VO2peak, observational cohort, cardiovascular medicine, propensity score analysis, exercise capacity, digital health, patient recovery

Chronic heart failure is far more than a problem of a failing pump. The condition disrupts the delicate interplay between the heart and the lungs, producing pulmonary congestion, altered gas exchange, and impaired lung mechanics. As a result, the work and energy cost of every breath rises, and even modest physical effort becomes exhausting. This physiological burden explains why patients with heart failure often experience profound breathlessness and fatigue, and why rehabilitation programs that target only the legs and arms may miss a crucial piece of the therapeutic puzzle. The Bialystok team designed their intervention with this cardiopulmonary coupling in mind, pairing conventional endurance training with structured breathing exercises and inspiratory muscle training.

The evidence base for exercise training in heart failure is already strong. Large randomized trials and meta-analyses have shown that regular exercise improves physical endurance and quality of life, reduces all-cause and heart failure-related hospitalizations, and may even lower long-term mortality. The European Society of Cardiology currently recommends supervised exercise training and rehabilitation for all patients with chronic heart failure who are able to participate. Yet in practice, cardiac rehabilitation remains dramatically underused, with participation rates estimated at only 10 to 30 percent. Distance, cost, frailty, and simple logistics keep many patients from ever setting foot in a center-based program, creating an urgent need for models that work beyond the clinic walls.

To test whether rehabilitation could be safely and effectively moved into patients’ homes, the researchers enrolled 63 patients with stable heart failure with reduced ejection fraction, meaning their hearts pumped at less than 40 percent of normal capacity. Participants were randomized in a 3:2 ratio to an intervention or control group. The intervention group received detailed instruction in a tailored home program: physical training performed once daily, at least five times per week, at an intensity of 4 to 5 points on a 10-point Borg scale of perceived exertion, building toward sessions of 45 to 60 minutes. Each patient also received a Pulmogain RespiTrain device for resistance training of the respiratory muscles, along with an illustrated booklet, a pedometer, and a self-monitoring diary to record heart rate, blood pressure, breathlessness, and step counts.

Crucially, the program did not abandon patients to their own devices. Scheduled clinic visits at one and three months allowed the team to verify exercise technique and adjust the training plan, while weekly telephone support reinforced adherence. Family members or caregivers were trained to supervise sessions at home. This hybrid of autonomy and remote oversight proved remarkably effective: adherence to the recommended protocol, defined as completing at least 120 sessions over 24 weeks, averaged an impressive 91.5 percent, and 82.8 percent of patients who started the program completed the full six-month assessment. Patients logged an average of more than 9,000 steps per day, including roughly 3,300 steps within each dedicated training session.

The physiological results were striking. After six months, the distance patients could walk in six minutes, a standard measure of functional capacity, increased by an average of 37.86 meters, a change the authors describe as clinically meaningful. Maximal inspiratory pressure, the force the diaphragm and other inspiratory muscles can generate, rose by 20.21 centimeters of water, while maximal expiratory pressure climbed by 20.75 centimeters of water, both highly statistically significant gains. Fatigue, measured with the validated Fatigue Severity Scale, fell by an average of 0.68 points. Notably, the magnitude of the inspiratory pressure improvement closely matches results from meta-analyses of supervised inspiratory muscle training, which reported gains of roughly 16 to 25 centimeters of water, suggesting that home-based delivery can achieve comparable physiological effects.

The respiratory component of the program deserves particular attention. Heart failure impairs ventilation and the matching of airflow to blood perfusion in the lungs, and previous research has shown that breathing exercises and inspiratory muscle training can improve not only respiratory mechanics but also exercise tolerance and quality of life. Meta-analytic data indicate that patients with inspiratory muscle weakness benefit most from this form of training, and the baseline inspiratory pressure of the Bialystok cohort, around 63 centimeters of water, was consistent with substantial respiratory muscle impairment. The study’s combined approach, pairing endurance walking with targeted respiratory resistance training, produced gains consistent with the best results reported in the supervised literature.

Safety, often the central concern when prescribing unsupervised exercise to cardiac patients, was reassuring. No serious adverse events related to training were reported, and no deaths occurred in the heart failure group. The few exercise-related complaints were minor: one case each of excessive fatigue, breathlessness, and calf cramps, and two episodes of chest pain. The researchers attribute this safety profile to careful patient selection, thorough instruction in contraindications and safe exercise principles, and the structured self-monitoring system that kept the study team informed of each patient’s status week by week.

The study was not without limitations, and the authors are candid about them. The COVID-19 pandemic disrupted the original design, and the control group could not be assessed after six months because most participants were unwilling to attend hospital visits during lockdowns. This means the analysis effectively became a single-arm before-and-after comparison, so some of the observed improvement could reflect natural variability, regression to the mean, or the motivating effect of increased attention. The sample was also small, dominated by men, and enrolled before newer heart failure drugs such as SGLT2 inhibitors became standard. These caveats temper the strength of the conclusions, though they do not erase the consistency of the physiological gains with the broader supervised-rehabilitation literature.

Even with those qualifications, the implications are considerable. Prior systematic reviews have found home-based cardiac rehabilitation to be non-inferior to center-based programs in clinical outcomes, with marginally higher completion rates, and the landmark HF-ACTION trial struggled to keep long-term adherence above 30 percent even with intensive support. Against that benchmark, an adherence rate above 90 percent in an unsupervised, home-delivered program is remarkable, and the authors suggest that simple tools such as pedometers, diaries, and weekly phone calls may offer a viable, cost-effective alternative to high-tech telemonitoring, especially in low-resource settings. For the vast majority of heart failure patients who never receive rehabilitation today, a program that requires little more than a pair of legs, a breathing device, a booklet, and a telephone line could bring the benefits of the clinic directly into the home.

Subject of Research: Home-based exercise and respiratory rehabilitation for chronic heart failure

Article Title: Beyond the clinic: a six-month home-based exercise and respiratory rehabilitation program improves functional capacity, respiratory muscle strength, and fatigue in chronic heart failure

Article References: Ciołkiewicz, M., Wojciuk, M., Kuryliszyn-Moskal, A., Dakowicz, A., Sawicka-Śmiarowska, E., & Kamiński, K. (2026). Beyond the clinic: a six-month home-based exercise and respiratory rehabilitation program improves functional capacity, respiratory muscle strength, and fatigue in chronic heart failure. Frontiers in Rehabilitation Sciences, 7, Article 1958027. https://doi.org/10.3389/fresc.2026.1958027

Image Credits: AI Generated

DOI: 10.3389/fresc.2026.1958027

Keywords: heart failure, cardiac rehabilitation, home-based exercise, respiratory muscle training, inspiratory muscle training, six-minute walk test, fatigue, functional capacity, HFrEF, adherence, telemonitoring, pilot study

The commentary, written by Joseph Russo, Vinita Vidya, and Robert Stansbury of West Virginia University’s Division of Pulmonary, Critical Care and Sleep Medicine, responds to a growing body of evidence suggesting that oral appliance adherence is far more complicated than a single nightly usage figure can capture. The authors center their argument on a one-year longitudinal pilot study by Zhang and colleagues that tracked both objective and subjective adherence in adults using mandibular advancement devices, and their conclusion is provocative: patients and clinicians often disagree about how much the device is being used, and neither number alone tells the full story of therapeutic benefit.

Obstructive sleep apnea affects hundreds of millions of people worldwide and is driven by the repeated collapse of the upper airway during sleep, fragmenting sleep, starving the body of oxygen, and raising the long-term risk of hypertension, cardiovascular disease, stroke, and daytime cognitive impairment. Oral appliances work by holding the lower jaw, and with it the tongue and surrounding soft tissues, in a forward position, mechanically propping open the pharyngeal airway. They are recommended by clinical practice guidelines, including the American Academy of Sleep Medicine’s 2015 update, as a first-line option for patients with mild to moderate apnea and for those with severe disease who cannot tolerate or decline CPAP.

The appeal of these devices is obvious. They are small, silent, portable, and free of the pressurized airflow that drives many patients away from CPAP. But that same convenience creates a measurement problem. A CPAP machine is, in effect, its own compliance monitor, logging pressure, flow, and mask-on time every night. A mandibular advancement device is a piece of molded acrylic and hardware that sits silently in the mouth, generating no data of its own unless it is fitted with embedded sensors. Historically, clinicians have therefore relied on what patients tell them, and self-report is notoriously unreliable in sleep medicine, with patients consistently overestimating how often and how long they use their devices.

The Zhang pilot study highlighted in the commentary tackled this gap by comparing objective adherence data with subjective patient reports over a full year of therapy, an unusually long follow-up window for this kind of device monitoring. The commentary’s authors use those findings to make a broader conceptual point: adherence to oral appliance therapy is not a single number but a multidimensional behavior. It includes how many nights per week the device is worn, how many hours per night, whether it is worn consistently across the entire sleep period or removed partway through the night, and whether the device’s titration, the gradual forward adjustment of the jaw, has actually been optimized to control the patient’s apnea.

That last dimension may be the most underappreciated. A patient can wear a mandibular advancement device faithfully every night for eight hours and still have untreated, or undertreated, sleep apnea if the jaw has not been advanced far enough to keep the airway open during rapid eye movement sleep, when muscles relax most completely and airway collapse is most likely. Conversely, a patient who wears the device fewer hours but at an effective titration position may derive more genuine protection. Hours per night, in other words, is a proxy for exposure, not for efficacy, and conflating the two risks mislabeling adherent-but-undertreated patients as successfully managed.

The timing of this rethinking is significant because the therapeutic landscape of obstructive sleep apnea is changing rapidly. The field has moved decisively toward precision or endophenotype-based approaches, as reflected in a 2025 American Thoracic Society research statement on translating apnea subtyping into clinical practice. Pharmaceutical options have arrived as well: the GLP-1 receptor agonist tirzepatide demonstrated meaningful reductions in apnea severity in obese patients in a landmark 2024 New England Journal of Medicine trial, and a combination therapy of aroxybutynin and atomoxetine, known as AD109, completed a randomized phase 3 trial targeting the neural control of upper airway tone. In a world of tailored, multimodal therapy, the commentary argues, a blunt nightly-hours metric for oral appliances looks increasingly anachronistic.

Technology is also converging on the problem. Digital dentistry workflows, including intraoral scanning and computer-aided design and fabrication of custom devices, have been shown in pilot studies to produce mandibular advancement devices with comparable or improved usability compared with conventional fabrication, and they open the door to embedded sensors that log temperature, movement, and wear time objectively. The commentary situates these developments within a broader vision of combination therapy, in which oral appliances are paired with positional therapy, weight management, pharmacotherapy, or even surgically fabricated hybrid devices, each component monitored on its own terms rather than collapsed into a single adherence statistic.

The clinical implications are concrete. If adherence is multidimensional, then follow-up visits should ask not only how often the device is in the mouth but whether the patient wakes refreshed, whether a bed partner still hears snoring, and whether objective testing shows the apnea hypopnea index actually falling into the treated range. Sleep physicians and dentists, who jointly manage most oral appliance patients, need shared frameworks for distinguishing a device that is worn but ineffective from one that is effective but inconsistently worn, because the interventions differ completely: the first calls for retitration or combination therapy, the second for adherence support and troubleshooting discomfort, dry mouth, dental changes, or temporomandibular symptoms that drive patients to quietly abandon the device.

What makes the commentary resonate beyond the sleep clinic is its challenge to a habit of measurement that extends across medicine. Adherence metrics are convenient because they are countable, but countable is not the same as meaningful. For the millions of patients who choose a mouthguard over a mask, the question that ultimately matters is not how many hours the device spent in the mouth but whether the airway stayed open, the oxygen stayed up, and the long-term health risks of untreated apnea actually receded. Reframing adherence around those outcomes, the authors suggest, is the necessary next step for a therapy whose popularity continues to grow while the way it is judged has barely evolved since the first practice parameters were written three decades ago.

Subject of Research: Redefining adherence measurement for oral appliance therapy in obstructive sleep apnea

Article Title: Beyond hours per night: rethinking oral appliance adherence in OSA

Article References: Russo, J., Vidya, V., & Stansbury, R. (2026). Beyond hours per night: rethinking oral appliance adherence in OSA. Journal of Clinical Sleep Medicine, 22(1), Article 196. https://doi.org/10.1007/s44470-026-00207-3

Image Credits: AI Generated

DOI: 10.1007/s44470-026-00207-3

Keywords: obstructive sleep apnea, oral appliance therapy, mandibular advancement device, adherence, CPAP, sleep medicine, titration, digital dentistry, tirzepatide, precision medicine, Journal of Clinical Sleep Medicine, Beyond

The research team followed the PRISMA 2020 reporting guidelines and searched six major databases—PubMed, Embase, PsycINFO, Web of Science, Scopus, and the WHO Global Index Medicus—up to August 2025, with no language restrictions. To be eligible, studies had to be observational in design, assess depression using either a validated rating scale or a clinical diagnosis, evaluate patients undergoing anti-tuberculosis therapy, and report treatment outcomes. Thirteen studies ultimately met these criteria. Risk of bias in the included studies was appraised with the Newcastle-Ottawa Scale, a standard instrument for non-randomized research, and the pooled estimates were generated using random-effects modeling with the DerSimonian-Laird method, which assumes that the true effect may vary from study to study rather than being a single fixed quantity.

The headline result is striking. Across the pooled data, depression was associated with substantially higher odds of an unfavorable end-of-treatment outcome, with an odds ratio of 3.66 and a 95 percent confidence interval spanning 1.51 to 8.90. In practical terms, depressed tuberculosis patients were roughly three and a half times more likely to experience treatment failure, abandonment of therapy, or death than their non-depressed counterparts. Heterogeneity between studies was high, with an I-squared statistic of 81.2 percent, indicating that the underlying effect varied considerably across populations and settings. The authors also calculated a 95 percent prediction interval ranging from 0.20 to 65.99, a sobering reminder that in a future study the effect could, in principle, be very small or extraordinarily large depending on context.

Because heterogeneity and small-study effects can distort meta-analytic conclusions, the team subjected their findings to a battery of sensitivity analyses. Leave-one-out analyses, in which each study is removed in turn and the pooled estimate recalculated, produced odds ratios ranging from 1.31 to 4.79 for unfavorable outcomes. While this range confirms that the direction of the effect remained consistent, it also reveals how sensitive the magnitude is to individual studies. The Doi plot, a graphical alternative to the traditional funnel plot for detecting publication bias, showed major asymmetry, quantified by an LFK index of 6.96—a value well above the thresholds conventionally interpreted as indicating minor or no asymmetry. This suggests that smaller studies reporting stronger associations may be overrepresented in the literature, a common problem in observational meta-analyses that readers should keep in mind when weighing the headline figure.

The analysis of treatment non-compliance, based on seven of the included studies, told a similar but somewhat more stable story. Depression increased the odds of non-compliance with anti-tuberculosis therapy, with a pooled odds ratio of 2.85 and a confidence interval of 1.48 to 5.46. Heterogeneity was again high at 80.6 percent, and the prediction interval stretched from 0.34 to 23.79. The Doi plot showed only minor asymmetry here, with an LFK index of 1.85, and leave-one-out estimates clustered more tightly, ranging from 1.99 to 2.67. Taken together, these checks suggest that the link between depression and failure to adhere to the demanding months-long drug regimen is robust, even if its precise size varies across settings.

Perhaps the most technically interesting result emerged when the authors restricted the non-compliance analysis to the four studies that reported adjusted odds ratios—estimates that statistically account for confounding variables such as age, sex, HIV status, socioeconomic position, and disease severity. When these adjusted estimates were pooled, the association not only persisted but strengthened, yielding an adjusted odds ratio of 3.48 with a confidence interval of 2.51 to 4.45. Crucially, heterogeneity collapsed to zero percent. The disappearance of heterogeneity in the adjusted analysis is notable because it implies that much of the variability seen in the crude estimates may stem from differences in the confounder profiles of the study populations rather than from genuine differences in the underlying biological or behavioral relationship. In other words, once confounders are properly controlled, depression appears to act as a strong and remarkably consistent independent predictor of non-compliance.

The mechanistic plausibility of this link is not difficult to construct. Tuberculosis treatment typically requires six months or more of daily multidrug therapy, and in drug-resistant cases the regimen can stretch to two years with injectable agents and burdensome side effects. Depression is known to sap motivation, impair executive function, and promote social withdrawal, all of which can erode the daily discipline that successful therapy demands. There are also biological threads worth exploring: inflammatory cytokines such as interleukin-6 and tumor necrosis factor-alpha, which are elevated in tuberculosis, have been implicated in depressive symptomatology, raising the possibility of a bidirectional relationship in which infection worsens mood and poor mood worsens treatment engagement. The included studies used a variety of validated instruments, including the Patient Health Questionnaire-9, the Beck Depression Inventory, the Hospital Anxiety and Depression Scale, the Center for Epidemiologic Studies Depression Scale, the Hamilton Depression Rating Scale, and the Aga Khan University Anxiety and Depression Scale, as well as clinical diagnoses under DSM and ICD frameworks, lending credibility to the exposure assessment.

The public health implications are considerable. The World Health Organization’s End TB Strategy and the classic DOTS framework of directly observed treatment were built on the assumption that patients, once diagnosed, will complete therapy if drugs and supervision are available. This meta-analysis suggests that assumption fails a substantial subset of patients whose untreated depression quietly sabotages their recovery. The authors argue that routine depression screening at the start of tuberculosis treatment, followed by integrated, stepped mental health care within tuberculosis services, is likely to improve both adherence and treatment success. Stepped care models, which match the intensity of psychological and pharmacological intervention to symptom severity, have proven feasible in other chronic disease settings and could be adapted for tuberculosis programs in high-burden countries where mental health resources are scarce.

Several caveats temper the enthusiasm. All thirteen included studies were observational, so causality cannot be definitively established; reverse causation and residual confounding remain possible, and the major asymmetry detected in the outcome analysis hints at publication bias. The high heterogeneity in the crude analyses and the wide prediction intervals mean that the pooled odds ratios should be read as central tendencies within a broad distribution of context-dependent effects rather than as universal constants. The authors themselves call for prospective trials of integrated depression screening and treatment models within tuberculosis care, which would provide the interventional evidence needed to move from association to actionable policy.

Even with those limitations, the study lands at a consequential moment. Drug-resistant tuberculosis is rising in many regions, and every patient who abandons therapy risks not only personal relapse but the selection of resistant strains that are far costlier and harder to cure. If depression triples the odds of that abandonment, then mental health care stops being a luxury adjunct and becomes core tuberculosis infrastructure. The message for clinicians, program managers, and funders is blunt: a curable disease cannot be cured by drugs alone when the mind carrying the regimen is left untreated. Screening a tuberculosis patient for depression takes minutes; the analysis suggests it could be one of the highest-yield interventions in the entire treatment cascade.

Subject of Research: The association between depression and treatment compliance and outcomes in tuberculosis patients

Article Title: Association between depression and compliance to treatment of tuberculosis and its outcomes: a systematic review and meta-analysis

Article References: Han, J., Yang, F., Wang, J., & Chen, Y. (2026). Association between depression and compliance to treatment of tuberculosis and its outcomes: a systematic review and meta-analysis. BMC Psychiatry. https://doi.org/10.1186/s12888-026-08627-4

Image Credits: AI Generated

DOI: 10.1186/s12888-026-08627-4

Keywords: tuberculosis, depression, meta-analysis, treatment compliance, mental health, systematic review, odds ratio, public health, adherence, BMC Psychiatry, drug-resistant TB, screening