Meeting the Challenge of Virtual Diabetes Care: A Consensus Viewpoint on the Positioning and Value of Oral Semaglutide in Routine Clinical Practice.

While glucagon-like peptide-1 receptor agonists (GLP-1 RAs), such as semaglutide, are among the most effective drugs for treating people with type 2 diabetes (T2D), they are clinically under-utilised. Until recently, the only route for semaglutide administration was via subcutaneous injection. However, an oral formulation of semaglutide was recently licensed, with the potential to address therapy inertia and increase patient adherence to treatment, which is essential in controlling blood glucose and reducing complications. The availability of oral semaglutide provides a new option for both clinicians and patients who are reluctant to use an injectable agent. This has been of particular importance in addressing the challenge of virtual diabetes care during the COVID-19 pandemic, circumventing the logistical problems that are often associated with subcutaneous medication administration. However, there remains limited awareness of the clinical and economic value of oral semaglutide in routine clinical practice. In this article, we present our consensus opinion on the role of oral semaglutide in routine clinical practice and discuss its value in reducing the burden of delivering diabetes care in the post-COVID-19 pandemic period of chronic disease management.

Prior Injury, Health-Related Quality of Life, Disablement, and Physical Activity in Former Women's Soccer Players.

CONTEXT: Former collegiate athletes may be at risk for negative health outcomes such as lower health-related quality of life (HRQoL), greater disablement, and lower lifetime physical activity (PA) participation. A history of severe sport injury may play a role in these outcomes. OBJECTIVE: To assess the role of prior sport injury in self-reported HRQoL, levels of disablement, and PA behaviors of former National Collegiate Athletic Association Division I women's soccer players. DESIGN: Cross-sectional study. SETTING: Online survey. PATIENTS OR OTHER PARTICIPANTS: Former Division I women's soccer players (n = 382, age = 36.41 ± 7.76 years) provided demographics and injury history and completed the Patient-Reported Outcomes Measurement Information System (HRQoL), the Disablement in the Physically Active Scale (disablement), and the Godin Leisure Time Physical Activity Questionnaire (PA). MAIN OUTCOME MEASURE(S): The dependent variables were the physical and mental component summary scores for HRQoL and disablement and the frequency of moderate-to-vigorous PA. Means, SDs, and correlations among the main outcome variables were examined for those who reported a severe injury (n = 261) and those who did not (n = 121). To address our primary aim, we conducted multiple regression analyses to predict HRQoL, disablement, and PA based on a history of severe injury, accounting for age. RESULTS: Having a severe injury significantly predicted worse physical HRQoL and worse physical disablement. Severe injury predicted a >2-point decrease and 5-point increase on the respective scales. Injury status did not predict mental HRQoL, mental disablement, or PA. CONCLUSIONS: Most participants reported sustaining a prior severe soccer-related injury, which may have had a negative long-term effect on health outcomes for former women's soccer players. Athletic trainers should be aware of the risk for decreased HRQoL and increased disablement with injury and encourage continued monitoring of relevant patient-reported outcomes.

Optimising the Heart Failure Treatment Pathway: The Role of SGLT2 Inhibitors.

Sodium-glucose cotransporter 2 (SGLT2) inhibitors were first developed as glucose-lowering therapies for the treatment of diabetes. However, these drugs have now been recognised to prevent worsening heart-failure events, improve health-related quality of life, and reduce mortality in people with heart failure with reduced ejection fraction (HFrEF), including those both with and without diabetes. Despite robust clinical trial data demonstrating favourable outcomes with SGLT2 inhibitors for patients with HFrEF, there is a lack of familiarity with the HF indication for these drugs, which have been the remit of diabetologists to date. In this article we use consensus expert opinion alongside the available evidence and label indication to provide support for the healthcare community treating people with HF regarding positioning of SGLT2 inhibitors within the treatment pathway. By highlighting appropriate prescribing and practical considerations, we hope to encourage greater, and safe, use of SGLT2 inhibitors in this population.

Diabetes and Frailty: An Expert Consensus Statement on the Management of Older Adults with Type 2 Diabetes.

Prognosis and appropriate treatment goals for older adults with diabetes vary greatly according to frailty. It is now recognised that changes may be needed to diabetes management in some older people. Whilst there is clear guidance on the evaluation of frailty and subsequent target setting for people living with frailty, there remains a lack of formal guidance for healthcare professionals in how to achieve these targets. The management of older adults with type 2 diabetes is complicated by comorbidities, shortened life expectancy and exaggerated consequences of adverse effects from treatment. In particular, older adults are more prone to hypoglycaemia and are more vulnerable to its consequences, including falls, fractures, hospitalisation, cardiovascular events and all-cause mortality. Thus, assessment of frailty should be a routine component of a diabetes review for all older adults, and glycaemic targets and therapeutic choices should be modified accordingly. Evidence suggests that over-treatment of older adults with type 2 diabetes is common, with many having had their regimens intensified over preceding years when they were in better health, or during more recent acute hospital admissions when their blood glucose levels might have been atypically high, and nutritional intake may vary. In addition, assistance in taking medications, as often occurs in later life following implementation of community care strategies or admittance to a care home, may dramatically improve treatment adherence, leading to a fall in glycated haemoglobin (HbA1c) levels. As a person with diabetes gets older, simplification, switching or de-escalation of the therapeutic regimen may be necessary, depending on their level of frailty and HbA1c levels. Consideration should be given, in particular, to de-escalation of therapies that may induce hypoglycaemia, such as sulphonylureas and shorter-acting insulins. We discuss the use of available glucose-lowering therapies in older adults and recommend simple glycaemic management algorithms according to their level of frailty.

Therapeutic inertia amongst general practitioners with interest in diabetes.

INTRODUCTION: As the therapeutic options in the management of type 2 diabetes increase, there is an increase confusion among health care professionals, thus leading to the phenomenon of therapeutic inertia. This is the failure to escalate or de-escalate treatment when the clinical need for this is required. It has been studied extensively in various settings, however, it has never been reported in any studies focusing solely on primary care physicians with an interest in diabetes. This group is increasingly becoming the focus of managing complex diabetes care in the community, albeit with the support from specialists. METHODS: In this retrospective audit, we assessed the prevalence of the phenomenon of therapeutic inertia amongst primary care physicians with an interest in diabetes in UK. We also assessed the predictive abilities of various patient level characteristics on therapeutic inertia amongst this group of clinicians. RESULTS: Out of the 240 patients reported on, therapeutic inertia was judged to have occurred in 53 (22.1%) of patients. The full model containing all the selected variables was not statistically significant, p=0.59. So the model was not able to distinguish between situations in which therapeutic inertia occurred and when it did not occur. None of the patient level characteristics on its own was predictive of therapeutic inertia. CONCLUSION: Therapeutic inertia was present only in about a fifth of patient patients with diabetes being managed by primary care physicians with an interest in diabetes.

Assessment of attitudes towards sun-protective behaviour in Australians: A cross-sectional study.

OBJECTIVE: To assess the knowledge, attitudes and behaviour towards sun protection measures in a sample of Australian adults. METHODS: A multicentre, cross-sectional study was undertaken during 2014 using a population-based survey of 416 individuals over the age of 18. The knowledge, behaviour and attitudes towards sun protection measures in this group of adults were assessed. The impact of educational level and employment status on responses was also evaluated. RESULTS: Sunscreen is the most common sun-protective measure. Daily sunscreen use is below 20%. Forgetfulness was the largest barrier to sunscreen use. A total of 85% of respondents did not apply a sufficient amount of sunscreen. Only 32% of individuals reapplied sunscreen every 2 hours and 20% never reapplied it. In the preceding year, one or more sun burns were suffered by 46% of the participants in the survey. In all, 36% of individuals rarely or never check their sunscreens expiry date and less than 50% of individuals replaced their sunscreen each year. Furthermore, 65% were unaware that sunscreens stored above 25°C were less effective than when stored correctly as per manufactures labelling. CONCLUSIONS: This study highlights a number of significant deficiencies that future sun-protection programmes could target in order to improve the general public's knowledge and attitudes towards sun protection. There is also a need for this to be translated into the public's sun-protection behaviour.

The influence of age and gender in knowledge, behaviors and attitudes towards sun protection: a cross-sectional survey of Australian outpatient clinic attendees.

OBJECTIVE: The aim of this study was to evaluate the differences in knowledge, attitudes, and behaviors regarding sun protection in different age groups and between men and women. METHOD: A multicenter cross-sectional study using a population-based survey of 416 individuals over the age of 18 years was undertaken during 2014. RESULTS: Of individuals aged 18-30 years, 94% had experienced at least one episode of sunburn in the previous year. The likelihood of self-examining increased as age increased (p < 0.001). Only 15% of participants used the recommended amount (40 ml) of sunscreen. Women were twice as likely to put on sunscreen as men. Women had better knowledge about sun protection and sunscreen use, and were twice as likely to know that sunscreen was denatured by heat and had an expiry date (p = 0.01). Women were more than twice as likely to put on sunscreen every day compared with men (p = 0.002). Reported barriers to sunscreen use included greasiness and forgetfulness and this was more commonly reported as age decreased (p = 0.002; p = 0.004). The younger population was less likely to use more than one modality of sun protection (p = 0.05). CONCLUSION: This study highlights a number of gender- and age-specific findings with regards to sun protection. There are knowledge, attitude, and behavior deficiencies within each demographic group that need to be specifically targeted through educational and public health efforts in order to improve general sun protection measures and decrease the incidence of skin cancers.

Reduction of pro-tumorigenic activity of human prostate cancer-associated fibroblasts using Dlk1 or SCUBE1.

Human prostatic cancer-associated fibroblasts (CAFs) can elicit malignant changes in initiated but non-tumorigenic human prostate epithelium, demonstrating that they possess pro-tumorigenic properties. We set out to reduce the pro-tumorigenic activity of patient CAFs using the Dlk1 and SCUBE1 molecules that we had previously identified in prostate development. Our hypothesis was that mesenchymally expressed molecules might reduce CAF pro-tumorigenic activity, either directly or indirectly. We isolated primary prostatic CAFs and characterised their expression of CAF markers, expression of Notch2, Dlk1 and SCUBE1 transcripts, and confirmed their ability to stimulate BPH1 epithelial cell proliferation. Next, we expressed Dlk1 or SCUBE1 in CAFs and determined their effects upon tumorigenesis in vivo following recombination with BPH1 epithelia and xenografting in SCID mice. Tumour size was reduced by about 75% and BPH1 proliferation was reduced by about 50% after expression of Dlk1 or SCUBE1 in CAFs, and there was also a reduction in invasion of BPH1 epithelia into the host kidney. Inhibition of Notch signalling, using inhibitor XIX, led to a reduction in BPH1 cell proliferation in CAF-BPH1 co-cultures, whereas inhibition of Dlk1 in NIH3T3-conditioned media led to an increase in BPH1 growth. Our results suggest that pro-tumorigenic CAF activity can be reduced by the expression of developmental pathways.

Development of cutaneous sarcoidosis during treatment with tumour necrosis alpha factor antagonists.

The use of tumour necrosis factor alpha (TNF-α) antagonists is increasing in the field of dermatology. These agents have been used for multiple inflammatory and immune skin conditions, but most notably, psoriasis. Adverse effects of anti-TNF-α agents have been reported, including the paradoxical development of sarcoidosis. We present an unusual case of limited cutaneous sarcoidosis developing while the patient was on etanercept therapy, and a review of the current literature.

Waist circumference in primary care.

Current literature suggests that waist circumference may be marginally better than BMI as a surrogate marker for total body fat and can identify thinner people with increased visceral adipose tissue and increased cardiometabolic risk. This commentary explores the use of WC in primary care, including how and when to measure, and how to use the results.

Substrate utilization during and after exercise in mild cystic fibrosis.

PURPOSE: To determine substrate utilization and energy expenditure during maximal and submaximal exercise and recovery in adolescents with cystic fibrosis (CF) and healthy age-matched controls (C). METHODS: Ten clinically stable CF patients (four girls, six boys; age = 10-22 yr) were matched by body mass index, age, gender, and Tanner stage to healthy controls. Subjects completed VO(2peak) testing and submaximal exercise (20 min) on a cycle ergometer at a relative intensity of 50% VO2(peak) and at an absolute power output (PO). Metabolic parameters were assessed during exercise and recovery (20 min). RESULTS: Similar respiratory quotient (RQ) values occurred in both groups during maximal exercise and recovery, despite differences in the maximal PO [CF = 114 (60-180) W and C = 171 (105-280) W, P = 0.006], the total work completed [CF = 27 (9.0-54.3) kJ and C = 55 (25.3-126.5) kJ, P = 0.008], or the VO(2peak) value attained [CF = 30.6 (8.5-45.2) mL kg(-1) min(-1) and C = 40.6 (29-64.5) mL kg(-1) min(-1), P = 0.027]. Submaximal exercise at the same absolute PO resulted in similar RQ values during exercise and recovery despite higher heart rates and average VO2 [CF = 18.8 (9.3-28.7) mL kg(-1) min(-1) and C = 15.2 (6.5-20.1) mL kg(-1)min(-1), P = 0.031] values in CF adolescents, and submaximal exercise at the same relative intensity also resulted in similar RQ values despite significantly greater average PO in the C group [CF = 38.7 (12.3-80) W and C = 67.8 (25.5-140) W, P = 0.039]. Excess postexercise oxygen consumption (EPOC) was greater in CF [2.79 (1.14-5.24) L O2] than C [1.46 (0.56-2.80) L O2] after submaximal exercise at a fixed PO (P = 0.036) but not after the relative exercise bout. CONCLUSIONS: Habitual physical activity participation does not warrant adjustment of macronutrient intake ratios in adolescents with mild to moderate CF, but total caloric intake may need to be increased based on the level of EPOC and upon the intensity and the duration of the habitual activity.

Breaking the cycle/mending the hoop: adverse childhood experiences among incarcerated American Indian/Alaska Native women in New Mexico.

Incarcerated American Indian/Alaska Native (AI/AN) women have multiple physical, social, and emotional concerns, many of which may stem from adverse childhood experiences (ACE). We interviewed 36 AI/AN women incarcerated in the New Mexico prison system to determine the relationship between ACE and adult outcomes. ACE assessment included physical neglect, dysfunctional family (e.g., household members who abused substances, were mentally ill or suicidal, or who were incarcerated), violence witnessed in the home, physical abuse, and sexual abuse. The most prevalent ACE was dysfunctional family (75%), followed by witnessing violence (72%), sexual abuse (53%), physical abuse (42%), and physical neglect (22%). ACE scores were positively associated with arrests for violent offenses, lifetime suicide attempt(s), and intimate partner violence.

Quality of life in psoriasis improves after standardized administration of narrowband UVB phototherapy.

SUMMARY Psoriasis is a chronic fluctuating dermatosis with demonstrable impact on patients' quality of life. Our aim was to investigate if narrowband UVB phototherapy administered to psoriatic patients in a standardized manner leads to an improvement in patients' perceived quality of life. A total of 138 patients with psoriasis were recruited from referrals to the Skin and Cancer Foundation, Australia between January 1998 and September 2002. Patients had psoriasis inadequately controlled by topical therapies alone and no contraindications to the use of phototherapy. Patients completed a pre- and post-therapy questionnaire on quality of life parameters. The differences in mean and standard deviation of quality of life parameters were measured using a paired sample t-test based on pre- and post-phototherapy questionnaires. Ninety patients were included in the study. Forty-eight patients were excluded as they had not completed post-phototherapy questionnaires. The course of narrowband UVB phototherapy was found to significantly improve quality of life in psoriasis patients (P