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Abstract Objective:The progression of long-term diabetes complications has led to a decreased quality of life. Our objective was to evaluate the adverse outcomes associated with diabetes based on a patient’s clinical profile by utilizing a multistate modeling approach. Methods:This was a retrospective study of diabetes patients seen in primary care practices from 2013 to 2017. We implemented a five-state model to examine the progression of patients transitioning from one complication to having multiple complications. Our model incorporated high dimensional covariates from multisource data to investigate the possible effects of different types of factors that are associated with the progression of diabetes. Results:The cohort consisted of 10,596 patients diagnosed with diabetes and no previous complications associated with the disease. Most of the patients in our study were female, White, and had type 2 diabetes. During our study period, 5928 did not develop complications, 3323 developed microvascular complications, 1313 developed macrovascular complications, and 1129 developed both micro- and macrovascular complications. From our model, we determined that patients had a 0.1334 [0.1284, .1386] rate of developing a microvascular complication compared to 0.0508 [0.0479, .0540] rate of developing a macrovascular complication. The area deprivation index score we incorporated as a proxy for socioeconomic information indicated that patients who reside in more disadvantaged areas have a higher rate of developing a complication compared to those who reside in least disadvantaged areas. Conclusions:Our work demonstrates how a multistate modeling framework is a comprehensive approach to analyzing the progression of long-term complications associated with diabetes. 

Solving the domain shift problem during inference is essential in medical imaging as most deep-learning based solutions suffer from it. In practice, domain shifts are tackled by performing Unsupervised Domain Adaptation (UDA), where a model is adapted to an unlabeled target domain by leveraging the labelled source domain. In medical scenarios, the data comes with huge privacy concerns making it difficult to apply standard UDA techniques. Hence, a closer clinical setting is Source-Free UDA (SFUDA), where we have access to source trained model but not the source data during adaptation. Methods trying to solve SFUDA typically address the domain shift using pseudo-label based self-training techniques. However due to domain shift, these pseudo-labels are usually of high entropy and denoising them still does not make them perfect labels to supervise the model. Therefore, adapting the source model with noisy pseudo labels reduces its segmentation capability while addressing the domain shift. To this end, we propose a two-stage approach for source-free domain adaptive image segmentation: 1) Target-specific adaptation followed by 2) Task-specific adaptation. In the Stage-I, we focus on learning target-specific representation and generating high-quality pseudo labels by leveraging a proposed ensemble entropy minimization loss and selective voting strategy. In Stage II, we focus on improving segmentation performance by utilizing teacher-student self-training and augmentation-guided consistency loss, leveraging the pseudo labels obtained from Stage I. We evaluate our proposed method on both 2D fundus datasets and 3D MRI volumes across 7 different domain shifts where we achieve better performance than recent UDA and SF-UDA methods for medical image segmentation. Code is available at https://github.com/Vibashan/tt-sfuda.