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Barrett’s oesophagus is the only known precursor to oesophageal adenocarcinoma, a cancer with very poor prognosis. The main risk factors for Barrett’s oesophagus are a history of gastro-oesophageal acid reflux symptoms and obesity. Men, smokers and those with a family history are also at increased risk. Progression from Barrett’s oesophagus to cancer occurs via an intermediate stage, known as dysplasia. However, dysplasia and early cancer usually develop without any clinical signs, often in individuals whose symptoms are well controlled by acid suppressant medications; therefore, endoscopic surveillance is recommended to allow for early diagnosis and timely clinical intervention. Individuals with Barrett’s oesophagus need to be fully informed about the implications of this diagnosis and the benefits and risks of monitoring strategies. Pharmacological treatments are recommended for control of symptoms, but not for chemoprevention. Dysplasia and stage 1 oesophageal adenocarcinoma have excellent prognoses, since they can be cured with endoscopic or surgical therapies. Endoscopic resection is the most accurate staging technique for early Barrett’s-related oesophageal adenocarcinoma. Endoscopic ablation is effective and indicated to eradicate Barrett’s oesophagus in patients with dysplasia. Future research should focus on improved accuracy for dysplasia detection via new technologies and providing more robust evidence to support pathways for follow-up and treatment.

To explore reasons behind treatment inertia in current approaches to early cardiorenal risk management in type 2 diabetes (T2D). A global, web-based, quantitative panel survey of primary care physicians (PCPs) and primary care diabetes specialists treating people living with T2D. The questions covered current management of T2D, particularly the use of sodium–glucose co-transporter 2 inhibitors, glucagon-like peptide-1 receptor agonists, and dipeptidyl peptidase-4 inhibitors as second-/third-line therapies. Of 1677 respondents from 18 countries who completed the survey, 73.4% were responsible for second-/third-line therapy initiation. Two thirds had modified treatment decisions based on recent cardiovascular outcomes trials (CVOTs). Respondents cited restricted access to therapies and limits on regular appointments as the greatest barriers to second-/third-line therapy prescription. Although 81.6% agreed that early intensification to second-/third-line therapies is associated with clinical benefits, 46.1% of respondents still reserve these for later lines of therapy, and 23.8% would not consider changing therapeutic approach in patients with well-controlled T2D but increasing cardiovascular risk. Substantial barriers still prevent optimization of primary setting T2D patient care. Education programs which enable PCPs to translate CVOT evidence into clinical benefits for patients with T2D could address many of the remaining knowledge gaps identified. •Recent guidelines recommend glucose-lowering therapies with cardiorenal benefits.•Most primary care physicians (PCPs) are aware of recent cardiovascular outcomes trials.•Some PCPs remain unsure of the clinical implications of these trials.•PCPs may resist adjusting therapies even as patient cardiovascular risk increases.•Healthcare/insurer restrictions are a key barrier contributing to treatment inertia.

Introduction Perceived difficulties in initiating insulin in patients with type 2 diabetes (T2D) may prevent many general practitioners (GPs) from using insulin even when recommended in guidelines. This paper describes a Royal Australian College of General Practitioners accredited education program on starting insulin in T2D, and its impact on GPs’ attitudes and behavior. Methods A faculty comprising GPs with diabetes expertise, Credentialed Diabetes Nurse Educators, and endocrinologist developed and implemented the education program. The program content was highly procedure focussed, emphasizing simple, best-practice processes for starting insulin therapy and focussing on multidisciplinary models of care. The highly interactive format of the workshops included peer-to-peer learning, in which education was led by diabetes-experienced GP educators, as well as case study-based approaches and small group discussions. GP attendees were asked to rate their individual confidence and attitudes at the beginning and end of the meeting. In addition, participants ( n  = 220) from two workshops in 2013 were sent a survey 3 months after the meeting to gauge the longer-term impact on their clinical practice. Results Since 2008, more than 2500 GPs have attended the workshops, and report substantial improvements in confidence; after attending, more GPs were willing to start insulin within their practice. Evaluations at 3 months post-meeting indicate that the increased confidence was associated with behavioral changes in the subgroup evaluated at this time ( n  = 48). Success of this program was attributed to peer-to-peer education, multidisciplinary input, easily implemented best practice procedures and checklists for starting insulin, and constant adjustment of meeting process and content based on feedback and guideline changes. Conclusion A peer-to-peer, interactive GP education program reduced GPs’ perceptions of the difficulties of starting insulin in T2D and achieved changes in attendees’ clinical practice. This education program offers an effective approach to overcome the therapeutic inertia that is too common in diabetes management.

Background Globally, a substantial proportion of general practitioners (GPs) incorporate integrative medicine (IM) into their clinical practice. Objective This study aimed to map the IM education and training pathways and needs of a cohort of Australian GPs who are members of the Royal Australian College of General Practitioners’ IM Specific Interest Network, which is a group of GPs with interest in IM. Methods We conducted a mixed-methods study comprising of an online, cross-sectional survey supplemented with in-depth semi-structured interviews. Data from the survey and interviews were initially analysed separately and then combined. Results Eighty-three (83) of 505 eligible GPs/GPs in training (16.4%) participated in the survey, and 15 GPs were interviewed. Results from the two datasets either converged or were complementary. Almost half (47%) of survey respondents had undertaken formal undergraduate or postgraduate IM education, a short course (63%), informal education (71%) or self-education (54%), in at least one of 20 IM modalities listed. Interviewees affirmed there was no single education pathway in IM. Survey respondents who identified as practicing IM were significantly more likely to have IM education, positive attitudes towards IM, particularly natural products, and higher self-rated IM knowledge and competencies. However, knowledge gaps were identified in professional skills domains of population health and context, and organisational and legal dimensions of applied IM practice. Interviewees also highlighted a range of professional and systemic barriers to the practice of IM, education, and training. There was broad support for recognition of IM as a sub-specialty through formalised post-graduate training and accreditation. Most survey respondents (62%) expressed interest in post-fellowship recognition of GPs with advanced skills in IM. Conclusion Our findings demonstrate that it is important to define best practice in IM for GPs in Australia and provide a standardised pathway towards recognition of advanced skills in IM.