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For me, diabetes has been a specialized practice area for nearly 2 decades. What started as a practice area of need in serving pediatric patients in our underserved area of the state grew into a passion that has grown to impact nearly every clinician I work with and now affects large number of my adult patients.

What clinician doesn’t have a patient in their practice with type 2 diabetes mellitus (T2DM)? Of our T2DM patients in our practice, how many of them also have comorbidities or complications? The National Diabetes Statistics Report of 2022 recognizes that over 37 million Americans have diabetes and 48% of all persons over age 65 have prediabetes.1 Diabetes is the leading cause of blindness, renal failure, and non-traumatic amputations in the U.S. Diabetic patients are more than twice as likely to experience mental health comorbidity of depression.2 The estimated cost of diabetes in 2017 was 327 billion dollars.3

Diabetes and Medication Management: Yearly, the American Diabetes Association openly publishes its Standards of Care. In recent years, the pharmacology section of this document has drastically changed due to excellent after-market research on benefits of diabetes treatments. The 2024 Standards of Care in Diabetes provide some important updates all clinicians need. Below are some key take aways that should be emphasized:
– Weight loss management is forefront of overall diabetes and glycemic management. If a patient needs weight loss, medication considerations for diabetes should include this.
– Patients with comorbidities need medications based on the comorbid conditions regardless of glycemic control. For example, in patients with early renal disease, urine albumin and creatinine ratio over 30 or eGFR changes, use an SGLT-2 inhibitor. If a patient has CAD, HF, or CKD in any form diabetes medications should help improve cardiac or renal outcomes respectively.
– In patients who meet the criteria for starting insulin, consider starting a GLP-1 RA first alone or in combination with the insulin. Avoid over-nasalization with insulin or giving more than 0.5 units/kg/day of basal or long-acting insulin.
– In all therapies, but particularly combination therapies, be mindful of hypoglycemic risk.
– Consider combination therapy earlier and possibly first to get to the treatment goal sooner.
– Monitoring, data, routine review of all medications and how the patient takes them, and early and possibly repeated diabetes education is key.

To learn more about the new standards you can read them at – https://diabetesjournals.org/care/issue/47/Supplement_1 If you learn better by listening, you can soon partake of diabetes updates through Gary Graff in our Hilton Head on-demand conference package that will be available in June of 2024.
To better help your patients with diabetes, stay well educated on diabetes every year. NPACE can help! Reach out to us if you have specific practice questions or learning needs.

References
1. Diabetes Research Institute (2022). Diabetes Statistics. Retrieved from https://diabetesresearch.org/diabetes-statistics/
2. Center for Disease Control and Prevention (2023). Diabetes and Mental Health. Retrieved from https://www.cdc.gov/diabetes/managing/mental-health.html
3. American Diabetes Association (2024). Standards of Care in Diabetes – 2024. Diabetes Care, 47 (supp 1). Retrieved from https://diabetesjournals.org/care/issue/47/Supplement_1

Ah, Spring – flowers, birds, bees … they’re all wonderful reminders that April is National STI Awareness Month! With that in mind, we wanted to highlight two communications which have recently caught our attention. First up – the latest STI surveillance numbers.

According to the CDC’s 2022 STI Surveillance Report1 (released January 2024), there has been a significant and worrisome rise in cases of all stages of syphilis, including congenital. In 2022, over 3,700 cases of syphilis were reported, indicating an 80% increase over the past five years, and, even more alarming, a 937% increase in the past decade. Where do we see the most concerning rates? Louisiana, Mississippi, Alaska, South Carolina, and Georgia (with many other states above the national average). With regards to congenital syphilis, rates were highest in New Mexico, South Dakota, Arizona, Texas, and Oklahoma.

This same report showed a leveling-off of chlamydia cases (compared to 2021), and nearly a 9% decrease in gonorrhea cases (the first decline in a decade). Of note, 2019 had the highest rate of chlamydia cases ever on record (551.0 per 100,000 population), and the 5-year trend in gonorrhea cases has actually increased by 11%!2

It’s unclear what the newest chlamydia and gonorrhea numbers mean – are they a true flattening and decline in infections, or do they relate to diagnosing and reporting issues? We know screening for STIs was disrupted during the pandemic3 – are we still catching up? Looking at future data will help researchers clarify these questions.

With the above findings in mind, it’s prudent for us to look closely at who is most affected by STIs –racial minorities, MSM (men who have sex with men), and adolescents/young adults ages 15-24 years. Their numbers reveal trends which continue to suggest that the success of testing, treatment, and prevention strategies greatly hinge on improved access to care, particularly to underserved and vulnerable populations.4

To that point, another promising development in the prevention of bacterial STIs (gonorrhea, chlamydia, and syphilis particularly) has been the use of doxycycline for post-exposure prophylaxis (aka “doxy-PEP”).5

A series of studies6 have recently shown a demonstrated benefit of the use of doxy-PEP in reducing incidences of bacterial STIs when given to gay or bisexual men or transgender women within 72 hours of condomless intercourse (cisgender women studies are ongoing). One such study8 showed a 70% and 73% reduction in chlamydia and syphilis infections, respectively. While this is currently an off-label use of doxycycline, the CDC has suggested the following to providers considering its use7: administer doxycycline 200mg within 24-72 hours of condomless sex, counsel about adverse effects of the medication, and continue to screen/test/treat for bacterial STIs.

Here’s our takeaway from these reports – people need testing and treatment to meet them where they are. Furthermore, it’s imperative to continue to explore new approaches to address STI prevention in at-risk populations. When this is done, we see real demonstrated benefits to our patients, particularly those most in need of STI testing and treatment service.

Resource:
Syphilis Treatment and Prevention Strategies: Syphilis Pocket Guide (CDC)

References:
1. Sexually transmitted infections surveillance, 2022. Centers for Disease Control and Prevention. January 30, 2024. Accessed March 20, 2024.
https://www.cdc.gov/std/statistics/2022/default.htm#print.

2. Table 1. sexually transmitted infections – reported cases and rates of reported cases*, United States, 1941–2022. Centers for Disease Control and Prevention. January 30, 2024. Accessed March 20, 2024. https://www.cdc.gov/std/statistics/2022/tables/1.htm.

3. Post-pandemic rise in sexually transmitted diseases imminent, experts warn. NBCNews.com. July 1, 2021. Accessed March 20, 2024. https://www.nbcnews.com/health/sexual-health/post-pandemic-rise-sexually-transmitted-diseases-imminent-experts-warn-n1271996.

4. Haley DF, Edmonds A, Belenky N, et al. Neighborhood Health Care Access and sexually transmitted infections among women in the Southern United States: A cross-sectional multilevel analysis. Sexually transmitted diseases. January 2018. Accessed March 20, 2024. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5726943/.

5. Wolff K. Guidelines for the Use of Doxycycline Post-Exposure Prophylaxis for Bacterial Sexually Transmitted Infection (STI) Prevention; Request for Comment and Informational Presentation. The Federal Register. [FR Doc. 2023–21725 Filed 9–29–23; 8:45 am]. September 27, 2023. Accessed March 20, 2024. https://www.federalregister.gov/documents/2023/10/02/2023-21725/guidelines-for-the-use-of-doxycycline-post-exposure-prophylaxis-for-bacterial-sexually-transmitted.

6. Efficacy of doxycycline as PEP to prevent bacterial stis. Centers for Disease Control and Prevention. August 28, 2023. Accessed March 20, 2024. https://www.cdc.gov/std/treatment/doxycycline-as-pep-toe.htm.

7. Primary prevention methods. Centers for Disease Control and Prevention. September 29, 2023. Accessed March 20, 2024. https://www.cdc.gov/std/treatment-guidelines/clinical-primary.htm#CautionsForDoxyPEP.

8. Molina JM;Charreau I;Chidiac C;Pialoux G;Cua E;Delaugerre C;Capitant C;Rojas-Castro D;Fonsart J;Bercot B;Bébéar C;Cotte L;Robineau O;Raffi F;Charbonneau P;Aslan A;Chas J;Niedbalski L;Spire B;Sagaon-Teyssier L;Carette D;Mestre SL;Doré V;Meyer L; ; Post-exposure prophylaxis with doxycycline to prevent sexually transmitted infections in men who have sex with men: An open-label randomised substudy of the ANRS Ipergay Trial. The Lancet. Infectious diseases. Accessed March 20, 2024. https://pubmed.ncbi.nlm.nih.gov/29229440/.

March is Colorectal cancer awareness month. The National Cancer Institute reported that in 2023 there were approximately 153,020 new cases of colorectal cancer in the United States (US) and over 50,000 deaths were attributed to this disease.1 It is the 4th most diagnosed cancer in the US and the 2nd leading cause of cancer deaths in this county.1 While the overall death rate from colorectal cancer has decreased over the last several decades in the US, this trend has been observed only in older adults.2 In adults less than age 55, death rates have been increasing approximately “1% per year since the mid-2000s.”2 Colorectal cancer is more common in men versus women and in people of African & Native American descent.1

Risk factors for colorectal cancer are age (>50) but as previously mentioned, the incidence rate has risen in individuals who are <55. Other non-modifiable risk factors are race, sex, family history, inherited syndromes like Lynch, inflammatory bowel disease, a history of adenomatous polyps, and a personal history of other cancer types (ovarian & uterine).3 Type 2 Diabetes Mellitus also increases the risk.3 Modifiable risk factors include: physical inactivity, obesity, smoking, and dietary influences.3 Various dietary risk factors have been identified including a high fat and low fiber diet, decreased fruit & vegetable intake, increased intake of processed and red meats, cooking meats at high temperatures, and alcohol intake.2,4 Low levels of serum Vitamin D have also been associated with an increased risk.2

So why is colorectal cancer increasing among younger individuals? Researchers are not completely sure but many of the above cited risk factors have been implicated and overall, it is likely an interplay between environmental and hereditary/genetic risks.5.6 Metabolic syndrome, insulin resistance, obesity, the typical “Western” diet, sugar-sweetened beverages, alcohol use, and intestinal dysbiosis have all had an association with increased colorectal cancer incidence in younger individuals.6 These factors increase the risk of inflammation which has also been implicated in general cancer pathogenesis but more research is needed and ongoing.5,6 Regardless of why this specific cancer type is diagnosed in younger individuals, the bottom line is nurse practitioners have a pivotal role in identifying these risks, educating patients about colorectal cancer, and advising on screening.

In 2021, the USPSTF recommended that colon cancer screening for people at average risk should begin at age 45 versus age 50, which was previously advised.7,8 This was due to the increased incidence of colorectal cancer cases diagnosed in younger adults. If an individual has a family history, screening should begin at age 40.8 Nurse practitioners and other health care providers (HCPs) also need to be cognizant that racial disparities are highly prevalent in cancer screening and given that colorectal cancer has a higher incidence in individuals of African and Native American descent, screening should be discussed earlier with these patients to improve overall outcomes.6,7,8 We should all make colorectal cancer education and screening a priority not only for this month, but in our daily practice.

References

1. Cancer Stat Facts: Colorectal Cancer. National Cancer Institute Surveillance, Epidemiology, and End Results Program. Accessed March 1, 2024. https://seer.cancer.gov/statfacts/html/colorect.html
2. American Cancer Society. Key Statistics for Colorectal Cancer. Accessed March 4, 2024. https://www.cancer.org/cancer/types/colon-rectal-cancer/about/key-statistics. html#:~:text=In%20the%20United%20States%2C%20colorectal,about%2053%2C010%20deaths%20during%202024.
3. Cancer.Net. Colorectal Cancer: Rick Factors and Prevention. Accessed March 4, 2024. https://www.cancer.net/cancer-types/colorectal-cancer/risk-factors-and-prevention
4. Centers for Disease Control and Prevention. Colorectal (Colon) Cancer. What Are the Risk factors for Colorectal cancer? Accessed March 4, 2024. https://www.cdc.gov/cancer/colorectal/basic_info/risk_factors.htm#:~:text=A%20diet%20low%20in%20fruit,Alcohol%20consumption.
5. Yale Medicine: Colorectal Cancer: What Millennials and Gen Zers Need to Know. January 4, 2024. Accessed March 5, 2024. https://www.yalemedicine.org/news/colorectal-cancer-in-young-people#:~:text=Nobody%20knows%20for%20sure%20why,been%20associated%20with%20the%20disease. 6. Dharwadkar, P, Zaki, TA, & Murphy, CC. Colorectal cancer in younger adults. Hematol Oncol Clin North Am. 2022;36(3): 449-170. 10.1016/j.hoc.2022.02.005
7. American Cancer Society Guideline for Colorectal Screening. Accessed March 4, 2024. https://www.cancer.org/cancer/types/colon-rectal-cancer/detection-diagnosis-staging/acs-recommendations.html
8. UCLA Health. Colorectal cancer screening guidelines have changed to address rise in cases among younger adults. Accessed March 4, 2024. https://www.uclahealth.org/news/colorectal-cancer-screening-guidelines-have-changed-address#:~:text=In%202021%2C%20the%20U.S.%20Preventive,growing%20cases%20among%20younger%20adults.

Do you need to do beach?

“What if there’s beach? You’ll need someone professional in that.” — Ken, Barbie Movie 2023

Everyone needs a break. I prefer mine at the beach doing beach.

I was recently reminded by a dear friend with that typical ‘is the jar full?’ experiment that the right life things need to go into my space (aka jar) first. You know the life metaphor example… the one where ping pong balls go in first to the jar representing the big things in life – family, friends, rest, and then the pebbles that are like bills, house, etc., and then finally the sand which is job, tasks, chores, commitments, and so forth. The point is, there is still room in the jar to add the smaller less meaningful things if the right things go in first. If the sand, representing jobs, chores, and ‘to dos’- goes first there is no room for the bigger or more important and beautiful experiences of life.

The example hit me hard. I rarely take time for downtime and simply practice being present instead of doing tasks or working. Making sure the ping pong ball of downtime is in my jar is critical to ensuring it is not pushed out by smaller items. Considering this, I was reminded of Ken in the recent Barbie movie and how good he was at doing ‘beach’. Sometimes we all just need to just ‘beach’ and be present in our favorite place with our favorite people, without goals or tasks, simply presence. One of my favorite places to do ‘beach’ is actually at the beach! I am grateful because this year NPACE will frequently be at the beach and offer multiple locations to ‘beach’ in 2024. There is still time to join us in Hilton Head right on the water in March, in Clearwater Beach, Florida at the beautiful Wyndham Grand in May, in Cape Cod in October at the Sea Crest Beach Hotel, or in November at the beautiful Laguna Cliffs Marriott Resort and Spa in Dana Point, California. At each place, my goal is to take one down day to myself with no social media or electronics to exercise, read a physical book, and be outside near the water! Join me and hold me accountable and maybe we can all do a little better about doing beach.

Although it is well known that heart disease is a leading cause of death, many do not recognize that in women, it is the number one killer1. It is important for healthcare providers to be abreast of the unique risks and challenges associated with heart disease in women. Hypertension is a major risk factor for heart disease. Hypertension is underdiagnosed in women and 23% of women with hypertension have inadequate blood pressure control1. Although family history of heart disease is a determinant of heart disease for men and women, family history is a greater risk factor for the development of heart disease in women3. Women undergo changes across the life cycle that increase their cardiovascular risk. Pregnant women who have hypertension, preeclampsia, or gestational diabetes have a higher risk of developing heart disease later in life1, 2, 3. The hormonal changes associated with menopause accelerate the risk of small vessel heart disease in women1, 3.

As healthcare providers we recognize that the classic signs associated with acute myocardial infarction may not be present in women. Women with heart disease may be asymptomatic1. Those with symptoms tend to have vague, nonspecific symptoms like nausea, shortness of breath, abdominal pain, dizziness, and fatigue1, 3.

Although women are more likely to present for treatment of suspected heart disease than men, up to 50% of women report that the healthcare provider did not associate their symptoms with heart disease3. Evidence suggests that women are treated less aggressively when they report to the ED with complaints of chest pain; especially young women and women of color4. Even though aspirin and statins have demonstrated efficacy in treating heart disease, they are less likely to be prescribed to women than men3. Despite well-established benefits, women are less likely to be referred to cardiac rehabilitation than men3.
The reasons for these disparities are probably multifactorial. There may be an element of gender bias, women may verbalize their symptoms differently than men, and underrepresentation of women in clinical trials may impact clinical practice.

Although there is no quick fix here, Nurse Practitioners can educate patients about the nuances of heart disease in women. It is especially important to empower women through education so they understand the vague symptoms of heart disease and can be active healthcare participants who are comfortable advocating for themselves. It is also critical to educate women on the significance of clinical trials. Greater representation of women in clinical trials may increase awareness and foster the development of treatment strategies for women with heart disease.

1. CDC (2023). Women and heart disease. https://www.cdc.gov/heartdisease/women.htm 
2. AHA (n.d.). Go red for women. https://www.goredforwomen.org/en/about-heart-disease-in-women/facts
3. Mayo Clinic (2022). Heart disease in women: Understand symptoms and risk factors. https://www.mayoclinic.org/diseases-conditions/heart-disease/in-depth/heart-disease/art-20046167
4. Gordon, D. (2023). Why don’t women get the same treatment for heart disease as men? Healthy Women. https://www.healthywomen.org/condition/heart-disease-in-women-treatment
5. NIH (n.d.). NIH Inclusion Outreach Toolkit: How to engage, recruit, and retain women in clinical research. https://orwh.od.nih.gov/toolkit/recruitment/history