Wednesday, 22 June 2016

Exercise and Type 1 Diabetes: part 1

London skyline including the London Eye and Big Ben
View from the conference centre, May 2016
The recent study day I attended was about exercise and Type 1 diabetes (T1D), which is a truly difficult topic to write about, and even more difficult to manage.

Many hormones are involved in keeping blood glucose levels stable with exercise, including insulin, glucagon, growth hormone, cortisol and adrenaline. For someone with T1D, insulin is delivered in a very non-physiological way via subcutaneous fat rather than into the hepatic bloodstream from the pancreas. It is also thought that glucagon production by the pancreas becomes less efficient over time following a diagnosis of T1D. Each of these hormones has multiple effects at different organs (brain, muscles, liver, pancreas etc.) and all interact with each other. This complex situation means that the tight regulation of blood glucose with exercise that happens automatically when the pancreas is working properly is almost impossible to achieve with a broken pancreas.

The study day


The course was a single day, but they packed a great deal into it. Speakers presented slides with graphs and evidence and whizzed through topics at such a pace that I could barely keep up let alone take comprehensible notes. The slides were supposed to be available after the event, but I don’t think they have appeared yet, a month later. My scribbled note “good slide explains this bit” will have to wait for interpretation later.

The first speaker talked about ‘normal’ exercise metabolism, the second introduced T1D into the metabolic picture, and the third session was presented by paediatric and adult Dietitians. After a break there was more detail about managing blood glucose before, during and after exercise. The workshops after lunch gave us the chance to think about case studies and individual scenarios.

Overall I think everything was included that needed to be included, but much too fast, and the main focus was on serious athletes and people who were going to be running or cycling or weight lifting or at least going to the gym regularly. There was very little about the unfit or overweight person who might be starting with walking up a flight of stairs rather than taking the lift, or trying to increase their level of activity for weight loss or fitness rather than competing for an Olympic medal. Gardening, DIY, housework and shopping are the more common types of activity that I encounter in my caseload.

I did a little brainstorm for this blog entry just listing all the issues that pertain to the subject – the list was 2 pages long. So what shall I include here? Of course, this particular blog post probably isn’t going to be of much interest to you unless you have Type 1 Diabetes and you want to know about managing your blood glucose while exercising, and I think I may have fewer than one reader in that particular category. No, this blog post is for me, to enable me to assemble my thoughts and produce a reference point for that future day when I might have to advise a patient on this subject.

Fuel for activity


So, first to recap the basics. Dietary carbohydrate is digested into glucose which moves into the blood to be transported around the body. Insulin allows blood glucose to be taken up by cells in the body where it is metabolised into energy or stored as glycogen in muscle and liver. Excess glucose is converted into fat in the form of triglycerides (a triplet of linked fatty acids) and stored in the liver, muscle and in fat cells. High levels of insulin promote this storage process and inhibit the release of glucose or fat into the blood from fat and liver cells.

When energy is needed for activity, the most accessible sources are muscle glycogen and blood glucose. The hormone glucagon prompts the liver to very quickly start converting its stored glycogen into glucose (glycolysis) and send it out into the blood. Triglycerides in the muscles are also easily accessible and are used as fuel (fat oxidation). It takes a bit longer for new glucose to be manufactured in the liver (gluconeogenesis) and for the liver to break down triglycerides into free fatty acids and send them out to be used as fuel (fat oxidation). Insulin levels need to be low for all these processes to work efficiently.

If exercise is more intense (anaerobic) there is more reliance on carbohydrate as fuel; if exercise is less intense but goes on for longer (aerobic) there is a shift towards fat as the main fuel. Obviously exercise drains glycogen stores in muscles and liver, and these are ‘topped up’ afterwards using dietary glucose (fat stores don’t need to be topped up!) Non-diabetic metabolism manages all the hormone levels so all this takes place with blood glucose maintained between 4 and 7 mmol/L at all times.

The main difference that makes things difficult for someone with T1D is that insulin cannot be regulated up and down in a physiological way. It is certainly possible to adjust insulin levels according to various ‘rules’, but adjustment is crude and doesn’t reflect the metabolic state minute by minute.

There are also a couple of scenarios when it is not advisable to exercise. If your blood glucose is high (over 14 mmol/L) then it is possible that you don’t have enough insulin on board, and the official advice is that you need to check for ketones. If blood glucose is high without ketones then a small correction dose of insulin might be all that is needed, but if ketones are present then the full correction dose should be given and exercise postponed until ketones have gone. The majority of people with T1D don't have a meter that will measure blood ketones, however, so this advice is moot.

The other situation when you might choose not to exercise is if you have had a hypo in the last 24 hours, because this makes a hypo with exercise even more likely. If it wasn’t a serious hypo needing third party assistance then you might go ahead bearing in mind the need to be extra vigilant. If the hypo was within an hour before planned activity you would be advised to wait for 45-60 minutes after your blood glucose level has stabilised before exercising.

Changes in blood glucose and insulin


The level of your blood glucose will fluctuate according to:
  • the duration, intensity and type of activity
  • the type and amount of food and snacks eaten or drunk before, during and after the exercise
  • the level of stress and competitiveness
  • your level of fitness or previous training
  • hydration status
  • the time of day
and probably more.

The level of your blood insulin will fluctuate according to:
  • the timing of insulin injections/infusion
  • the amount and type of insulin injected/infused
  • the site of the injection or cannula
  • the ambient and body temperature.

Poor ‘reproducibility’ was highlighted in the study day, meaning that the same exercise for different people or even for the same person on different days may have very different effects on blood glucose levels. With all these variables it’s not surprising that matching blood glucose levels and blood insulin levels in order to manage T1D and exercise is a minefield.

So this is the landscape we're working in, with different sources of fuel and the action of hormones all interacting, and we have to try to maintain blood glucose levels without going low or high using tools (carbohydrate and insulin) that are about as precise as trying to steer a car at full speed with just your elbows on the steering wheel. At some point you're probably going to crash.

So having set out the scale of the problem, how can it be managed? Look out for part 2 in the series, coming soon!

Friday, 17 June 2016

What I've been reading

Image of the book cover

Non-Stop
by Brian Aldiss

narrated by David Thorpe
"Curiosity was discouraged in the Greene tribe. Its members lived out their lives in cramped Quarters, hacking away at the encroaching ponics. As to where they were - that was forgotten. Roy Complain decides to find out."
The first book by Brian Aldiss, and it does a good job of describing the unfamiliar world where humans live among outsiders, giants and other tribes as well as intelligent rats, mind-reading moths and other creatures. Perhaps a few too many strands to the tale, and the rats are never fully explained, but the final chapter solves most of the conundrums. The story ends without letting on what finally happens, which in this case isn't frustrating but allowed me to think on about the different possibilities.


Image of the book cover

Invitation to the Waltz
by Rosamond Lehmann

narrated by Joanna Lumley
"Olivia Curtis wakes to her seventeenth birthday and her presents: a roll of flame-coloured silk for her first evening dress, a diary for her innermost thoughts, a china ornament, and a ten shilling note."
This is a calm, reflective and descriptive book that takes us from Olivia's birthday up to her attendance at her first ball, plus a tiny bit of the aftermath. It contained some memorable scenes: the dress had to be made, and it wasn't made all that well. The scene between Olivia and the itinerant lace saleswoman was excruciating in its reality. Olivia's older sister and younger brother were beautifully brought to life. The characters at the ball were all so different, and so nicely described. It wasn't a thrilling read, but I did enjoy living the early twentieth century life for a little while.


Image of the book cover

The Disappearing Spoon
by Sam Kean
"The fascinating tales in The Disappearing Spoon follow carbon, neon, silicon, gold and every single element on the table as they play out their parts in human history, finance, mythology, conflict, the arts, medicine and the lives of the (frequently) mad scientists who discovered them."
At last, back to the type of book I once used to read for pleasure. I discovered I had a lot of money tied up in book tokens so I treated myself to a trip to a real world high street bookshop. Such indulgence! And it's a good book, no doubt of that - I read it all and enjoyed it, but none of it was memorable. I only finished reading it yesterday but if you were to ask me for a nugget of information I wouldn't be able to remember anything worth telling.


Image of the book cover

The Return
by Victoria Hislop

narrated by Jane Wymark
"Beneath the majestic towers of the Alhambra, Granada's cobbled streets resonate with music and secrets. Sonia Cameron knows nothing of the city's shocking past; she is here to dance. But in a quiet café, a chance conversation and an intriguing collection of old photographs draw her into the extraordinary tale of Spain's devastating civil war."
I've read two others by this author, and I liked the first one best, and this one least. The use of a story within a story was clunky, but it did provide a flavour of the Spanish Civil War in the context of one family's experience. The resolution was obvious a mile off. The very worst thing about it was the narrator's Spanish accent, which was about as good as mine.


Image of the book cover

News of Paul Temple
by Francis Durbridge
"Leading lady Iris Archer pulls out shortly before the play is due to open and declares that she is heading for France. However, shortly after her disappearance Paul Temple receives a guest at his Scottish holiday home – none other than Iris Archer."
The last of the Paul Temple books I lifted from the 'free books' basket, and just as bad as the other two, except in this one absolutely all the bad guys are murdered or meet some other sticky end along with several innocent bystanders. The headcount is ridiculous for a 200-page book; there must have been at least ten deaths.

Saturday, 11 June 2016

Difficult decisions

Impressive hotel frontage with fountain and sweeping driveway
Art deco hotel, Borovetz, February 2016
I don't want to write much about last week because it's been dominated by family stuff that's not particularly suitable for public airing. I haven't felt like doing much in the evenings, which is unlike me. On Thursday I decided to go for a run anyway, but two thirds of the way round my usual route I decided to stop because I just wasn't enjoying it. I haven't even started sorting the stamps and envelope collection.

I have started to clear the loft and took a couple of boxes of books to Oxfam. There's a load of old papers from the loft in the downstairs hall that need to be sorted and shredded or recycled, which will leave quite a few ring binders and suspension files that I can't bring myself to throw out, so I'll have to find a good home for those. I also responded to a conversation on the local website Streetlife, offering the trampoline to a good home, so now I need to get that down from the loft too.

Getting the tenor sax serviced was on the list as a priority for this week. I was given contact details for a local chap who came highly recommended, and so far I have sent an email, left a voice message and sent a text without any form of response. I think this suggests either he isn't that interested in the work or is on holiday. There is an alternative but it's in the centre of Birmingham, so nowhere near as convenient.

At work there's been an interesting discussion about my job. I trained to deliver the 'DESMOND' education for people with Type 2 diabetes when there was a huge waiting list in the neighbouring city, and got some extra paid hours to help clear the backlog, and since then I've continued to deliver a course there about every two months. However, in the town where I actually work the course is delivered by two nurses once a month and a waiting list has now built up there, so we enquired about whether I could be paid to help them clear the backlog too.

This has opened a can of worms. It has exposed my ignorance of how the whole edifice of NHS funding operates. I find it very frustrating, but I had pretty much come to terms with the fact that there seems to be no way to find out, let alone understand, how our diabetes services are paid for, apart from the fact that ultimately the funding is allocated by the Clinical Commissioning Group. But are we paid per consultation? Do they give us a fixed amount for all we do in a year? How is my salary allocated between the Dietetic department, the Diabetes department, the hospital where I work and the Trust that employs me? Does the Diabetes service pay the Dietetic department for my support, and if so, what exactly am I supposed to be doing? What exactly are my responsibilities within the Diabetes service? Should I be delivering DESMOND at all, and if so, how often, and where?

This is further complicated by the fact that I am aware there are circumstances where I shouldn't see someone - if they are referred by their GP to a Dietitian but not to a Consultant then it ought to be a Dietitian from a different service, despite the fact that the Nurses in the same building can accept these referrals. And recently one of our Diabetes Consultants asked me to see someone for dietary input who doesn't actually have diabetes - should I accept that referral? Apparently I shouldn't, but what if I do? What difference will it make? Who will care?

Our Diabetes service is going to be reviewed, and I don't want it to appear as though I'm not fully occupied simply because I've been recording my activity wrongly. I'm not in the least bit interested in any of this but it looks as though I'm going to have to ask some more questions. The NHS is a wonderful institution, but it is mind-bogglingly complex.

Thursday, 2 June 2016

Philharmonia and philately

Various varieties of attractive mushrooms in baskets
Borough Market, May 2016
There has been a long weekend, which in my case extended to Tuesday due to my habitual day off, and it feels as though I have packed in several weekends' worth of excitement. Things that happened: I did not buy a tenor saxophone mouthpiece, I met a man who struck up a conversation (and this in London, mind) and who then offered to sell me a baritone saxophone, I bought said baritone saxophone, I met a lot of fans of the football club Sheffield Wednesday, I met two people I last worked with in 1988 (and one of whom I had not seen since then), people who weren't Lola II and Mr M came round to my house and stayed overnight and I think I managed to behave as a welcoming host rather than a reclusive hermit, two other people who still weren't Lola II and Mr M came round to my house and had a play with the baritone saxophone and were almost as excited as me, and I went to an organ recital. And this doesn't include regular ordinary things like cleaning, cooking, food shopping and running. And I went to my physiotherapy appointment about my painful shoulder.

The previous week-and-a-bit was also full of mysteries and wonders which did include Lola II and Mr M as well as the rest of my UK-based family and a little bit of non-UK-based family. Things that happened: I attended a Study Day about Type 1 diabetes and exercise (a blog post on that subject is a complex scholarly work and still in the pipeline), stayed with Lola II and Mr M, went to Borough Market and the Museum of London with Lola II, attended the UK-based family event, had lunch at a nice garden centre in Little Venice, didn't attend the non-UK-based family event (but neither did the non-UK-based family so that was all right), and spent a day with mum and a Postal Mechanisation Man sorting through dad's collection of philatelic material. I'm using the word 'philatelic' loosely to mean anything relating to the postal service.

I think I should stop complaining about being busy because this now seems to be my normal state. Since I bought the Fitbit there have only been two days when I haven't walked more than 10,000 steps without any extra effort - I thought I would have to try much harder.

I shall pick a few highlights from all the things that have been happening.

The non-UK-based family event involved a cousin who had been in touch to see if he could catch up with us on his way through London. We very nearly put mum and dad in a taxi for an hour and me in a car for even longer in order to meet at Lola II's house but in the end, for various reasons, we didn't. This was a good thing, because the meeting that the cousin was attending between flights took up all the intervening time and he didn't make it to Lola II's house either.

Dad's philatelic collection is big, very big. We have been trying to whittle it down now that he is not actively collecting it any more. One large chunk is all about Postal Mechanisation - in basic terms, the use of machines rather than people to sort mail. Just to prove that for any human interest there is an interest group, there exists a Postal Mechanisation Study Circle (PMSC), whose newsletter led me to contact its Secretary to see if they could provide any support in disposing of dad's collection in a more constructive way than through the medium of a bonfire.

Having spent four hours in his company, I can say that the Secretary of the PMSC is a lovely man. He extended a trip to London with a Tube journey out to mum and dad's house and went through the entire postal mechanisation collection with enthusiasm and excitement. He took a small proportion away with him for auction, and left the rest in piles representing valuable material, stuff that might sell on eBay, and a disappointingly small amount that could be thrown out. There is still much work to do - this collection is perhaps a quarter of the stuff that's still in boxes and cupboards - but I can't manage any more at the moment, especially with the LTRP and the new saxophone-related activity.

The new saxophone-related activity started with a proposal to meet up with people who were kibbutz volunteers at the same time as me back in 1987-88. The proposed venue was Baker Street, and there is a shop nearby that had been recommended as somewhere that would allow me to try out different saxophone mouthpieces, because I had been told that the difficulties I had with the low notes on my tenor sax might be resolved with a different mouthpiece. The tenor sax is extremely heavy, and usually when I go to London it is to the outer fringes where my family lives, so this was a perfect opportunity to get the sax to the shop without a great deal of messing about on the Tube.

So I arrived at the shop with my tenor saxophone and they duly provided me with different mouthpieces to try. It became very clear that the problem was between the mouthpiece and the chair - or possibly the saxophone itself. None of the different mouthpieces solved the problem, so I sat in front of the cafe next door (it was a lovely morning) with a cup of tea and pondered my options. This is when conversation started with the chap at the next table about saxophones and he offered me the baritone sax which was to be found in the basement of his shop across the road. A friend had recently managed to borrow one of these and told me it was worth more than his car, so the £100 price tag seemed like a bargain, especially as it played much better than my tenor sax.

This left me in London with two large saxophones and a meeting in the Baker Street pub - it is a large pub but none of us anticipated that it would be entirely full of football supporters due to an event known as a 'play-off' (I had to ask) which would allow either Sheffield Wednesday or Hull City to be promoted to the Premier League. This pub was restricted to the Sheffield supporters - Hull fans were refused entry and directed to a different pub to avoid any trouble. Unfortunately kick-off was not until 5pm so the pub would be full to bursting for several more hours. Which meant that I and my two large saxophones were not ideally suited to a quiet pint and a chat with ex-volunteers. We eventually decamped to an alternative location and had a lovely time.

There was a lot more activity to come within the long, long weekend, but I shall jump to the physio appointment I had on Tuesday to see if anything could be done about my painful shoulder. This was damaged during ski holiday #2 and has been giving me some trouble for two months but only in certain movements: applying the car handbrake, removing tight clothing over my head, carrying heavy luggage up steep stairs. I wasn't optimistic that physiotherapy would achieve anything, but in fact it achieved a diagnosis of inflammation in the joint between the top of the humerus and the acromion process of the shoulder blade causing some 'impingement'. Three treatments were suggested - a stretching exercise I should do a few times a day, anti-inflammatory gel and ice. It should get better slowly, but I have the option to contact the physio again within a month if I think I need to.

Tuesday, 24 May 2016

Meditation and Buddhism

Interesting tree on the bank of the Seine
Paris, March 2016
I have now attended all four sessions of meditation and Buddhism - the meditation is difficult but I think it may be useful for those times when one's mind refuses to settle. It's one of those things that needs practice to determine whether it is actually worthwhile.

The main reason I signed up for the four-week course is because the good friend I wrote about a few weeks ago has been a Buddhist for more than 20 years. He hasn't had anything that resembles a traditional job (with hours of work and a wage) for quite a long time, and has spent a total of about two years on and off at a 'retreat' in Spain. I have struggled to come to terms with this lifestyle (not that it's any of my business), and concluded that the answer must lie within Buddhism. So I want to know more about Buddhism, and the course takes place very conveniently about 2 miles from my home.

Each session starts with a short meditation focusing on the physical body, then a bit of chat about what we'll talk about later, then a longer (different) meditation, then a tea break. I like the tea break. Then there's a bit about Buddhism and its practice and another meditation session to end.

I don't mind meditation - sitting quiet and still is rather nice, but my mind dances off all the time and I have to put some effort into bringing it back. The leader describes this as 'flapping like a fish out of water', and this is indeed how it feels. The bit about Buddhism is sometimes done in small groups, which I prefer to discussions with the whole room, and has given me the chance to clarify a few things.

Obviously after just four sessions I'm only scratching the surface, but the main messages I've taken away are:

- Buddhism is not a theist religion. The Buddha is not a god or a prophet, but a man who came up with some good ideas that made him into a rather special person. By emulating his methods, a person should be able to reach their fullest potential. The word 'enlightenment' was used along with lots of other words that are difficult to pin down (I have to let most of the words go past otherwise I'd be challenging something every two minutes). You can be an atheist Buddhist, in fact if you commit yourself to Buddhism it would be difficult not to be atheist. I have no problem with this, I like a religion that doesn't believe in gods.

- The principles of Buddhism as I understand them so far (after a whole eight hours of learning, six hours of which were silent meditation) are about contributing the most possible to oneself, one's community and society, and I suppose the wider world as well. Although the group leader deliberately avoided labelling principles or actions as good' or 'bad', in lay terms it's about being a 'good' person both in isolation and in interactions with others. The group leader described being able to do anything that you want to do - there are no specific rules - but understanding that your deeds have consequences and you must take responsibility for them. I have no problem with this either, I have long been reflecting on my personality and actions, committing to change for the better, and trying to fulfil my potential.

What I've been trying to elicit, therefore, is what the role of Buddhism is exactly. I'm happy not to believe in God, prepared to believe that Buddha was a good sort with some useful ideas, and that not hurting yourself or others is a sensible course in life. Anyone can do meditation, and behave in the best way they can, and try to be a vegan, and live the best life possible for themselves and others without being a Buddhist. Why do we need Buddhism?

I think the answer is the same for Buddhism as I have decided it is for other religions - probably all religions, although I only have personal experience of a couple. Here's the answer in brief: it's much harder to be a good person on your own. If you can adopt a set of pre-prepared guidelines alongside others who are happy with the same guidelines, you get loads of help from a ready-made extended family when life is difficult, which it often is. You get some answers to difficult questions (why is there cruelty in the world? what is consciousness? what happens after we die?) and if it's a religion that's worth anything there will be someone prepared to look after you when you are ill, disabled or old if you don't happen to have taken precautions by having children and bringing them up properly.

Many people deal with the difficult questions by using words like 'spirituality', and many religions expect you to accept as truth their theories about unprovable concepts (gods, angels, miracles, what happens after death). I don't have a spiritual atom in any of the molecules that comprise my corporeal body. I am made of physics, which results in chemistry, which leads to biology. I know there are many things we do not yet know (what is consciousness?) and many things we cannot know (what happens after we die?) and I'm happy to agree that there is probably more to life than we can know or touch. What I'm not prepared to believe is that anyone else knows the answers, so unfortunately most religions won't work for me.

I know that many people take comfort in the notion that someone or something they believe in is looking out for them - I am lucky enough not to need this notion, given that I don't believe there is anything out there. Buddhism seems to take a more practical line, that the people looking out for you are those around you within your own community. So that's good.

The two types of meditation we learned were mindfulness of breathing, which involves trying to focus on your breathing and determinedly bringing your attention back when it inevitably wanders, and 'metta bhavana' which is about fostering a positive attitude towards yourself and others. I've been more or less successful at doing these within the sessions and a few times at home, and I like the approach. The leaders of the group declare that there is some sort of emotional or spiritual benefit that emerges from successful meditation, but I can't say I've experienced much, although perhaps I managed a little glimpse of something on one occasion before my mind sped off down the road and I had to catch it up and drag it back to the matter in hand.

The group continues to meet on a Tuesday night and all are welcome; I don't know whether I'll be joining them or not. I like the meditation but I'm much less keen on the Buddhism, because despite being sympathetic to the concepts expounded so far I still find it a bit too much like organised religion. There are bits that have been hinted at but not discussed, including a brief reference to 'puja' which is a bit like worship although it might be more like paying your respects. I am being fairly vague about my intentions because I thought after I'd run 5km, and then 10km, that I'd stop running, but I'm still doing it and even enjoying it. So it might be the same with Buddhism. I'll keep you posted.

Wednesday, 18 May 2016

The usual complaining about being busy

Badminton match
Barclaycard Arena, Birmingham, May 2016

Well, it's been a busy time. If it hadn't been for some blog posts I drafted a while ago there would have been a whole lot of nothing new in this space. So I thought I'd just make a quick list of the few things that I might write about that have taken up my time in the last fortnight. Within a minute I had this:

Work


Cover for colleague: group education  and clinic
Type 1 education in new location
DESMOND Type 2 education
Meeting about insulin pump service

Not work


Badminton AGM
Shoulder: nurse/physio
Sports: running, badminton, Fitbit™
Cymbeline
Buddhism/meditation
Water meter
Blood donation
Sunday lunch in the pub
Police and Crime Commissioner election
Clarinet choir
National Badminton League final
St Albans
Disc golf

I should just leave it there and lie down in a darkened room. But I suppose I could expand a little on some of them.

Work


I was asked nicely to cover for a colleague who is off sick, and so far I have said yes to each request, although it means I have not had any period in the last two weeks within which I can catch up e.g. read or respond to emails and telephone messages, write letters etc. It has been made worse by delivering our Type 1 education in a new venue where we don't have access to computers, internets etc. This whole situation is unsustainable. The coming week will be no better, but I am going to use the extra hours I have accrued to take a day off and help mum with some Philatelic Business, of which more may be revealed after it has happened.

The meeting about the insulin pump service was quite interesting. We have been precipitated into a minor crisis by one of our nurses being on long term sick leave. Having coped for rather a long time we are now reviewing what we do a bit more seriously than usual, and it has become clear that the service we provide to people who use insulin pumps is particularly stretched. It was set up in 2006 on the basis of anticipating four new patients a year, and now we support more than a hundred people on pumps with at least one new one every month, not to mention the children and young people that we inherit from the paediatric service. From one consultant clinic once a month we now have two consultant clinics twice a month with no additional funding for nurses or dietitians.

It looked for a while as though a business case was going to be formulated for more nurses but with no reference to dietitians, and my manager has now retired (with a new one recruited but not yet started). So I pitched up at the meeting with the nurses, doctors, managers and finance people, and carried out my self-appointed role which was to add the words "and dietitians" every time the word "nurses" was uttered in the context of needing to fund more of them. Clearly this was irritating enough for them to start nodding in my direction and saying "and dietitians" for themselves. So that worked rather well.

The outcome of the meeting is slightly unnerving because rather than just scope the increased requirement for the pump service, they have decided to scope the requirements of the whole diabetes service at the site where I work. It would have taken an incredibly long time to look at just the pump service, so now we'll have to wait until quite close to the end of time before we get any new money. Not that there is any new money; the finance person revealed that the Clinical Commissioning Group (CCG) who pay for health services is pretty much broke.

Not work


Badminton club #2 has an AGM and stops for the summer. Club #1 is more disorganised in terms of administration - we had AGMs when I was club secretary, but not before or since, and hardly anyone turned up - but at least we play on over the summer. Club #2's AGM is held with a fish and chip supper and then a game of skittles, and was great fun. I sometimes think I can do this socialising thing; I used to be good at it long ago.

My left shoulder is still painful and has hardly improved in the six weeks since my injury, so I finally made an appointment to see a Nurse Practitioner at the surgery, who gave me a form to allow me to self-refer to a physiotherapist. She also advised me to take paracetamol instead of ibuprofen. I look forward to the physio appointment not least for its blog potential. I am not optimistic that the shoulder situation will be improved by physio, but what do I know?

Running and badminton continue, and I have bought a Fitbit™ with my TV watching points (and what do points mean?) but am struggling to operate the software that makes it worth having, which I take to be another sign of the inevitable march towards senility. For those not aware of the latest in fitness technology, a Fitbit is a device, in my case a wristband, which monitors the wearer's activity. I let it count my steps. If you enter the food and drink you consume it will advise on calories in and out; it should monitor your sleep but I can't make that bit work. It has exposed the limitations of my mobile phone, but my contract is about to expire and I'll see if an upgrade will help the situation.

Culture news: I went to see Cymbeline at the RSC in Stratford. I haven't been there since they remodelled the theatre, which is a long time. We had seats in the gods, which in the new theatre entails raised seats a bit like stools with footrests. It was OK to start with, but as the play entered its fourth hour I definitely started to feel a bit fidgety. A little way into the second half one of the friends I came with very suddenly left the auditorium. It turned out that he remembered he'd left the oven on, and had quite a time of it trying to contact various people to check that his flat wasn't on fire. I'd given him a lift so he couldn't just nip back home.

I meant to look up the plot before going but didn't get round to it, but another of the friends I was with had looked on Wikipedia and gave us a quick outline. Unfortunately for us in this production they'd decided to change the sex of some of the key characters, so the Wikipedia description of the king made no sense until we worked out he was now a queen. Also, the white queen and her white consort had managed to produce a black son, which was also rather confusing. Which just demonstrates our ignorance of our literary inheritance. But the play was good, and I'm always surprised at being able to follow the plot despite understanding only about one line in four.

I have a whole blog post about the Buddhism and meditation thing waiting in the wings, so I'll say no more about that. I also had a water meter installed which took no more than fifteen minutes and has reduced my (albeit estimated) water bill to a shadow of its former self. Blood donation went without incident, Sunday pub lunch was enormous and delicious, and the PCC election was pointless. I looked up the candidates the day before but I haven't bothered to find out who won. I take part in elections because I believe everyone must, but I have to admit finding it more difficult to justify this stance with each successive bunch of useless self-serving politicians.

The clarinet choir is good fun, although this time our leader has chosen pieces that stray much too far into the upper registers, to the extent that a much more enthusiastic and committed first clarinettist has invested the thousands of pounds required to buy an E flat clarinet, and I am envious. I am having to look up fingerings for top F's and G's that I haven't used since I was at school.

More badminton: the NBL competition was invented very recently to fill the gap between National teams and ordinary club leagues (the two league teams I play with were both relegated, so I am delighted that we may avoid being beaten into the ground every time I step onto the court next year). Four of these NBL teams battled it out for the top spot on the warmest sunniest day of the year so far, meaning that I spent the majority of the day indoors. It wasn't as good as the International competition in the same venue, but a nice day out. Birmingham Lions beat Loughborough University in the final.

The day in St Albans came about at short notice when Lola II phoned to say she was going there with some overseas visitors on a Tuesday when I wasn't working, so I avoided many of the jobs I was supposed to be doing by joining her there. We went around the Verulamium museum, a Roman theatre and the cathedral with interludes of tea, lunch, more tea and cake.

On Sunday I organised a badminton (club #1) social event to play disc golf, which uses baskets instead of holes and small frisbees in place of golf balls. After a full round of 18 baskets in sunny weather with only one frisbee lost in the river, I was tired out. Not that we're at all competitive (except we really are), I came second last.

And to bring us bang up to date, I have Ilf working in Lola Towers today and within the first hour he changed two door handles, cut another door to allow it to close, finished the unfinished laminate flooring and is now working on the external lights and the kitchen electrics that he condemned last time he was here. I've chased Olf the garage man for the last two jobs, but still haven't looked for an architect to advise on remodelling the ground floor. Mowing the lawn yesterday I was even considering more ambitious plans for the garden!

Wednesday, 11 May 2016

My home situation improves further

Close up of pink flower
Harlow Carr, July 2015
Lola Towers Restoration Project update - it's been wonderful. Really satisfying. Bits of Lola Towers are looking almost respectable, and it doesn't half improve my mood, although it makes me a little less sociable because I'm so much happier at home.

Ilf the Handyman continues to be a godsend and a good chap - he brought me more wood offcuts for the fire, and I gave him the deep fat fryer that nobody wanted on Streetlife (a site a bit like a local Freegle but better). I begged him to prioritise the shower ceiling because going without showers at home for two weeks to dry the room out properly was dreadful - I used sports centres after badminton, and had baths, but it's not the same. Not only was the shower ceiling done when I got back but he'd also put up my new living room light as well as starting on the door handles. I've now got a new wall light in the living room and a new lock on the front door too.

We had a conversation about the loft ladder and he took on board my suggestions and seems to have fixed it (I must go and have a look), but there is a bit of difficulty with the upstairs lighting and I'm going to have to empty the loft sooner than anticipated. He has expressed proper horror at some of the things he found behind the light switches in the kitchen, in his words: "This switch will be replaced the next time I come round, even if I have to pay for the switch!"

I'm still enjoying opening and closing the door that now closes properly, and my additional activity now includes switching the lovely new living room lights on and off. And having showers.

Olf and his team have worked wonders on the garage too. It is pointed, and has new UPVC windows and a side door that locks properly, and the big front door has been tweaked so it closes properly and has a new hardwood frame. The gutter has been replaced, the lights have a proper fuse box and switch and there are four properly wired sockets too. All those involved continue to be puzzled at my idea of putting the car inside - one chap's opinion was that with a bit of insulation and a lick of paint I could rent it out for a student to live in. All that is left to do is to sort out one corner of the roof (a bit complicated because of asbestos) and fit a new lock to the main door.

The other benefit of Olf and the gang working on the garage was that I felt obliged to hang around on my Tuesday off, making them tea and answering questions about where electrical supplies were routed and where I wanted sockets etc. I decided to use the time to address the ivy situation in the garden, and took two carloads to the tip. This has stiffened my resolve to get rid of the bloody ivy once and for all - a half-hearted attempt with weedkiller was not enough, and the wall is crumbling beneath its onslaught.

I am happy with my project management so far, the costs have not been excessive and I am immensely pleased with the results. I am now in two minds about how ambitious to be as I go forwards with the LTRP. Should I limit myself to replacing and possibly extending the kitchen, or should I consult some sort of architect to address the ground floor layout on a rather grander scale, including doing something about the staircase? There's lots more to do in the spare room and in the garden, and the whole house (with the possible exception of the bedroom) badly needs redecorating. What next, readers?

Tuesday, 3 May 2016

What I've been reading

Image of the book cover

The Magus
by John Fowles

narrated by Nicholas Boulton
"Nicholas Urfe goes to a Greek island to teach at a private school and becomes enmeshed in curious happenings at the home of a mysterious Greek recluse, Maurice Conchis."
This is a weird book. I have been picking 'classic' audiobooks at random, then reading the blurb about the book followed by some of the things that people have said about it, usually on Audible and Amazon and Goodreads websites. If it looks as though it's worth it, I'll download and listen. Many people cited this one as their favourite book ever, lifechanging, that sort of thing. It's a long, long book (more than 26 hours in its audio version) and now I've finished it I still don't see the point. The main character is tormented in a 1950's version of The Truman Show where nothing is real, all is staged, and despite being perfectly at liberty to walk away he keeps coming back for more. I can believe that falling in love keeps him involved for a certain amount of time, but when that particularly folly ends he still doesn't leave them to it and get on with is own life. The story isn't even concluded particularly well either, and that really made the whole ordeal even more annoying. I must get back to the Galsworthy and I'll be much happier.

[Later - I've been thinking about what I wrote above, and I've changed my mind. Nowadays I like books when there's a rattling good story that has a beginning, a middle and an end that satisfies all my questions. I also like books when they are a bit challenging and make me think, but the story seems to be the most important factor for me at the moment. It wasn't always this way, and this book exemplifies the sort of thing I might have been looking for twenty or thirty years ago, because it isn't trying too hard with the story, there's much more to it about the world and our beliefs and our place and who we think we are and how we see everything that isn't our self. What if we couldn't trust anything we saw or were told? If we were just seeing shadows on the cave wall and thinking this was reality? I can see how this book would feed that thought experiment, and could have made an impression on the twenty-year-old me. I just don't want to bother with that sort of effort any more.]


Image of the book cover

And The Mountains Echoed
by Khaled Hosseini
"It's a funny thing... but people mostly have it backward. They think they live by what they want. But really, what guides them is what they're afraid of. What they don't want."
I liked this book a lot, so much in fact that I'd like to read it again, mostly so that I appreciate the links between different sections of the story. There is a thread running through all sections and they are sometimes connected in ways that are not obvious. The heart of all the stories is Afghanistan, and we are taken from 1959 to the present day, but not sequentially. I never stopped wanting to know what happens next, where will these people end up, will they be happy?


Image of the book cover

Paul Temple Intervenes
by Francis Durbridge
"In a small country lane, the well-known American, Myron Harwood, is found dead. The murder heralds the start of a spate of celebrity deaths – and each time the victim is found with a small white piece of cardboard, bearing the inscription ‘The Marquis’."
The second of three I picked up from a book swap box, and just as bad as the first. I used to think they were quite good on the radio, but I've been listening to the radio version as well recently and the problem is too many characters and such convoluted plots that the outcome is not only implausible but disappointing. I'm sure I'll still read the third anyway because it's so easy, and sometimes easy reading is what's needed.


Image of the book cover

The King of Torts
by John Grisham
"As he digs into the background of his client, Clay stumbles on a conspiracy too horrible to believe. He suddenly finds himself in the middle of a complex case against one of the largest pharmaceutical companies in the world and looking at the kind of enormous settlement that would totally change his life."
This book is terrible. I've read John Grisham before and I seem to remember it was OK, but this one was just boring. The lawyer makes a fortune and loses a fortune and that's the end of the book. People on the whole are mean and greedy (with a few exceptions) and anyway the world of US class actions isn't one that I particularly want to know about. I should have been able to tell from the title.


Image of the book cover

The Wind in the Willows
by Kenneth Grahame

narrated by B. J. Harrison
"When Mole goes boating with the Water Rat instead of spring-cleaning, he discovers a new world. As well as the river and the Wild Wood, there is Toad's craze for fast travel which leads him and his friends on a whirl of trains, barges, gipsy caravans and motor cars, and even into battle."
It occurs to me that I've been listening to 'The Classic Tales' podcast for some time now, and the guy's narration has improved no end. He still makes the odd mistake but nowhere near as often, and he made a good job of this book. Obviously I've read it before but there are bits I'd forgotten, although most of the forgotten bits are somewhat odd. For example, the chapter called 'The Piper at the Gates of Dawn' (when Rat and Mole find Otter's son Portly at the feet of the god Pan) is beautifully lyrical and evocative and has supplied the name of quite a good Pink Floyd album, but in terms of story and plot the chapter is wholly unnecessary.

Friday, 29 April 2016

Leicester

Tree-lined pedestrian pathway

This was a Lola II birthday weekend, postponed from when her birthday actually took place because we have both been a bit busy most weekends. By all rights it should therefore have been warmer than late February, but it wasn't really. Apart from the chilly days it was a brilliant weekend.

We started with the accommodation on Friday, which was not our usual guesthouse or B&B, but a private residence booked through AirBnB, belonging to Muriel. Muriel was Not Very Well so our contact with her was quite limited, but we were out most of the time so it didn't matter. She has some very interesting wallpaper but the room was comfortable and there was Redbush tea.

We decided that Leicester is quite good. Many of its inhabitants have got over the discovery of the skeleton of King Richard III in favour of their football team (although the city still displays an RIII logo on lamp posts, posters and anything else it can think of). Leicester City Football Club has unexpectedly emerged from obscurity and is almost in a position to win the League, and everyone seems to be rather excited and nervous about it.

On Friday we ate at a rather meat-focused restaurant, but on the way home we passed a small Japanese restaurant that looked very promising, so that was Saturday's dinner venue sorted.

Lola I in pretend shop with trolley and list
On Saturday we decided to head for the Tourist Information Office, but were waylaid by some loitering market researchers. I persuaded Lola II that it might be interesting, and so it was - rather than answering a few questions off a clipboard in the street we were taken into an office and answered rather a lot of questions about shampoo, toothpaste and cereal. Then we had to pretend to shop for shampoo in a pretend shop with a real trolley while being filmed, and lastly answer a trillion questions about three types of shampoo, many of which were stupid. Did the pictures of shampoo make me think that it was 'efficient'? or 'natural'? or 'smell good'? Stupidest of all given that there was no information about price, did it look like 'value for money'? Good luck to them analysing my answers. They gave us each a £5 Boots voucher so I suppose it wasn't three quarters of an hour completely wasted (they'd said it would be 15 minutes).

Lola I trying to eat an eclair

Leicester Market is good and there was a 'Continental' market going on too with some wonderful-looking cheeses. We found a deli for lunch and I had an eclair from the Boulangerie stall which showered me with icing sugar and anointed me with cream. Then we made our way to the Jewry Wall Museum and a guided tour of the Roman baths. This was less interesting than I'd hoped because once you've seen a few Roman baths what more is there to say? And there wasn't actually much to see except the foundations, not even a trace of hypocaust, but there was a very large Roman wall. It was pretty cold and the guide clearly knew a lot but spent many words conveying minimal information. Kathleen Kenyon was the original archaeologist who worked on the site in one of her very earliest jobs, so that was a bit interesting. Being told how the original residents would have welcomed the warmth of a Roman bath house made us reflect that we would too.

Tomb of Richard III with Lola II
After that we sat in a cafe drinking tea until we'd warmed up, then had a look around the cathedral, where Richard III was re-interred about a year ago. His tomb is rather impressive and there was a guide hanging around whom we quizzed for some time. She doesn't think the king was all that bad, and her view is that he was slandered by poets and playwrights; times were different and politics was pretty ruthless back then. She had attended the re-interment and was responsible for the bit of the church where Benedict Cumberbatch, Julian Fellowes and Robert Lindsay were seated.

Leaving the cathedral we made our way to where we remembered the Japanese restaurant was, but there it wasn't. Eventually with the help of Google we found it elsewhere in quite a different spot from where we remembered. It was also a little disappointing, as the rice was formed into nigiri by a machine and rather small pieces of pre-sliced fish out of the fridge simply placed on top. Several of the dishes were better than the sushi, but there was quite a lot of confusion with the order and Lola II's chicken was undercooked (they took that off the bill).

Sushi, agedashi tofu, edamame, gyoza
The evening's entertainment was provided by a performance of 'Legally Blonde' the musical, which went very well. There was a small incident with a bar of chocolate - when I went to get some water I though how hilarious Lola II would find it to hide some chocolate that was in my bag, so I moved it to a less obvious place and then completely forgot that I'd done it. When I came back and looked for the chocolate I was halfway through accusing Lola II of hilariously hiding it when I remembered what I'd done. We both thought that was very funny indeed.

Last notable event of Saturday - we ordered a minicab by phone to take us back after the performance, and the driver phoned to say he was waiting in a silver Zafira car. What are the chance of two identical silver Zafira cars waiting in front of the theatre? The man waiting for his wife was very nice about it, and we didn't actually get into his car...

Half timbered house
Sunday started with another visit to the market Boulangerie (chocolate twist and pain au raisin this time). We had a bit of time to spare before our next booked event, so we walked along a pretty road converted for pedestrian use and found the Art Gallery, but it wasn't yet open. The tours we'd booked were of the Magazine Gateway (gateway to a monastical complex not the city, and which in more recent times housed arms) and Wygston's House (15th century half-timbered with Georgian and Victorian extensions about to be sold off and converted into a restaurant due to lack of public funds for restoration). The guide for these two tours was much better, even though it was still very cold to be standing around in unheated buildings.

Several curries, rice, naan, chapattiLeicester is famed for its Golden Mile - a bit like Rusholme in Manchester, it holds a concentration of Indian restaurants, and we chose one that was busy on the basis that it was likely to be good. It was delicious and very good value. There was just enough time for a quick look in one of the rooms of the Art Gallery that was now open before Lola II had to catch her train.

Leicester - I'd go back for the curries, but not for the sushi. And good luck with the football.

Lola II and the chaat

Tuesday, 19 April 2016

Lola Towers Renovation Project

Two runners rounding the bend from the road into the park
Lead runners entering Victoria Park, April 2016
It's all going quite well. Handyman Ilf has turned out to be quite a find. I have been told rather a lot about his misspent youth and past history along with some details of his current situation while he has run his hand disapprovingly over my damp walls, tutted at my leaking tap and dodgy door hinges, and frowned at the situation with the loft ladder. We have discussed where I might acquire door handles and light fittings and he has expressed the surprise I am accustomed to hearing at the idea of a woman who has trouble with shopping.

I came home from work to find that the door which has been falling off its hinges now opens and closes as if by magic. I even opened and closed it several times, like an imbecile, just for the joy of being able to do it. I could not have anticipated the pleasure of shutting a door that previously would not shut. I feel I have already said too much on this subject, but I am going to get up, go to the door and open and close it again. Now I will stop talking about the door, but in terms of the pleasure to cost ratio, this is looking like a pretty high number.

Ilf has also been working on the loft ladder, polyfilla'd a few holes, done a couple of small electrical jobs and fixed the outside tap. He has advised me against using the shower for a while so as to allow the room to dry out thoroughly, at which point we may be more successful at getting paint to stick on the ceiling. I await his invoice but unless he wants to be paid in unicorn tears there's very little that will stop me from insisting that he continues to minister to my every whim, at least in terms of DIY.

The shopping didn't go too badly either and I only had to go back two or three times to decide what I really wanted and just once to replace a thing. I have bought light fittings and door handles and made decisions on other aspects of the Project, and Ilf is planning to return next week for more. Meanwhile, Olf and his assistant have arrived to start on the garage.

At the weekend I managed to make the final push towards emptying the garage, right down to taking the oil-soaked pieces of carpet to the tip, along with four bin bags of assorted small rubbish and some bigger pieces. It is a surprisingly large space and I am faced with the real prospect of actually being able to put my car inside. Not yet, because the door is still not independently lockable - it relies on a couple of lockable shackles set into the concrete in front of the door. But soon.

While I was outside working on the garage clearance I had time to have some lovely conversations with neighbours, and I even went and watched the Regency Run, a local 10k race that goes pretty much past my front door. The weather was fine, as it is today for Olf and his assistant. Further henchmen have visited to measure up the garage windows and assess the state of the electrics. It will not be finished this week, but I am confident. Now I'm going to open and close that door again. Oooh, lovely.

Many runners in the park
Regency Run 2016, in Victoria Park

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