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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.

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.

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.

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.

Meaghan once remarked (I think to the poet and art critic Ken Bolton) that she didn’t like poetry because of all the empty space on the page. A quarter of a century ago in 1992, in Ecstasy and Economics: American Essays for John Forbes, she said she was ‘a desultory reader of poetry’ and that reading poetry might induce a ‘scary cultural estrangement’.1 In the foreword, she extrapolates the ‘awkward’ place of poetry in cultural studies then as being more an American problem than an Australian one but nearly a quarter of a century later I wonder if poetry has made an individuated local spot for itself, or even if it cares to. I mean, ‘should poetry worry?’

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.

To assess the utility of clinical predictors of persistent respiratory morbidity in extremely low gestational age newborns (ELGANs).We enrolled ELGANs (29 weeks' gestation) at ≤7 postnatal days and collected antenatal and neonatal clinical data through 36 weeks' postmenstrual age. We surveyed caregivers at 3, 6, 9, and 12 months' corrected age to identify postdischarge respiratory morbidity, defined as hospitalization, home support (oxygen, tracheostomy, ventilation), medications, or symptoms (cough/wheeze). Infants were classified as having postprematurity respiratory disease (PRD, the primary study outcome) if respiratory morbidity persisted over ≥2 questionnaires. Infants were classified with severe respiratory morbidity if there were multiple hospitalizations, exposure to systemic steroids or pulmonary vasodilators, home oxygen after 3 months or mechanical ventilation, or symptoms despite inhaled corticosteroids. Mixed-effects models generated with data available at 1 day (perinatal) and 36 weeks' postmenstrual age were assessed for predictive accuracy.Of 724 infants (918 ± 234 g, 26.7 ± 1.4 weeks' gestational age) classified for the primary outcome, 68.6% had PRD; 245 of 704 (34.8%) were classified as severe. Male sex, intrauterine growth restriction, maternal smoking, race/ethnicity, intubation at birth, and public insurance were retained in perinatal and 36-week models for both PRD and respiratory morbidity severity. The perinatal model accurately predicted PRD (c-statistic 0.858). Neither the 36-week model nor the addition of bronchopulmonary dysplasia to the perinatal model improved accuracy (0.856, 0.860); c-statistic for BPD alone was 0.907.Both bronchopulmonary dysplasia and perinatal clinical data accurately identify ELGANs at risk for persistent and severe respiratory morbidity at 1 year.ClinicalTrials.gov: NCT01435187.

OBJECTIVE: To determine patterns of respiratory medications used in neonatal intensive care unit (NICU) graduates. STUDY DESIGN: The Prematurity Respiratory Outcomes Program enrolled 835 babies

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.

Five of 730 replacement gimmers in a 5000-ewe crossbred flock presented with progressive ataxia and recumbency over a two-week period. On gross postmortem examination, there was spinal cord compression and large fibrogranulomatous masses in the spinal canal of two lambs. Histological examination of one mass and the adjacent tissues revealed chronic active necrotising and granulomatous inflammation with acid-fast bacilli and severe granulomatous osteomyelitis, respectively. PCR of the mass was positive for Mycobacterium aviumsubspecies paratuberculosis (MAP). Lambs had been injected six weeks previously with a Johne’s disease vaccine (Gudair, Merial Animal Health). Gross and histological findings unequivocally suggest an intrathecal injection; the acid-fast bacilli and PCR-positive result for MAP confirm that the maladministration of vaccine was the cause of the pathology. Great care must be taken when injecting sheep in the neck region to avoid iatrogenic damage. Clinical signs may manifest some weeks or months after injection.

Contamination of soils by a variety of pollutants in urbanized and rapidly urbanizing regions is an ongoing problem in the world. Our objective in this study was to determine the contamination levels of trace metals and polycyclic aromatic hydrocarbons (PAHs) in urban residential soils. Surface (0–15 cm) samples of soils were collected and analyzed from an urbanized region of Florida (Pinellas County: 725 km2, population: 921,482), for basic soil properties, trace metals, and PAHs. The pH of urban residential soils was between 5.4 and 8.0, the electrical conductivity ranged from 18 to 1170 μS cm−1 with an average value of 233 μS cm−1, and total organic carbon of soils varied widely from 1 to 88 g kg−1. Among the major elements determined in soils, contents of Mehlich 1 (M1) Ca were highest at 2330 mg kg−1 followed by M1–Mg (136 mg kg−1) and M1–Al (135 mg kg−1). Among the trace metals in soils, mean M1–Zn values were highest (18.6 mg kg−1) followed by M1–Fe (10 mg kg−1) and M1–Mn (8.6 mg kg−1). The content...

The cost-effectiveness modelling used by NICE in its 2008 guidance on the prevention of osteoporotic fracture in postmenopausal women has recently been challenged. Here, the author presents alternative cost-effectiveness analyses and discusses the disparities with that published by NICE. Copyright © 2009 Wiley Interface Ltd

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

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.A multicenter cross-sectional study using a population-based survey of 416 individuals over the age of 18 years was undertaken during 2014.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 (p0.001). 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).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.

BACKGROUND: An important aspect of the economics of fracture prevention is averted fracture costs. However, while vertebral fractures represent a significant burden to society, quantifying their cost is difficult for several reasons. In this paper, we examine the health care costs of symptomatic vertebral fractures occurring in women aged 50 years and above in the UK. METHODS: We used a variety of data sources. The prevalence of pharmaceutical treatment for fracture prevention and number of general practitioner consultations, referrals, and hospital admissions associated with a diagnosis of vertebral fracture were identified from a case control study. For the unit cost of a general practitioner consultation, referral, and cost per inpatient day, we used 2002 data produced by the Personal Social Services Research Unit. Hospital Episode Statistics (HES) for 2001-2002 were used to estimate the median length of stay in hospital for women aged 50 years and above, and the Monthly Index of Medical Specialities (MIMS) was used to identify the costs of pharmaceutical treatments. Costs were discounted at 6%. RESULTS: From these data, we estimated that for the year prior and post diagnosis the average additional health care costs for those diagnosed with vertebral fracture were pounds 165, pounds 134, and pounds 2314 for general practitioner consultations, referrals, and hospital admissions, respectively (i.e., pounds 2613). The cost of pharmaceutical treatments prescribed for fracture prevention in the year following diagnosis was pound 97. DISCUSSION: Vertebral fractures are associated with significantly increased health care costs. These costs need to be set against the costs of fracture prevention.

To assess the knowledge, attitudes and behaviour towards sun protection measures in a sample of Australian adults.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.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.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.

Severe psoriasis presents a difficult therapeutic challenge. Some modalities such as synthetic retinoids, phototherapy and methotrexate have been available for many years and need reappraisal, cyclosporin has only recently become available and requires careful administration. In this article we focus on the therapeutic modalities available to the dermatologist in Australia.

Purpose: To evaluate the efficacy of macular grid photocoagulation in preserving or improving central visual acuity in eyes with macular edema due to central vein occlusion (CVO) and best-corrected visual acuity of 20/50 or poorer. Methods: Patients with angiographically documented macular edema due to CVO were entered into a multicenter randomized controlled clinical trial supported by the National Eye Institute. Eligibility was determined based on both clinical examination findings and photographic documentation evaluated at a photograph reading center. Eyes were assigned randomly to macular grid photocoagulation (77 eyes) or no treatment (78 eyes). Patients were followed every 4 months for 3 years or until the end of the study. The outcome measure was visual acuity. Results: The study population consisted of 155 eyes in 155 patients. There was no difference between treated and untreated eyes in visual acuity at any point during the follow-up period. Initial median visual acuity was 20/160 in treated eyes and 20/ 125 in control eyes. Final median visual acuity was 20/200 in treated eyes and 20/160 in control eyes. However, treatment clearly reduced angiographic evidence of macular edema. Conclusion: The results of this study do not support a recommendation for macular grid photocoagulation for the population meeting the Central Vein Occlusion Study macular edema group eligibility criteria.

Windows Wound Down by Pam Brown.

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.

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.

Inhaled anticholinergic bronchodilators are a treatment of choice for chronic obstructive pulmonary disease (COPD). Tiotropium is currently the only long-acting inhaled anticholinergic bronchodilator available and works by selectively inhibiting muscarinic receptors involved in mucus hypersecretion and bronchoconstriction, two characteristic features of COPD. Clinical trials have demonstrated the efficacy of tiotropium across all degrees of severity of stable COPD. Tiotropium improves airway function, symptoms of dyspnoea, exercise endurance and health status. Treatment with tiotropium also reduces acute exacerbations associated with COPD as well as associated hospitalisations. The clinical improvements observed with tiotropium are associated with changes in airway volume, particularly inspiratory capacity, which translate into improvements in patient-centred outcomes, such as breathlessness during exercise. Emerging evidence indicates that tiotropium may exert additive effects when used in combination with the long-acting β2-agonist (LABA), formoterol, consistent with the current recommendations for combination therapy in patients who do not respond to a single bronchodilator. Encouraging results have also been obtained with tiotropium in triple combination with salmeterol/ fluticasone propionate. Furthermore, post hoc analyses suggest that tiotropium may slow the rate of decline in lung function characteristic of COPD. Recent studies indicate that combining tiotropium therapy with pulmonary rehabilitation programmes can yield significant improvements in exercise endurance time. In safety evaluations, tiotropium was generally well tolerated with a similar safety profile to ipratropium, a short-acting anticholinergic bronchodilator. Dry mouth is the most common adverse event reported with tiotropium, although this is generally transient and does not lead to treatment discontinuation. © 2008 CSF Medical Communications Ltd.

Human papillomavirus (HPV) is the pathological agent required for the development and progression of precancerous lesions in the cervical epithelium. Just two HPV types account for around 70% of all cases of cervical cancer. Therefore, there is a clear rationale for the development of prophylactic vaccines that protect against infection by these oncogenic HPV strains in order that the substantial burden of cervical cancer can be reduced. Two vaccines have been developed which comprise type-specific virus-like particles (VLPs) of the L1 capsid protein produced in recombinant expression systems. These VLPs are structurally similar to the native virus, but as they contain no viral DNA, they are non-infectious and non-oncogenic. Cervarix is a bivalent vaccine, which targets the two HPV typed (HPV 16 and 18) responsible for the majority of cervical cancers. Clinical trials have shown that Cervarix, formulated with a proprietary adjuvant (ASO4), stimulates a robust immune response in vaccinated women, such that virtually all vaccinees seroconvert within 1 month of completing the vaccine schedule. High titres of type-specific antibodies lead to a significant reduction in the number of incident and persistent HPV 16 and 18 infections. Clinically, this manifests as a reduction in the incidence of pre-cancerous cervical lesions. Cervarix has no efficacy in clearing pre-existing HPV infections, but should continue to protect against infection by the remaining vaccine type to which women have not been exposed. The vaccine has a favourable safety profile, with localised injection-site reactions the most common adverse event. The introduction of Cervarix has the potential to substantially reduce the burden of HPV infection, and thus reduce the morbidity, mortality and socioeconomic burden associated with cervical cancer. © 2008 CSF Medical Communications Ltd.

This research demonstrates two methodologies for detecting cracks in a metal spindle housed deep within a vehicle wheel end assembly. First, modal impacts are imposed on the hub of the wheel in the longitudinal direction to produce broadband elastic wave excitation spectra out to 7000 Hz. The response data on the flange is collected using 3000 Hz bandwidth accelerometers. It is shown using frequency response analysis that the crack produces a filter, which amplifies the elastic response of the surrounding components of the wheel assembly. Experiments on wheel assemblies mounted on the vehicle with the vehicle lifted off the ground are performed to demonstrate that the modal impact method can be used to nondestructively evaluate cracks of varying depths despite sources of variability such as the half shaft angular position relative to the non-rotating spindle. Second, an automatic piezo-stack actuator is utilized to excite the wheel hub with a swept sine signal extending from 20 kHz. Accelerometers are then utilized to measure the response on the flange. It is demonstrated using frequency response analysis that the crack filters waves traveling from the hub to the flange. A simple finite element model is used to interpret the experimental results. Challenges discussed include variability from assembly to assembly, the variability in each assembly, and the high amount of damping present in each assembly due to the transmission gearing, lubricant, and other components in the wheel end. A two-channel measurement system with a graphical user interface for detecting cracks was also developed and a procedure was created to ensure that operators properly perform the test.

Background: De-institutionalization of health care services provided to terminally ill cancer patients is a cost-effective strategy that underpins health care reforms in Canada. The objective of this study therefore is to evaluate the economic implications associated with Canadian innovations in the delivery of palliative care services. Methods: We identified 16 282 adults who died of cancer between 1993 and 2000 in two Canadian cities with newly introduced palliative care programs. Linkage of administrative databases was used to measure healthcare resource utilization. We sought to describe the utilization of palliative care services and its consequences for overall health care system costs. Results: Use of palliative services increased from 45 to 81% of cancer patients during the study period. Identifiable public health care services cost $28 093Cdn/patient (19 033US$, 11 508GB£, 17 778t) for terminally ill cancer patients in their last year of life. Acute care accounted for two-thirds (67%) of these costs; physician (10%), residential hospice care (8%), nursing homes (6%), home care (6%) and prescription medications (3%) comprise the remainder. Increased costs associated with the introduction of palliative care programs were offset by cost savings realized when terminally ill cancer patients spent less time in hospital. Palliative home care and residential hospice care accounted for the bulk of this substitution effect. Cost neutrality was observed from the public perspective. Discussion: These results demonstrate that the introduction of comprehensive and community-based palliative care services resulted in increased palliative care service delivery and cost neutrality, primarily achieved through a decreased use of acute care beds. Palliative Medicine 2005; 19: 513/520

This randomized, double-blind, placebo-controlled study assessed the efficacy and safety of a topical gel containing 3% diclofenac in 2.5% hyaluronan in 150 patients with solar keratoses (SK). The active treatment was compared with the vehicle only, hyaluronan gel, as placebo over a 12-week period. Patients in both groups applied the active treatment or placebo to a targeted area of skin (0.25 g b.d.). At 12 weeks the mean lesion-count reduction in the targeted area was not significantly different between treatments. However, at post-termination follow up (16 weeks), there was a highly significant decrease in the number of lesions, 6.2 +/- 7.5 standard deviations (SD) (56.1% reduction) in the active treatment group compared with 2.4 +/- 4.3 SD (23.6% reduction) in the placebo group (P0.001). Other efficacy measures (complete lesion resolution,50% lesion reduction) were also significantly different (P0.01) between treatments at 16 weeks. In conclusion, topical 3% diclofenac in 2.5% hyaluronan gel was effective and well tolerated in this study, suggesting a role for this therapy in the treatment of SK.

The conflict between agriculture and urban development is intense in urbanizing areas of the United States and is a problem best resolved at the local level. To effectively develop and apply techniques for preserving farmland, areas of conflict must be identified. This article describes the application of a geographic information system (GIS) for determining the location and level of conflict between agriculture and other forms of human intervention. The procedures used for assessing conflicts are described through a case study in the city of Westfield, Massachusetts and the findings show that GIS can be an effective tool for local decision makers, allowing alternative strategies to be developed and evaluated for agricultural protection.