Friday, 2 October 2015

What I've been reading

Image of the book cover

The Book of You
by Claire Kendal
"Being selected for jury service is a relief. The courtroom is a safe haven, a place where Rafe can’t be. But as a violent tale of kidnap and abuse unfolds, Clarissa begins to see parallels between her own situation and that of the young woman on the witness stand."
Absolutely not a book I would have chosen, but at the place where I worked one day a week they get through a lot of books so they offered a few to me. I gave this one a try and got away with it, but I don't enjoy reading about cruelty and abuse and feeling really tense, and the story isn't that good anyway - I didn't like any of the characters, not even the 'good' guy or the heroine. I avoid horror films for the same reason - some people must like feeling scared, but it would just give me nightmares. I won't be trying this experiment again.

Image of the book cover

The Return of Sherlock Holmes
by Sir Arthur Conan Doyle

narrated by Simon Vance
"The great Sherlock Holmes is back from the dead and devoting his life once more to examining the criminal complexities of the capital."
Poor old Conan Doyle wasn't allowed to kill off his hero, and here he is writing another lot of short stories to the same formula. Holmes: crime-solving genius, Watson: well-meaning duffer, with a side order of wily criminals and desperate clients and bumbling policemen. I love it.

Image of the book cover

Ten Things I Love About You
by Julia Quinn
"Annabel Winslow is in a pickle. Having newly arrived in London for her first season and being in possession of a voluptuous figure, is being openly courted the the Earl of Newbury, who is at least 75 and a nasty brute to boot."
Another ridiculous mock-Regency romance. Half way through I was determined to give up this author because all her books are fundamentally the same, and I may still pack it in. But I did enjoy it in the end. It's just that there are much more worthy and thoughtful books on my shelf waiting to be read, and spending time on this insubstantial fluff feels like a wasted evening.

Image of the book cover

Rabbit, Run
by John Updike

narrated by William Hope
"At twenty-six Harry 'Rabbit' Angstrom is trapped in a second-rate existence, stuck with a fragile, alcoholic wife, a house full of overflowing ashtrays and discarded glasses, a young son and a futile job."
What an excellent writer, and what a shame he has written such a horrible book. I was transported by the imagery he uses and his skill with words - wonderful, brilliant writing - but the people he has created and imbued with life are so mean, selfish and ignorant. Nobody is given any generosity of spirit and the lives they lead are bleak. Maybe this was the reality of life in 1959, and maybe I'm limiting my horizons by not wanting to read about it but I do want just a little bit of joy in my reading matter, and this has close to none.

Image of the book cover

Tom Brown's Schooldays
by Thomas Hughes
"The book is semi-autobiographical and is based on Hughes’ own experiences at Rugby school, including his respect for his schoolmaster Dr Thomas Arnold, who is portrayed as the perfect teacher in Hughes’ novel."
When I started this book it felt very much like reading a set text for English at school: a worthy book with plenty of material for O level essays. Despite the language and attitudes to class and religion typical of a book written in 1857, it improved no end as I went along. I enjoyed setting the scenes of school life into the same Rugby School I visited earlier this year, and relished the detailed descriptions of the life of public schoolboys so different from my schooldays forty years ago, and even more different from what I imagine schools are like today. It is a historical document as much as anything else, and that is the most fascinating part - how our values and attitudes have changed, and how much our present has derived from its past! I am almost ready to write that O level essay...

Sunday, 27 September 2015

Pumping insulin - Part 2

View of the hotel beyond a meadow
Coombe Abbey, June 2015
In part 1 I wrote about the basics of how a pump works in comparison with using insulin pens and MDI - multiple daily injections. Now we come to how I got on with the course, and some fancy features of the pump in more detail.

Tube or Not Tube?

The course I attended was run by a company whose pump delivers insulin to the cannula via a tube. Other pumps, like Mr M's, combine the pump and cannula in one unit and you stick the whole lot onto your body and control it from a separate handset. The pumps that we were using also had a handset that duplicated the interface on the pump and communicated with it via Bluetooth. The benefit of this approach is that when you administer insulin you can leave the pump in whatever inaccessible place you have stashed it - such as in your pants. Some pumps don't have this convenience, so you have to retrieve the actual pump in order to deliver insulin. You probably don't want to be fishing down the front of your trousers at the dinner table so your options for carrying the pump are more limited, and slinky dresses present a similar problem.

Here's a slightly blurry picture - the handset is on the left, and the pump with its tube is on the right.

There are a few different cannula types to choose from, but they all require you to stick a needle into your body. We were given the opportunity to try two types, one inserted manually and one using an insertion gadget, and I was very surprised that I hardly felt the insertion at all. You load the insulin into the pump either using a pre-filled cartridge or by filling the reservoir yourself with a syringe and a vial of insulin. Then you have to prime the tubing to fill it with insulin, connect the tube to the cannula and fill the cannula with insulin, and then it's all set and ready to go. The whole process takes a few minutes, which isn't long, but I imagine could be very annoying if it needs to be done at an inconvenient time.

Cannula, tube and pump connected to yours truly
Obviously I wasn't delivering any insulin through the cannula (I produce my own very nicely, thank you), and we weren't given strips to test our blood glucose. But we were given a pump to wear and encouraged to go through the process of estimating carbohydrate and programming a dose of insulin using the pump or its handset. This is something I'm pretty familiar with given that I've been interested in diabetes for some time above and beyond what the job requires.

12 hours connected to a pump

At dinner we were encouraged to estimate the carbohydrate portions and pretend to bolus insulin using the pump. I tend to forget that most normal people don't do this every now and again just for fun - for some it was actually the first time! We shared our guesses about the carbs in various dishes, and established the kind of variation in estimation that you get when there's no correct answer. But then one of the most enthusiastic pump reps suggested that to try and estimate carbs more accurately we should ask the chef, and then went as far as to haul the chef out of the kitchen to talk to us.

I had a problem with this. "Do you expect the chef to be more skilled at carb counting than a room full of diabetes healthcare professionals, including Diabetes Specialist Dietitians?" I wanted to know. Undaunted, the rep persisted in asking the chef his opinion on the goat's cheese tartlets. The chef obligingly came up with a figure. I continued to make myself unpopular. "What are you basing that figure on?" I asked. "Is it the pastry? How much does the pastry weigh?"

At this point there was a murmur from the room. My questions were perceived as 'a bit much' by some of the other delegates, and sympathy was building for the chef. He was prepared to take me on, though. He said, "I'm basing it on the pastry, and the cheese, and the onion."

"The cheese? But cheese doesn't contain any carbs..."

At this point the enthusiastic pump rep proposed a vote of thanks to the chef, we all complimented him on the delicious spread, and he was hastily bundled out of the room, poor man. Nobody wants a smartarse Dietitian making a chef look like he doesn't know his carbs from his elbow.

Pump features

Lots of the two-day course covered the range of sophisticated features available on this particular pump, many of which are possible on most pumps on the market. These features are designed to help the user decide on the dose of insulin, and deliver it over a period of time rather than in a single injection.

There are quite a number of factors that influence the delivery of insulin in addition to the quantity of carbs eaten - the type of carbohydrate (sweet, starchy, liquid) what is being eaten alongside the carbs (especially fat, protein and fibre content of food and drink), the size and duration of the meal (quick breakfast before work or three leisurely courses at a dinner party), time of day, ambient temperature, whether the user is ill or well, the menstrual cycle, the site of the cannula, planned activity or alcohol, recent past activity or alcohol, whether there has been low blood glucose in the last 24 hours... the list goes on. All of this should be considered before you can even take a bite. It's a massive overhead for something that most of us take for granted as we tuck into our food without a second thought.

The help that most pumps give is confined to the maths involved in applying a ratio of insulin to carbs and adjusting it for the factors given above. The 'bolus advisor' comes up with a suggested number of units of insulin to be injected, which the user can accept or overrule. Then the user can decide how those units should be delivered.

There are three different ways to deliver the insulin. A standard bolus just squirts all the insulin required over a few seconds, much as an insulin pen or syringe would. An extended bolus allows you to spread out the insulin over a longer period of time. You can have it delivered at a constant rate for the whole period of time you select, or you can combine the standard and extended bolus and specify 30% (or 50% or 70%) to go in straight away as a standard bolus and the rest extended over however many hours you want. This type of  'multiwave' or 'dual wave' bolus is for foods that are digested quite slowly (low glycaemic index or low GI), usually because a large amount of carbohydrate is combined with a lot of fat and protein. Fish and chips, pizza, pasta in a cheesy or creamy sauce and curry are the main culprits.

The third insulin delivery option is the super bolus. It's used less than the other bolus types, and is a more extreme version of the multiwave bolus for food that is digested quickly (high GI). It's a little bit complicated because it involves the background insulin that is usually not included in calculations around food. Remember, the background level is programmed automatically to feed insulin dripwise over 24 hours. For these high GI meals (think candyfloss, Halloween or birthday party) you calculate the insulin needed for the food, then you add on the amount of insulin that you'd be getting from background insulin for the next 2 (or 3) hours and give that whole amount up front. Then you turn off the background insulin for 2 (or 3) hours. It gives you a big 'kick' of insulin with the sugary food then turns it off so you don't go low later on.

Other features that may be used more often than the different bolusing options are the different basal profiles and temporary basal rates. The basal insulin is the background 'dripwise' insulin, and the rate it is delivered is programmed into the pump as a 'basal profile'. This generally varies hour by hour, giving a little more insulin in the early hours of the morning for example, when blood glucose naturally rises as the body prepares for waking. You may have different basal profiles if you work different shifts, for example, or if your routine and pattern of activity varies between weekdays and weekends. Temporary basal rates (TBR) can be handy if you are ill and you need more insulin, or if you are exercising and you need less. A TBR is selected for a number of hours rather than for a whole day.


Writing this pair of posts has reminded me just how much is involved in managing diabetes day-to-day, with or without a pump. It's a lifetime's work - I have left out far more in these 'essays' than I have been able to include. For example, how do we decide on how much background insulin to program into the pump, or how much to give for food? How do people manage sport or illness or pregnancy or holidays or airports? What if you get it wrong, or drop the pump or handset in the toilet, or run out of insulin or needles or test strips? What if you can't do maths, or read, or you live in prison, or are homeless? These are all matters for other blog posts on other days.

I complained to the last group we had for structured education that they had an advantage over me, because I can't experiment and test out my dietary theories. I can estimate carbs in meals and suggest matching insulin doses and bolus types as much as I like, but I will never know if I am right. Obviously they showed no sympathy (and I expected none), but having diabetes is a process and a lifestyle and a challenge as much as a diagnosis, and one that takes a lot of effort and commitment to master.

A pump doesn't cure diabetes, but it can help. There are other technologies being developed including the holy grail of the 'Artificial Pancreas' which is intended to match the natural pancreas even more closely, but even that won't detect blood glucose or deliver insulin in the non-diabetic physiological manner. Glucose-detecting contact lenses or wrist-watches have been proposed, but these are all sticking plasters on the gaping wound that is Type 1 diabetes, and we are nowhere near any sort of cure, or even identifying a cause.

Tuesday, 22 September 2015

Pumping insulin - Part 1

Garden and fountain in courtyard of hotel
Coombe Abbey Hotel and Conference Centre, June 2015
This pair of posts have been brewing for a very long time, mainly because it's an interesting but a complicated subject, and I wanted to make sure I covered as much as possible in one go. Mr M has written a guest post about his insulin pump, and reading back over that gives quite a comprehensive view of pumping. On the course I attended I discovered there is much more to say, and I won't even be covering everything in these two posts. For more information from people with greater expertise, go to the INPUT website.

The insulin pump course I attended took place almost immediately after my extended (TEN DAYS!) U.S. holiday and before my Solitary Holiday, and was held in a very posh hotel and conference centre constructed within a former Abbey with adjoining Country Park. There were no bedrooms, only 'bedchambers'. Initially I wasn't going to be staying overnight because it is well within commuting distance of home, but the company who organised the whole event contacted me shortly beforehand to say that some attendees had dropped out but their rooms were booked and paid for, so I might as well use one. Which was nice, because dinner was included and I probably wouldn't have stayed for that if I weren't staying overnight.

Insulin Pumps and Insulin Pens

In the UK, insulin pumps are only available to people with Type 1 diabetes, i.e. their pancreas is completely broken and not producing any insulin. As a Type 1 without insulin you end up dead before too long, so you have to inject a modified synthetic insulin into subcutaneous fat, which most people do using 'pen' devices. There are different types of synthetic insulin which have been designed to enter the bloodstream from the subcutaneous depot at particular rates. There are a rare few people who haven't moved on from bovine or porcine insulin and some who even use old-fashioned hypodermic syringes, but these are a tiny minority.

A working pancreas responds automatically to blood glucose levels, secreting exactly the right amount of insulin to maintain blood glucose within the ideal range. The person with diabetes has to take on the role of the pancreas by measuring capillary blood glucose via a finger-prick, then guessing at what blood glucose levels will do next, and injecting insulin according to their guess. Insulin pen users inject a long-acting insulin once or twice a day and rapid-acting insulin at mealtimes or with snacks, or else a twice-a-day mixture of long- and short-acting insulins.

The insulin pump is designed to try and mimic the physiological action of a working pancreas more closely. It contains a reservoir of rapid-acting insulin, and a background rate is programmed to inject this dripwise at an adjustable rate instead of the daily or twice-daily injections of long-acting insulin. With food there is the same process of estimation and guesswork about what blood glucose is likely to do, and the user tells the pump how much insulin to deliver from the same reservoir of rapid-acting insulin.

The pump delivers its insulin into subcutaneous fat via a cannula, which is a hollow needle made of metal or teflon that you insert into your body. The cannula stays in place for only two or three days otherwise you risk irritation around the insertion site and the formation of lipohypertrophy, which is a lump caused by insulin being delivered into a specific location for too long. Available sites are round the abdomen, the top of the buttocks, back of arms and sides of legs as long as there is a decent covering of fat - the same locations as for standard insulin injections.

Benefits and drawbacks

We often come across people in our service who are desperate to have a pump because they think it will make their diabetes management easier. In fact a pump is no easy option, and if you don't put any effort into managing diet and insulin and lifestyle then your outcomes will be as bad or worse than on multiple injections with an insulin pen. None of the benefits I list below relate to doing less work in managing calculations and all the rest of the overheads associated with doing the job of your defunct pancreas.

So what are the pros and cons of pump vs pen? The obvious disadvantage of the pump is that you're attached to it 24 hours a day, although you can remove some pumps for bathing or swimming or sports for up to an hour. Some people don't have any sort of a problem with having a pump attached to them day and night, at work, in bed, on holiday, doing sport - everywhere. Some people just don't like the idea, and ladies who want to wear figure-hugging clothing or a bikini may not be keen to display their condition. It's a very individual choice.

Disconnect the pump for more than an hour and you start to risk rising blood glucose levels, because you don't have any long-acting insulin in your system. After about four hours insulin-free there is the further risk of developing ketoacidosis, which is unpleasant at best and life-threatening at worst. So another disadvantage is that if anything goes wrong with the pump or your cannula or your insulin, you'd better have a back-up option handy or you might find yourself in A&E. If you're away from home, even on a short trip, you may find the journey cut short or have to make a whole lot of calls or trips to hospitals or pharmacies unless you carry spare equipment with you.

One clear advantage of the pump is fewer injections - in the three days that one cannula lasts you might expect to give at least 12 injections using a pen, and probably more. Another advantage of the pump is the ability to reduce your dose of insulin as well as increase it - with a pen, once the injection is given you can't dial the dose down. The third main advantage is that the background dose can be varied in a diurnal pattern that better matches the body's requirement for insulin, and the fourth advantage is that insulin to match food can be delivered in an adjustable dose over a period of time, which better mimics the action of a working pancreas compared with one or more isolated injections. Lastly, insulin pens only allow administration of insulin in whole (or occasionally half) units, while the pump can deliver much smaller amounts.

Other pump features

The pumps on the market also have no end of other features that are useful rather than necessary, like alarms, and the ability to download data from the handset and pump for viewing in all sorts of different ways designed to help you improve your carb counting and insulin delivery. The software for the pump that nearly all our patients use has some further features such as the ability to create a new profile by adjusting the background insulin up or down by a percentage - the alternative would be to change each of the 24 hourly settings using the pump or handset menus. The main feature that this pump lacks is the ability to upload all its data to the Internet so that it can be accessed anywhere. In our department we can only view the data on the specific computer that it's downloaded to, although we're working on a networked option so at least we can see the data on more than one computer in the building.

Mr M has a number of objections to the way the the software for his pump works that are probably a bit too technical to discuss here. I expect there are annoying features with every pump and handset. We recently held a session where we invited all the different pump manufacturers to show us their wares in an afternoon, and while they all do roughly the same job they are all quite different.

Coming soon: Part 2 of the Pumping Insulin series covers my own experience on the course, including wearing a pump myself for 12 hours.

Thursday, 17 September 2015

Tired (again)

A sofa and footstool sculpted from stone
Somewhere in Rugby, May 2015
Usually I make a start on writing something vaguely interesting at the weekend, and finish it off ready to publish on a Tuesday. This week that hasn't happened, so I am putting this out without benefit of deep consideration or self-editing. I am tired.

This is my last month of full-time work. From October I am reverting to either 27 or 30 hours a week (I don't yet know which it will be - either way, not more than 4 days) and I am looking forward to it immensely. They are certainly getting value for money out of me this final month. An extra clinic has started, we are still short of one Dietitian who has left and a replacement not yet recruited, one of the remaining Dietitians is on holiday, but a new service is due to start shortly after she gets back and needs a load of preparation, which I'm not sure is being done. Two of the Diabetes Nurses are now off sick and another is about to have an operation on her foot that will keep her at home for six weeks.

On top of all that, a couple of weeks ago I committed the most heinous crime that it is possible to commit - I didn't turn up for a clinic which I was supposed to be covering. I got confused with where I was supposed to be and whose clinic I was standing in for. Luckily there were only three patients and apparently they didn't get too angry, although they were entitled to be cross because their previous appointments had been moved to this new date at short notice because one of the remaining Dietitians not previously off sick had been put out of action with a bad back, due to being made to work in a room with a coffee table instead of a desk (thankfully she's back at work now). I felt bad about missing that clinic for days. Actually, I still feel bad about it. I hope the feeling will wear off soon.

It's all been a bit much, and now that my age has exceeded the half-century I am starting to appreciate that I am no longer a bright young thing who can just pack as much as I like into my days. Playing badminton makes me much more tired than it ever did before - not that I'm about to stop playing, but I used to start early and finish late at club nights and now I'm much more inclined to start late and finish early. I am significantly tired the day after any vigorous activity, where in the past I wasn't. Of course as well as the badminton I'm doing the running that leads up to the event in November, so that makes for extra tiredness. Perhaps I'm overdoing things.

[Nostalgia note: When I was a child, my grandmother used to say that I was always overdoing things. "Do not overdo," is one of the few phrases I remember her saying, along with "Speak more slowly," the numbers in German and a rhyme that started "Hoppe hoppe Reiter" which I still remember word for word.]

This has turned into a bit of a whine - it's interesting what manifests itself when I sit with a blank screen and write whatever comes into my head. Things are fine. I am essentially fit and healthy and most of my complaining is about activity that I have chosen to do of my own free will and could stop at any time - in fact, I have missed a badminton opportunity tonight. I have completed some significant and difficult tasks and am optimistic that I will manage a few more by the end of the year. Work is essentially fine too, although there are and always will be annoyances and inefficiencies and personalities and conflict, as well as satisfaction and success and achievement and progress.

Outside work I've already mentioned badminton and running - there are also films on DVD, the usual reading in print and audio, food shopping and cooking, watching the one TV programme of the year that I like (The Great British Bake Off), cleaning the house, a massage, and welcoming Lola II and Mr M for the annual Leamington Food and Drink Festival. As usual I made sure I examined every stall in the arena over the two days of the Festival, and this year purchased three packs of sausages, a sachet of curry paste, a mushroom and garlic vegetarian Scotch Egg, three different cheese scones, a chocolate and cherry brownie, a Thai curry with cashew nuts and rice, and a pastrami and cheese toasted sandwich. I have already eaten all of them except one pack of sausages, but not necessarily in that order.

My ongoing plan for this evening is to go to sleep quite soon. I'm looking forward to recovering at the weekend before starting my penultimate week of full time work.

Tuesday, 8 September 2015

Developments at work

Horn-playing sculpture among flowers in garden
Caldecott Park, Rugby, May 2015
Crack open the champagne - they've finally installed an alternative web browser on my work PC! I tried for an upgrade to IE long ago but it was incompatible with another application on the PC and had to be removed again. At the time I didn't think to ask for a different browser, and they didn't offer it, but a colleague mentioned the option and now I've got Chrome. It's such a treat to be able to see websites that aren't completely garbled, and more and more sites were just refusing to load at all with the ancient version of IE. Now I can update my yogurt document (don't ask - it's just a list of the nutritional content of various strawberry yogurts).

Another work-related thing is that I've volunteered to be a subject in a research project. On a day when I'm being a guinea pig, using an app or via a website I have to:
  • weigh myself first thing
  • collect and measure all my urine throughout the day
  • put two small urine samples in a test tube on each occasion
  • eat less than 1200 Calories in the day, comprising a normal breakfast, a carb-free meal, and a snack that's less than 200 Calories
  • record everything that I eat and drink and any activity that I do as well as weight, urine volume and test tube numbers.
I've managed two days so far (it's not an every day thing) and it's actually quite demanding. The research is very relevant and all about a person's insulin response to food throughout the day - apparently there is measurable insulin in urine, which surprised me.

Then there's been our Teen course. I've written a lot about structured education, because it really is the key to managing diabetes. If you don't really understand the condition or how best to manage it (and it's quite a complicated business) then I don't see how you can expect to avoid having higher blood glucose than is ideal, and we know that this raises the risk of complications. But we find people are very reluctant to spend the time attending our structured education, and this is a particular problem with young people with Type 1 diabetes.

Most will have been diagnosed when they were too young to be expected to manage everything themselves, so if any education had been provided in the past it was probably aimed at parents. So we want to catch young people at a point when they are managing their own diet and insulin, to make sure they acquire all the knowledge that they need to stay healthy for the 50, 60 70 or more years that they may have ahead of them.

We decided we would try to attract 16-21 year olds, so we got together with the paediatric team to contact as many of this age group as we could. We did a mailshot and we encouraged people at their routine appointments to consider signing up, and ended up with 13 people who said they would attend. This seemed enough to justify putting on a course, so we cooked up a programme based on the usual version of our Type 1 Structured Education, but shorter, and including more that might be relevant to the younger audience - eating out, snacking, alcohol, drugs, festivals, travelling, sport and exercise, living away from home, that sort of thing.

As I wrote a while ago, only two turned up for the first week. The second week was scheduled on the same day as A level results are published, and one of our two attendees was due to get his results that day, so we agreed to skip that week and get them back the following week, covering everything in just two sessions seeing as how they were both pretty quick on the uptake. Only one of them came to the second session.

That solitary participant, however, gave us some good feedback and ideas about how we might attract more attendees if we tried again:
  • offer food e.g. doughnuts/pizza
  • start later in the day
  • change some of the wording in the invitation letter
  • arrange for transport from the city centre.
I'm not sure if we'll try this again, and it certainly won't be until next summer holidays, but it was a worthwhile exercise even if only one and a half people benefitted.

Tuesday, 1 September 2015

Sun + rain = camping + walking

Two chaps in period dress and one in armour
Sudeley Castle, August 2015
It's been a rainy Bank Holiday weekend, although to be fair, some of Saturday wasn't bad. As I write, I hear muffled clapping, cheering and shouts of encouragement or triumph from the bowling greens, where we are reaching the end of a month of National Bowling action. Our period of exclusive entry to our little trio of streets guarded by high-vis-vest-clad doormen is nearly over.

In the past couple of weeks I've had quite a few evening appointments, including appearing on a panel for a different Diabetes UK local group from the one I used to attend until I'd had enough of their rudeness. The demographic was very similar - nobody under 50, a couple of opinionated and outspoken members, polite attention and some interesting questions. The panel consisted of two podiatrists, an optometrist, me, and a retired local GP who is fairly eminent in the Diabetes professional world. People were very interested in what the podiatrists had to say and much less interested in my contribution. I expect it's because someone's always banging on at them about food, whereas they have few opportunities to raise questions about feet.

I also enjoyed a weekend away camping with Lola II. The campsite was fine, including excellent hot showers but with fields mostly on a slope. I managed to find a relatively flat bit to pitch the tent before collecting Lola II from the station. We did a bit of campsite cooking and some eating out, but I'd brought quite a lot of salad ingredients, because a) that's what I had in the fridge, b) it's supposed to be summer and c) Lola II and I are both grappling with weight management.

We visited an old prison and a castle. The prison also contained a Cotswolds information centre, and Sudeley Castle (and Gardens) was staging an event including re-enactment of the period of Richard III, including costumes, armour, archery and music. The castle was home to Henry VIII's last wife, Katherine Parr, and she is buried there too - the only Queen of England to be buried in the grounds of a private home. There are gardens as well as the castle, and exhibitions on all sorts of aspects of historical interest. We were there for hours and didn't see everything - there was plenty to keep us occupied, and it was really hot.

On Sunday we met up with Landrover Man and Bee Lady for a lovely walk in the countryside. LRM can always be relied on to plan a route and guide us around it, thus saving endless hours of getting lost which would happen if I were in charge.

The Weather Gods had a hand in the loveliness of the countryside, providing torrential rain halfway through when we were in the middle of a field, far from shelter. I had been too lazy to bother wearing proper boots so I was in trainers, and could wring my socks out at the end, but it was worth it - not cold, and good to catch up with bees, farmyard machinery, sheep and septic tanks. I can vouch for the impressive improvement to the vista chez LRM and BL because we were sent 'before' and 'after' pictures of the septic tank cover.

So that was a good weekend away. For the Bank Holiday weekend I decided I had procrastinated long enough and it was time to put in a bit of effort into choosing and buying a car. So early on Saturday I got up and did a Parkrun instead. I find that buying a car (or in fact buying anything except food and charity shop clothes) is really difficult and fairly unpleasant, but I found one in the end and it's probable that the ordeal will be over in a month or so. The dreadful experience is too fresh to write about now, but I'm sure I'll manage to bring further vehicular news at some point.

Two Lolas and a lady made of shrubbery
Sudeley Castle again

Thursday, 27 August 2015

What I've been reading

Image of the book cover

The Hound of the Baskervilles
by Sir Arthur Conan Doyle

narrated by Simon Vance
"Sir Charles Baskerville has been found dead. There are no signs of violence, but his face is hideously distorted with terror. Years earlier, a hound-like beast with blazing eyes and dripping jaws was reported to have torn out the throat of Hugo Baskerville. Has the spectral destroyer struck again?"
A good story - obviously I've read it before, but it must have been a long time ago because I barely remembered any details, let alone whodunnit. This Sherlock Holmes anthology is certainly living up to its promise so far.

Image of the book cover

The Man Who Was Thursday: A Nightmare
by G. K. Chesterton

narrated by Simon Vance
"Gabriel Syme is a poet of law. Lucian Gregory is a poetic anarchist. As the poets protest their respective philosophies, they strike a challenge. In the ruckus that ensues, the Central European Council of Anarchists elects Syme to the post of Thursday, one of their seven chief council positions."
This started badly and ended badly, but the middle was quite good. I didn't think I would relate to a story about anarchists, but I just substituted the word 'baddies', which worked well enough. The identity of the anarchist known as Sunday was revealed towards the end (it wasn't really a surprise), but after that the whole thing stopped making any sense at all. I got the impression that the author didn't really know himself how to finish it.

Image of the book cover

The Goshawk
by T. H. White
"This is the record of an intense clash of wills during the training of a great, beautiful hawk, in which the pride and endurance of the wild raptor are worn down and broken by the almost insane willpower of the schoolmaster falconer."
This is referenced extensively in Helen Macdonald's recent bestseller 'H is for Hawk', and having read that and unearthed this from my shelves it was obvious that I needed to read it. It's not quite as brutal as Macdonald makes out - she seemed to quote the worst bits, but even so, White has a tough time with his hawk and the hawk has a worse time with him. A classic for the aspiring austringer or falconer or someone like me who is a little bit obsessed with these birds; I don't think normal people would find much of interest other than to consider how things have changed since those difficult postwar years.

Image of the book cover

Guns, Germs and Steel
by Jared Diamond
"Since 1500, Europeans have, for better and worse, called the tune that the world has danced to. This book tries to explain why, and suggests that the geography of Eurasia was best suited to farming, the domestication of animals and the free flow of information. The more populous cultures that developed as a result had more complex forms of government and communication, and increased resistance to disease. Finally, fragmented Europe harnessed the power of competitive innovation in ways that China did not."
This was recommended ever so long ago, when I started my degree in 2007 and I've been looking out for it ever since. One of the lecturers was encouraging us to read around our subject, which is what I do quite a lot, so in return for this recommendation I provided him with a whole load of suggestions of other interesting books about science. In comparison with the books I recommended, this one is a dud as far as I'm concerned. The question the author sets out to answer is why Europeans tended to dominate the societies they met rather than being assimilated or even dominated by them, the simple answer being the title of the book. The discussion then becomes exceedingly anthropological, and I am not particularly keen on lengthy discussion about the development of farming and pottery or the spread of language throughout Austronesia. So read 'The Goshawk' if you are interested in birds of prey and read this if you are interested in anthropology, and avoid them both if you're not.

Tuesday, 18 August 2015


Succulent plant in pot
Peckover House, August 2014
"Another blog post so soon after the last?" I hear you cry. Well, I've been working on this one and another as yet unpublished post for ages, and I'm a bit busy for the rest of the week and the weekend, so here goes.

I have had a look back at the blog, and I can hardly believe that I haven't really explained what DESMOND is. Given that it has formed a large part of what I've been doing over the past 9 months or so, I'm surprised I haven't described the programme.

DESMOND is a nationally delivered structured education programme, designed to meet the criteria within the NICE guidelines for Type 2 diabetes, which has quite a lot to say about patient education:
1.1 Patient education

1.1.1 Offer structured education to every person and/or their carer at and around the time of diagnosis, with annual reinforcement and review. Inform people and their carers that structured education is an integral part of diabetes care.

1.1.2 Select a patient-education programme that meets the criteria laid down by the Department of Health and Diabetes UK Patient Education Working Group.
  • Any programme should be evidence-based and suit the needs of the individual. The programme should have specific aims and learning objectives, and should support development of self-management attitudes, beliefs, knowledge and skills for the learner, their family and carers. 
  • The programme should have a structured curriculum that is theory driven and evidence-based, resource-effective, has supporting materials, and is written down. 
  • The programme should be delivered by trained educators who have an understanding of education theory appropriate to the age and needs of the programme learners, and are trained and competent in delivery of the principles and content of the programme they are offering. 
  • The programme itself should be quality assured, and be reviewed by trained, competent, independent assessors who assess it against key criteria to ensure sustained consistency. 
  • The outcomes from the programme should be regularly audited. 
1.1.3 Ensure the patient-education programme provides the necessary resources to support the educators, and that educators are properly trained and given time to develop and maintain their skills.

1.1.4 Offer group education programmes as the preferred option. Provide an alternative of equal standard for a person unable or unwilling to participate in group education.

1.1.5 Ensure the patient-education programmes available meet the cultural, linguistic, cognitive and literacy needs in the locality.

1.1.6 Ensure all members of the diabetes healthcare team are familiar with the programmes of patient education available locally, that these programmes are integrated with the rest of the care pathway, and that people with diabetes and their carers have the opportunity to contribute to the design and provision of local programmes.
So we offer group education delivered by trained and quality assessed educators with a curriculum that is written down. The only part that deviates slightly from the guideline is that I don't believe we are meeting the cultural and linguistic needs in the locality, but we're working on it.

The name DESMOND stands for Diabetes Education for Self-Management of Ongoing and Newly-Diagnosed. The syllabus content is prescribed, as are the Educator Behaviours in delivering the content. Educators are assessed on the manner of their delivery as well as including the messages that need to be delivered, because there is also a philosophy behind the curriculum. I do agree with this approach but I sometimes find it difficult to educate in the approved manner without sounding patronising.

During our delivery we are supposed to give as few direct answers to participants' questions as possible, because the emphasis is on self-management - if they have questions after the course we want them to be able to work out how to find the answers when we're not around. Of course, if nobody knows what is represented by the two numbers in a blood pressure measurement or how sulphonylurea medications work then we're going to tell them. But if someone asks "Is [food x] good for you?" as they often do, we are supposed to first throw the question back to the group, and encourage them to use the principles they've learned in order to work it out for themselves.

The course is delivered by two DESMOND educators either in one full day or two half days a week apart. After introductions and housekeeping, sessions include information about what diabetes is, causes, medications, monitoring, carbohydrates, calories, long-term effects and how to avoid them, other aspects of health associated with diabetes (cholesterol, blood pressure, smoking, depression), the annual review, physical activity, fats and overall food choices. Participants are encouraged and supported in recording their own results in a 'Health Profile', and at the end they are expected to create an Action Plan containing one thing that they are going to try to change or achieve as a result of the course, and how they will go about doing it.

My journey as a DESMOND educator started in October last year, when I attended the two-day course in London. The next stage is for educators to go away and practise educating, and within six months they are supposed to arrange a session when they are observed for half a day by a mentor and given feedback, and then the final quality assessment of a whole day's course, of which you deliver about half, alongside your co-educator.

There are some interesting assessment tools, including a 'beep score'. The assessor listens to a track in one ear that beeps every ten seconds, and marks down who is talking at the point of the beep - is it the educator, the participants, or is something else happening (an activity, or silence, or laughter)? A percentage score is calculated to represent the proportion of time that the educator is speaking, which needs to be less than the particular percentage threshold set for that session. Other assessment is more conventional - is all the content delivered, are the educator behaviours as they should be, are the learning objectives met?

I had my mentor visit in February, and my final assessment in June. Thankfully I passed, so I am now DESMOND accredited, but it's lucky that the assessors have some leeway in their assessment. My Physical Activity session has never been great, but it was dismal on this occasion - I think it has since improved a little. We are expected to devise our own action plan along the same lines as the participants, and I really should have a look at mine soon. Accreditation is periodically re-assessed, and you have to deliver a certain number of courses a year in order to remain accredited.

I do enjoy delivering DESMOND, and of course every group is different. I haven't had anything very difficult to deal with - the most challenging was probably one participant with mental health issues who spent some of the time asleep, and walked in and out of the room at random. He wasn't very disruptive though, as we could ignore him or include him as appropriate. Every now and then a participant tells us that they don't know why they have been invited to the group because they don't actually have diabetes - of course we have checked beforehand and they do have diabetes, but the way the programme is delivered means that they usually work this out for themselves as we go along. The most negative comments we get are generally those that say they wish they had been given the information earlier.

We were given extra funding for a year because we got very behind with our courses and waiting times became unacceptable, so I have been employed one day a week to help catch up. We have caught up and that funding ends in September, and I will actually be glad to go back to four days employment a week. In order to keep up my DESMOND accreditation I do need to deliver a few courses, which will be on top of my four days a week.

So from October I hope to have an extra day in the week for all the jobs that are hanging over me - much work around the house and garden, buying a new car, a dress for Sister D (the fabric has now been bought!) Or, more likely, I'll doss about as usual and nothing will get done. Place your bets.

Friday, 14 August 2015

Travel and work and badminton and running and shopping and cooking

Blue skies and fluffy cloud over snowy peaks
Courmayear, February 2015
There's been another trip south, which is why there hasn't been much blogging action recently. I've been fully occupied all of one weekend on family stuff, and during the week there's been work and badminton and running and shopping and cooking, and the sole TV programme that I actually watch (The Great British Bake-Off) has started a new series. And I went out with work colleagues to celebrate my birthday, and met a friend while I was in London that I hadn't seen for more than 25 years. So blogging has had to take a back seat.

Lola II and Mr M and I ate well as usual during my visit. We decided to try somewhere we hadn't been before that offered Caribbean food from Trinidad. It was a fairly new restaurant and they were very keen to tell us all about the food, which had a more Indian influence than the Jamaican style food that's more commonly found. I had mutton, Lola II had chicken and Mr M had salt cod, and it was all very good indeed. Next day I wore my newly made dress for the Family Birthday Celebration (and I wore it the week before for the Works Night Out), and it looks so good and I was complimented so much that it all went to my head and I offered to make another one for Sister D. Using stretchy material it shouldn't take too long...

Badminton - the good news is that following rest and changing my mouse to the other side, my racquet arm is as good as new, possibly better. Running - I'm getting along OK, I'm nearly half way through a training plan leading up to this pesky 10k plus obstacle course that I've signed up to, but I have a feeling that the race will arrive before the end of the training plan... not that it matters that much.

Work - lots of interesting things and still many frustrations. We tried to entice as many 16 to 21 year-olds as we could onto a specially designed education course for Type 1 diabetes, but out of the thirteen or so who had verbally agreed to come, only two turned up (and for a period of about 15 minutes we thought it would only be one). One of the meter manufacturers has offered to sponsor a course that would include go-karting so as to attract the target audience, but I'm not sure if we'll take them up on it because we don't actually like their meter very much. The company that makes the meter we do like hasn't provided us with a rep since last December, otherwise I'd be very keen to put a bit of pressure on them to help us out.

Tuesday, 4 August 2015

Solitary holiday #3

Brasserie entrance with wrought iron, flowers and ivy
Harrogate, July 2015
I liked Harrogate, despite the rain. The town was accessible and attractive, as were the people. Maybe I'll go again next year.


Despite the forecast it didn't rain all morning, and I ventured out to have a look round. The town is larger than I was expecting and I wandered about fairly randomly, just getting oriented. My first impressions were that the architecture is lovely, there's quite a lot of history reflected in the buildings, and there is no shortage of places to eat, often advertising local produce that looks rather tasty. And lots and lots of shops that I didn't go into. Maybe later in the week.

Like my Solitary Holiday two years ago, I thought I'd like to make another dress, but this time for me rather than for Lola II. My inadequate preparations for this holiday (as usual) meant I hadn't bought any fabric in advance, but I did do a bit of Internet research and discovered that there are two fabric shops within walking distance of my apartment. Two! The first was very small, very crowded, the member of staff I found was rather unhelpful and they didn't seem to have the range I wanted. The other one, however, was bright and airy and despite having less stock overall, they had more than one design in the jersey fabric I was looking for. And I got a whole lot of invaluable advice and information about sewing with stretchy fabric, using a fancy double needle, tips for putting in the zip, and an offer to help me get the hem straight if I couldn't do it on my own.

Royal Hall exterior
'Kursaal' or Royal Hall, 1902


Looking into the hall from a box
The rain held off for my outing today, which was to the Royal Hall. This glorious building was built at the turn of the 19th century as an entertainment venue for those coming to Harrogate to take the waters. At the time it was named the Kursaal, but was renamed after the First World War due to anti-German sentiment. At the turn of the 20th century it had deteriorated to the point of demolition, but was saved and restored to its former glory.

'Ambulatory' circuit, Royal Hall, showing doors to boxes
There happened to be an Open Day on Tuesday including a tour of the building. Apart from the wonderful decor, stained glass windows, interesting private boxes and the provision of a walkway all around the outside of the inner hall, the part of the tour that made the greatest impression on me was when we were shown where the rear balcony was. In its heyday, the smart folk of the time would have looked out over a rose garden, a tennis court, statuary and parkland leading up to the grounds of the Majestic Hotel. Now you can see only concrete yards, the bins, and the back of some of the halls belonging to the International Conference Centre.


Today's cultural outing was a tour of the Turkish Baths. Unlike the single spring in Tunbridge or the few in Leamington (now reduced to just the one there too), there are many sources of spa water in Harrogate, and with varying composition including waters containing sulphur, iron and magnesium. The first spring was discovered in 1571, well before Leamington's or Tunbridge's.

The Pump Room (which I visited after the Baths) was built on top of four of these springs, and the Turkish Baths was built just up the road in an absolutely enormous heavy-looking building that now houses the Tourist Information office, a large Wetherspoons pub, a nightclub and a Chinese restaurant as well as the Baths, which have been restored to nearly how they would have been originally but taking account of modern sanitary requirements.

Frigidarium, Turkish Baths
The fixtures and fittings are wood, tile, terrazzo and mosaic floors and glorious walls painted in the Turkish style. Heat is provided by a boiler in the basement, and we were taken through successive rooms from the 'cold' room, the plunge pool through three stages of heat including the steam room. It is still owned by the Council and in use today (although obviously not during the tour) and also offers other 'treatments'.

As the popularity of spas declined in England, lots of buildings were repurposed. The Victoria Baths became Council offices, a building originally built as a theatre or assembly room is now an Art Gallery. In more recent times the town reinvented itself as a conference destination and even hosted the Eurovision Song Contest in 1982 and the end of the first stage of the Tour de France last year. There are still quite a few reminders of Le Tour around town in cycle logos, small sculptures or features on buildings.

The original Pump Rooms, now split into several separate establishments


This was supposed to be a mostly fine day so I planned to go to Harlow Carr, a Royal Horticultural Society garden. It can be reached on foot through the municipal Valley Gardens and Pinewoods, so that's what I did. I'm sure the gardens are very lovely and probably comparable with many other gardens I've visited and enjoyed. The main problem was the rain, which took much of the pleasure out of seeing plants and landscape, and then the battery on my camera ran out. Eventually I got so fed up of getting rained on that I gave it up and walked back, at which point the sun came out. Not for long, though.

Dinner was at a Turkish restaurant, where the lentil soup was particularly delicious.


Throughout the week at odd times here and there I've been working on the dress. Today I haven't planned anything else, so I had a good run up at the most difficult bit - putting the zip in. After two or three attempts I finally decided that the fabric is so stretchy that I don't actually need the zip, which made the business a whole lot easier and could have saved me three hours. I did some cooking, some reading, and I watched a film on DVD. Outside, it rained.

One of the reminders of the Yorkshire Tour de France


There's a Parkrun in Harrogate just a few minutes walk from where I'm staying, so I did that. Compared with the lovely Leamington route around the golf course with its monster hill in the second kilometer, Harrogate's course is almost completely flat and just three straightforward laps around a field. It was gloriously sunny and I felt optimistic for better weather at last.

The dress is almost finished, but the final hem went very wrong when I kept running out of thread. The fancy twin needle works surprisingly well at producing a stretchy seam, but is fairly hungry for thread and misbehaves badly when deprived. I had to unpick the whole seam, and it was lunchtime, and I wanted to go to a particular pub for lunch which was near the fabric shop. So I put on the dress with its slightly unfinished seam to show the lovely ladies in the shop, and the moment I stepped out of the door it started to rain.

The pub was a good choice for lunch and the lady in the fabric shop was pleased that I'd come to show her the almost-finished dress. I finished it in the afternoon and then finished up my holiday with a performance of The Gondoliers in the evening, the first event of the Gilbert and Sullivan Festival being held in Harrogate through August. Lovely.


More rain, obviously, but sunshine as soon as I got home and went indoors to unpack. That's life.

Red roses holding a lot of rain
Waterlogged roses