Tuesday, 24 December 2013

Nearing the end

Art deco frontage topped by statue of a woman holding aloft a large golden ball
The Assembly, Leamington Spa
As a parting gift to my current department, I have thrown together a draft of another new patient information leaflet, this one about Exercise and Type 1 Diabetes, which I will no doubt share on this blog in the fullness of time. I can tell you now, though, of all the difficult things you have to do to stay healthy if you have Type 1 Diabetes, managing activity and exercise is one of the most difficult. I'm not even talking about competitive sports, it might just be walking about for an afternoon.

I was inadequately prepared for Christmas in a multi-disciplinary team, which is what the Diabetes Team turns out to be. There was I, thinking it was a collection of individuals with little in common except a passion for diabetes and incessant complaining, and I was hoping that Christmas would be over soon so that the endless supply of cakes and chocolate would cease. (I have maintained my weight, which I consider to be a significant achievement, by dint of eating nothing at all in the evenings.)

So I was surprised when I was given presents (in order of physical size and weight) by the diabetes consultants, by the Diabetes Unit (which I think comprises the nurses and admin, but I got quite a vague answer when I asked), by my team leader, by RSB, and by my other Diabetes Dietitian colleague. I did not anticipate this, and had prepared no presents at all, although I did have the multiple cakes and vine leaves to contribute to departmental catering. I am the Scrooge of Diabetes, but it can't be helped, it's too late now.

My leaving buffet after work on Thursday was delightful. Colleagues had brought in two slow cookers full of vegetarian lasagne and chilli con carne, and there was rice, bread, tortilla chips and rather a lot of stuffed vine leaves, plus cake. As a leaving present I was given more than I felt I deserved in M&S vouchers, and made a short speech that I don't think was too awful. It all ended at a reasonable time too, and instead of going home to pack like I should have given that I was moving out the next day, I went to badminton instead, and packed up on Friday night.

So now I am no longer a resident of two different towns, and my possessions were spread over a large surface area of the house on Friday because I was too tired to put anything away. On Friday night I was in bed by 9.30 p.m. and didn't get up in the morning until nearly 11 a.m, and on Saturday I managed a trip to do final bits of Christmas shopping but that's about it. Sunday was better, with a good deal of tidying up, wrapping presents and a trip to the supermarket with Mr A for things he considers essential for satisfactory celebration of the winter festival season.

With only four working days spread over two weeks, I am looking forward to finishing, and have a few exciting plans for the nearly three weeks I will have without work. Mr A has been doing all the Christmas-related card-writing, and I have done absolutely none this year. I may possibly manage some emailed greetings, but even that is looking unlikely. I have received actual physical cards from four known readers of this blog, so thank you very much H&B, CERNoise, Landrover Man/Bee Lady and Lola II/Mr M. And season's greetings to everyone else who knows me.

Tuesday, 17 December 2013

What I've been reading

Image of the book cover

The Rendezvous and Other Stories
by Daphne du Maurier
"The stories in this collection, some written before du Maurier published her first novel, reflect many human emotions: romance, disenchantment, fantasy, nostalgia, ambition, irony, the longing for adventure."
They were a varied bunch of stories, none outstandingly good or memorable, but sharply drawn and beautifully atmospheric. I'm sure I used to enjoy short stories, but these didn't really hit the spot.


Image of the book cover

The Love Letter
by Fiona Walker
"When Allegra North parted from first love Francis after a decade together, she poured all her regret into a letter. He didn't reply. A year later, her job brings her back to the beautiful Devon coast where romance first blossomed."
The tenth of my 12 Books of Christmas, and I'm sure nobody will be surprised that I didn't enjoy it. It was, however, much better than most of the others, perhaps even the best yet, but still so far into the territory of Chick Lit that it couldn't be retrieved by the decent standard of the writing. A lot of characters are introduced, all of whom have complicated relationships with each other, and I couldn't be bothered to read back and untangle them all. It went on for ever, the eponymous love letter hardly featured, and I was relieved when it was all over.


Image of the book cover

Good Omens: The Nice and Accurate Prophecies of Agnes Nutter, Witch
by Neil Gaiman and Terry Pratchett

narrated by Stephen Briggs
"The armies of Good and Evil are amassing, the Four Bikers of the apocalypse are revving up, and everything appears to be going according to Divine Plan. Except that a somewhat fussy angel and a fast-living demon are not particularly looking forward to the coming rapture, having thoroughly enjoyed life on earth amongst the mortals."
Another disappointment - the effect of Terry Pratchett in audiobook form seems to have worn off. I found it too difficult to follow what was going on and who all the characters were. There seemed to be less cleverness in the story, or if it was there, I missed it. And it was a pity that the young characters sounded like they had been lifted from Just William, and seemed hopelessly out of date.


Image of the book cover
The Tenant of Wildfell Hall
by Anne Bronte

narrated by Alex Jennings and Jenny Agutter
"Helen Graham has returned to Wildfell Hall in flight from a disastrous marriage. Exiled to the desolate moorland mansion, she adopts an assumed name and earns her living as a painter."
In contrast with my recent choices of reading, this seemed exceptionally good. Despite being set in a period where social life and mores differ significantly from our own, it provided a realistic story with believable people, although I didn't find any of them particularly attractive. Against a background of the best of classic literature, however, I expect it is not quite as exceptional as it seemed on this occasion.


Monday, 9 December 2013

Commissioning diabetes services

Great Horned Owl
Cotswold Falconry Centre, April 2013
At this very moment, right now this instant, I should be getting on with my admin. After a triumph last weekend when I finally, FINALLY managed to switch energy companies, I thought I would keep up the momentum and finish the deal with sorting all the bits of paper heaped up in an enormous pile.

So far this weekend, I have been obliged to go to two, count 'em, TWO Christmas dinners, as well as having my hair cut and going to the greengrocer and making two cakes. Because I am leaving work and there is only one weekend left before my leaving 'party' and I want to stuff vine leaves next weekend and that takes ages. So cakes must be baked this weekend, but I can't do another one because I have run out of cinnamon, so I have to do my admin. Except for the small matter of blogging.

Christmas dinners: one was on Friday night in a local pub/restaurant with my home badminton club that I haven't played with for six months, and the other was on Saturday night in a posh hotel with the Dietitians from the hospital where I used to work a year ago. On balance I probably liked the second one better, because there was a live band and lots of dancing. But the first was very good too.

Cakes: one spiced with fruit, one lemon drizzle.

My leaving 'party': this is taking place after work in a couple of weeks, when a modest buffet will celebrate two people leaving and one going on maternity leave.

Work is a bit strange because I will be leaving in less than a month, so I have much less patience for all the annoying things that happen on a daily basis. Colleagues are constantly complaining about all sorts of things, some of which are genuinely troublesome, but a lot of which are just giving them the pleasurable sensation of feeling put upon. Nothing much has changed in my world, except that I have at last finished the Carbohydrate Reference Tables and sent them for approval by the Trust communications police via the approved route, and have heard nothing at all for two weeks.

The main complaint at the moment concerns a plan by the Clinical Commissioning Group (CCG) to improve the service given to people with stable Type 1 diabetes who are registered with City GPs. The CCG is the official body now authorised to commission services and spend the NHS's money, and it wishes to discharge these patients from care within the city hospitals to be seen in an 'intermediate' service in the community instead. The advantage to the patients is that clinics should be easier to get to and there will be some evening and weekend appointments. There is no change planned for patients who live further afield in the catchment area served by the Trust. People with Type 2 diabetes under the care of the City CCG have already been discharged in this way, but they are back under the care of their GPs rather than being seen in a specialist diabetes service.

In itself, this plan is a good thing. The difficulty lies with the bitter internecine conflict between staff in the Diabetes service based in the two hospitals within the Trust. I may have written long ago about the attempts being made to bring the two locations together somehow, but we have not only remained as two separate units, but the divisions between the two seem to have increased. All this is helped not at all by feuding Consultants and an extreme lack of nurses that is due to become worse when three nurses reduce their hours and one goes on maternity leave in January. Despite the lack of consensus and the lack of staffing, the CCG continues to press forward with the plan.

Some of the difficulty was brought into the open recently because we offer two completely different types of Structured Education, which NICE says should be offered to people diagnosed with diabetes soon after diagnosis. Quite a lot of information, knowledge and skill is needed to manage diabetes in the best possible way, and there are many courses available, some of which are based on a national curriculum and others developed locally. Suitable courses must be evidence-based, and must demonstrate that participants have better outcomes in their diabetes management after they have been on the course.

The two hospitals in the Trust currently offer different Structured Education packages, one developed locally and one licensed nationally. The CCG wishes to offer just one type of Structured Education in the new service, and it is proving difficult and divisive to decide which one this will be. Emotions are running high, as various people have a deep commitment to one or other of the courses, and not only seem unable to decide which to choose, but also seem unable to settle upon a method by which the choice should be made.

The decision to discharge these patients into the intermediate service has also been made seemingly without adequate consideration of the practicalities. How will appointments be made, and by whom? Who exactly will be seeing the patients, and what level of qualifications should they have? Where will they be seeing the patients? What data will need to be recorded, and where and how will it be kept and made available to people who need to see it? How will patients contact the key doctors, nurses and dietitians? A date has been circulated for when the new service will start, without any reassurance that these questions have been considered.

The more forcefully that the new service is pushed, the more resistance is developing, and where I sit and have my lunch all goodwill has evaporated towards the instigators and supporters of the scheme. It is unusual for a day to go by without someone starting up some sort of complaint about the whole situation, and all and sundry chime in, and my pleasant relaxing lunch break is over.

I am very much looking forward to the new job, and it was very useful chatting at the Dietitians' Christmas do. A colleague asked how many days I would be working, and I was able to turn to the manager (who was sitting next to me) and ask, "How many days a week will I be working?" Her answer was "At least four," so that's a bit clearer now. I'm not exactly sure what I will be doing, but another colleague said that she had trained my predecessor for a renal clinic (kidney damage is one of the complications of poorly-controlled diabetes). I was also told that the Diabetes Dietitians in the Trust who are based in a couple of other locations have regular meetings as a team, so I should be able to draw on the expertise of more experienced colleagues for support and for clinical supervision.

Stop Press: my Carbohydrate Reference Tables have been returned by the official people who approve such publications, and who now want us to get written feedback from five service users before approval will be given. And so it goes on...

Saturday, 30 November 2013

Learning, changing jobs and home news

Green plant
National Botanic Garden of Wales, May 2013
It's one of those times when I think I've written all that I can about everything, and there's nothing left to blog about. I have an interesting and fulfilling life, it's true, but there's nothing particularly interesting to write about. Living in two places, work, badminton, family, the house and the blessed car - nothing you need to know. Mr A and I have a new boiler, the brakes on the car have been fixed, I have been on a course, that's it.

OK, so let's try harder.

I handed in my assignment for the module I'm doing for a Masters degree. It was a case study, all about a patient who was newly diagnosed with Type 1 diabetes at a relatively late stage of life, but who also is very overweight and has other health problems too. As usual, I write this on the basis that there's no reason at all to think that the patient isn't reading along with us, which makes it difficult to describe much more about the situation. I learned quite a bit about various aspects of diabetes by reading up on the evidence base, but it seemed to take an enormous amount of time. I'm not sure that doing more modules towards a Masters is how I would like to carry on with further professional development.

I have had my exit interview with my current employer - I think the administrator whose job it is to arrange these things was a bit enthusiastic, seeing as it's more than a month until I finish. It's also ironic that I haven't yet been able to complete the mandatory training associated with my induction. Anyway, I fed that back, which gave us something to talk about, along with the difficulties of having a fixed term contract working in a Diabetes department that often feels like it's in a continuous crisis situation. I would have no hesitation working with any of the Dietitians in the hospital - not just the Diabetes Dietitians - but I'm not sure I'd want to work in this Diabetes department again.

Luckily, I was allowed to continue with the training I'd been booked to do before I handed in my resignation, which took place last week. It focused on behaviour change (level 1), and covered much of the same ground as the Communication Skills module I did while at university. If done well, it can transform a difficult interview, and can help patients to achieve the results they are after. At the moment, I can see the potential and know in principle what I should be doing, but achieving it is another matter. It is something that I plan to practise as much as possible.

The new boiler was installed in my weekend home without fuss, according to Mr A who was there at the time. I played in a badminton match for the 1st ladies team of my weekday home, which is well above my standard, so losing 6-3 was a good result. I failed to get my hair cut through lack of booking ahead, mostly because I couldn't remember the name of the hairdresser. I'm busy making extravagant plans for the nearly three weeks I will have between the old and the new jobs, but will probably just sit around, as usual.

Sunday, 17 November 2013

Gestational Diabetes

Statue of a bear looking over a ridged wall
Cardiff castle, May 2013
I started writing this post some considerable time ago, which is a little ironic. Not many posts have needed incubation.

Every week, I see a few patients who have just been diagnosed with Gestational Diabetes Mellitus (GDM). And when I say 'just diagnosed', sometimes it's been in the last hour or two. Some have had it before, some take it in their stride, and some are completely freaked out.

For each of these women, I aim to give them basic dietary information in 30 minutes, and then they can have lots more input the following week if they need it when they come back for a scan and a full check-up. When I started writing this post, the shortest time I had managed was about 40 minutes, and when I first started in the job it was more like an hour. Now I've got it down to a well-practised routine.

The diagnosis is made by screening women who have one of several risk factors, including pre-pregnancy BMI over 30 kg/m2, a previous baby that weighed 4.5 kg or more, previous gestational diabetes, a first degree relative who has diabetes, or one of several ethnic backgrounds that have a high prevalence of diabetes. Screening is usually done at around 26 weeks into the pregnancy. The fasting blood glucose is measured, then they are given a measured dose of glucose to drink, and after two hours their blood glucose is measured again. In our Trust, if the fasting level is greater than 5.4 mmol/L or the 2-hour level is greater than 7.7 mmol/L, then bingo - the diagnosis is Gestational Diabetes. Even if the fasting level is 5.5 or the 2-hour level is 7.8 mmol/L.

For most of the time when I see people in the general diabetes clinics, I have to respond to what the individual brings to the consultation. It could be anyone, with any type of problem, or no problem at all. For this ante-natal clinic, it's always a woman, it's always gestational diabetes, and the advice is always the same at this initial stage. So it's an opportunity for me to hone things over the weeks, to get the right messages delivered as well as I can do it.

My first inclination was to do a bit of research, to make sure that my advice is based on the best available evidence. Two documents were the obvious starting point: the NICE guidelines, and a Diabetes UK document, both from 2008. I also found a couple of academic papers.

There are two main reasons that diabetes in pregnancy needs to be addressed. High maternal blood glucose means that the baby will receive more glucose than necessary via the placenta, and will secrete higher levels of insulin to compensate. Any energy that isn't needed for growth will be laid down as fat, generally around the middle and the shoulders. This can complicate delivery, with a higher risk of the baby getting stuck (shoulder dystocia) and trauma to the mother. The other issue is that after the baby is born, its blood glucose will drop to normal levels, but it may still be producing a lot of insulin. Hence there is a risk of post-natal hypoglycaemia, to the extent that the baby might need a glucose drip for a day or two until it sorts itself out.

After delivery of their baby, mothers are offered a six-week follow up glucose tolerance test, and the good news is that for most mothers the diabetes will have gone away. According to the US National Diabetes Education Program, however, 5 to 10% are found to have diabetes at this point, usually Type 2. Those who don't have diabetes at this stage still have a seven times higher risk of developing Type 2 later in life than if they hadn't had GDM.

I work with a specialist midwife in the clinic, and we take it in turns to deliver our messages. She covers the clinical information, and provides a meter so that the mother can test her blood glucose seven times a day: before each meal, one hour after meals and once before bedtime. Seven times a day, every day until the end of the pregnancy. Some women have had to do this before, some women take it in their stride, some women... well, you can imagine.

So what is my dietary input? In 30 minutes, I cover the following:
  • An explanation of Gestational Diabetes, and how food affects blood glucose.
  • Reassurance that they haven't developed GDM through eating too much sugar or too many pies.
  • The treatments available (diet, tablets, insulin, in that order) and that if you progress to tablets and insulin it's not necessarily because you're doing anything wrong, but this is a progressive condition.
  • What is their 'normal' or 'typical' diet? [I love a good diet history, you find out such interesting things]
  • Foods that don't significantly affect blood glucose (protein, fat, vegetables/salad, diet drinks, sweeteners, vinegar, herbs, spices) and those that do (sugary and starchy carbohydrates, including fruit, milk and yogurt).
  • The difference between sugary and starchy carbohydrate in terms of their effect on blood glucose, and the difference between a lot and a little carbohydrate.
  • What a reasonable portion size of carbohydrate should be.
  • Check that they are aware of advice on food safety and hygiene, avoiding liver, pate, uncooked shellfish and eggs, blue, soft and unpasteurised cheese, limiting intake of certain fish (swordfish, marlin, tuna), and the suggested restriction on caffeine.
  • The benefit of activity on general health and particularly blood glucose control.
  • And... any questions, at which point I have an eye on the clock and hope that they are completely overwhelmed with the information so far and will keep their questions for another day.
One of the reasons for clock-watching so closely is that the only time the midwives can run this clinic is on a Friday afternoon, when up to four women are scheduled. Run over a few minutes on each, and we're not going home on time. I can fill an A4 sheet with drawings, graphs and lists of food in clear handwriting faster than you can imagine.

The evidence behind the dietary advice for GDM principally supports a focus on a healthy balanced diet containing low glycaemic index carbohydrate food that is digested quite slowly. I often use the analogy of a sink with a blocked drain, where the level of water in the sink is the blood glucose level. Turn the tap on full blast and the sink overflows; put in the same amount of water (carbs) at a slow trickle and the level will only rise a little. It is all meant to limit the period of time when blood glucose is above the optimum level.

Women often ask how much carbohydrate is enough, or whether cereal A or B is better. I can give a generic answer based on population studies and determination of glycaemic index and glycaemic load (which is the index multiplied by the amount of food). The easiest way to address this question, however, is to point out that they will be testing their blood glucose before and after meals, and after just a few days they will know what 'too much' looks like. 

My dietetic advice differs slightly from the usual 'healthy eating' messages, because short-term glycaemic control is much more important than long-term cholesterol levels, for example. So a high protein, low carb cooked breakfast isn't such a bad thing for the few final weeks of pregnancy, because eggs, bacon, sausage, mushrooms, tomatoes and baked beans hardly contain any carbs at all. Crisps are a comparatively good choice of snack compared with sweets, cake or chocolate, but nuts are even better (as long as there is no history of nut allergy in the family). Reduced fat houmous with vegetables is probably the best choice for a snack that I can think of - low in fat, high in fibre with minimal effect on blood glucose.

Follow up in clinic consists of reviewing the blood glucose numbers recorded, and seeing a) if there are any above the target levels and b) whether these are occasional and random or frequent and showing a pattern. The woman may want advice on better choices for a particular meal, or she may have been experimenting to find the best type and amount of cereal for breakfast. There has been only one woman I can remember who seemed to deliberately ignore dietary advice and who changed nothing. Most are prepared to put up with everything because it's usually for only three months, and it's clearly worth it for an easy delivery and a healthy baby.

Sunday, 10 November 2013

New job

Vegetable market stall
Munich Viktualienmarkt, March 2013
All the different employment options have finally coalesced into a nearly certain situation. I have a leaving date and a start date that are very nearly three weeks apart; I will be in a permanent job for nearly three days a week and there will be temporary work for definitely one other day and possibly two, all with the same employer. I got in touch with the other employer that was offering one day of Type 2 education, and they said extremely nice things and even suggested that they keep the post open until I start the new job, because the extra days cannot be put in writing (it's complicated) and may disappear into thin air.

The new job is probably very similar to my current job except without the pregnant women, which is fine by me. It is in a much smaller hospital than my current one or the previous one, with a much smaller team where I will be the only Diabetes Specialist Dietitian. I'm guessing the journey time will be about half an hour, compared with the current time of nearly two hours due to ongoing 'improvements' to motorway junctions.

I met my future boss (who is also my previous boss) at a Coeliac UK meeting on Saturday and had a nice chat. In the line for tea and cake I stood next to a lady who recognised me, and thanked me for giving her a recipe for gluten-free lemon drizzle cake three years ago. I thanked her for complimenting me on my gluten-free lemon drizzle cake three years ago in front of the Dietitian who I was hoping would give me a job - and who eventually did become my boss.

In other news: the heating company phoned Mr A and postponed the boiler replacement for another week - we are thinking of going away next weekend just in case it doesn't last that long. The car really does need more attention on the brakes, which I had been trying to ignore. I finished the module for the Masters degree with days to spare, by dint of working in the library every night until 8 p.m. last week. It was painful, but worth it, because I didn't have to work all through this weekend. But when I finally got round to attacking the task of switching gas and electricity suppliers, the website containing all my bills was closed for maintenance so I couldn't get started after all.

After the last mammoth blog post, I think this will do for the time being!

Tuesday, 5 November 2013

Dressmaking


I've been making a dress for Lola II. This is something I rashly offered to do after she had to return a dress that she really liked because it was such an unflattering colour. I'm not talking about a shade that didn't bring out the vivid colour of her eyes, I'm talking about a dress that made her look like she had a fatal disease. Seriously.

Dressmaking is something I used to do quite often when I was younger (a lot younger), and I used to rather enjoy it, so instead of doing a jigsaw puzzle on my Solitary Holiday back in May, I thought I'd make the dress.

It was touch and go whether we would find both a pattern and fabric that would do, but we managed it. Then Lola II said that she'd like to have a go a dressmaking herself, but wasn't sure a) what it entails, b) whether she'd like it, and c) whether she'd be able to manage it. So then I foolishly offered to blog my progress so she could see how it works. This is the consequence of all that foolishness.

Very shortly after this, she attempted a basic dressmaking operation (sewing a hem or something similar) and decided that there was no way on earth that she was going to do any dressmaking after all. Given that this post was already well on the way to completion, I thought I might as well carry on regardless.

A dress pattern comes on large sheets of tissue paper. The cover tells you how much fabric to buy, and there's a plan of how to lay the pieces out, usually with the fabric folded in two (right side inside) so the symmetrical pieces can be aligned to the fold and you can cut two identical (but mirror images) of the other pieces.

The 'nap' of the fabric matters (that's the direction parallel to the longitudinal threads in the material), especially if the printed design is asymmetrical (so all your Christmas trees point upwards in the finished piece), and the pattern pieces are printed with a line that has to be aligned to the nap. You measure from the line to the edge or the fold of the fabric to make sure it's straight.

Quite early on you have to decide exactly what dress size you are, which isn't as easy as it sounds. A pattern generally comes with different cutting lines for different sizes. That's one of the beauties of self-made clothes - if you are a non-standard size, you can adapt very easily. [It turned out that Lola II comprises four different
clothes sizes.]

Day 1

The first step is to cut out the pattern pieces roughly, and pin them (usually to the back of the fabric) according to the plan. Sometimes it helps to iron the pattern sheets and/or the fabric to make sure they're properly flat. It helps to have a table large enough to spread all the fabric out, but I didn't. Never mind.

Don't feel bad if you have to pin and unpin the pieces several times. I'm so out of practice that I think I made every mistake in the book - I looked at the wrong layout plan more than once - the main thing is that everything is as it should be before you pick up the scissors, because once the first cut is made, it's much harder to put mistakes right. In fact, it took me so long to get this bit right that I had to switch over to music from the dramatisation of Bleak House that I was listening to, just so that more of my brain was concentrating on the sewing. I unpinned and re-pinned some of the pieces three or four times.

That first cut with the scissors is scary, but necessary. I cut the pieces out roughly first, because I wanted to mark out the changes that would accommodate different sizes at bust, waist and hip, and also because then it's more easy to be accurate about cutting along the lines. I tend to do the final cut on just the pieces I'm working with, and leave the rest until their turn comes.

The next step is the one I find most tedious, which is to transfer the markings from the pattern to the fabric, both on the side where the pattern is pinned, and the other side. These marks are to help line up various points accurately when it comes to stitching, e.g. centre front and back on both bodice and skirt. There are various chalks and carbon papers available that will serve this purpose - I used an HB pencil.

A word about interfacing - this is a fabric used to stiffen the garment, like in a collar or cuff. It doesn't have a grain, which removes some complication, and nowadays it's usually got iron-on adhesive - we used to have to tack (roughly stitch) the interfacing on. Usually, you use one of the pattern pieces to cut the interfacing where directed. These instructions were a bit vague about the interfacing, which was annoying, so I made an educated guess. If the interfacing covers up any of the pattern markings then you have to mark them on the interfacing. If you make a mistake and have to move the interfacing, then iron it again and peel it back while the glue is warm. This dress seems to use interfacing to reinforce the V-neck at the front.

Before you start to sew a fabric for the first time, it's a good idea to test the thread colour, tension and size of stitching with a spare bit of fabric. For this pattern, the darts in the back of the bodice were the first thing to stitch. Always pin first, using as many pins as you think you'll need (it doesn't matter if it's hundreds) and align them at right angles to the seam. Sew over the pins and take them out afterwards. Sew as fast or as slowly as you're comfortable with.

Day 1 ends with interfacing in place and darts sewn in back of bodice.

Day 2

No dressmaking. I went to London.

Day 3

It occurs to me that there are many dressmaking words I take for granted, like 'nap'. This morning starts with 'baste', which just means sew roughly. I used to do it by hand, but now I generally use a larger stitch on the machine. There's an extra reinforcing piece that finishes the neckline at the back, it's a bit fiddly, so they get you to sew it roughly first. In fact, for the final 'topstitching' (which is stitching that isn't hidden but shows on the finished garment) I did sew by hand to baste, because as I've said the basting was fiddly and also needed to be removed after the final stitching was done.

Don't be afraid to unpick things if they don't go right. I wasn't happy with how I stitched the neck first time round, so unpicked the seam and had another go. Obviously, this gets very tedious and time-consuming, so if it isn't too bad, I would just live with it. Like the time I sewed the cuffs of a shirt onto the wrong sleeves. I had to live with cuffs that did up at the back rather than the front for the lifetime of that shirt.

Next is the pleating at the bottom of the bodice. Again, I pinned it all wrong before I worked out how it was supposed to be done - I blame the wording and the picture in the instructions. I needed to pin and sew each pleat individually.

Day 4

Shoulders. Another complicated part, but following the instructions and with a bit of intuition, I think I've got it right. It's useful to remember that things are often sewn and then turned inside out - if this is the case, the seams that end up on the inside need to be trimmed a bit so they aren't too bulky.

Next, the two pleated front pieces of the bodice need to be sewn together. Nothing terrible here, I just found that I had ironed the pleats in the wrong direction, which was easily fixed. Once that's done, there's some gathering needed to the front of the skirt - this is done by sewing two parallel lines of the longest stitches and then pulling on the threads to gather the fabric. Then it's time to sew the skirt to the bodice: front first, then the back.

There are a number of sewing equivalents to the toast always landing butter side down. On the trickiest seam, when it's taken you hours just to work out what should be sewn to what, and fiddled about getting it pinned just right - something like the top of a sleeve, a collar or a cuff - you will inevitably find (usually after you've taken the pins out with relief) that you've either caught some of the underlying fabric in the stitching by mistake, in which case all or part of the seam has to be unpicked and redone, or that the lower thread on the bobbin ran out at the start of the seam and you've got to fiddle about pinning it all up again. I can report that, up to this point, neither of these events has taken place, but now that I've typed these words, I'm expecting the worst.

Day 5

I forgot to take photos of this bit, and with hindsight I'm not sure they would be helpful. It involved constructing the decorative band that goes across the front, with two interlocking sections and a twist. I'm pretty sure I followed the instructions properly, but it seems to leave the edges of the band completely unfinished. Maybe this is OK with jersey fabric, which is what is recommended, but I took the initiative here and made a small change so that no frayed edges would be visible. The last thing I did during the holiday was to baste the band to the front of the dress. I'm sure it should also be sewn to the front so it doesn't sag in the middle, but I can wait to see how it works in the end before making this 'improvement'.

Due to a small mixup, the measurements that Lola II gave me for her waist turned out to be inaccurate, and the next step in the instructions was to sew the sides together (including a zip). To be on the safe side, I thought it would be a sensible idea to do this after Lola II had the chance to try it on, and we could measure her properly.

Day ?

So I didn't do any more on the dress until I dropped in on Lola II and Mr M on the way back from holiday. That gave us the chance to try it for size, and it was pretty good, so I sewed the full side seam on one side, and the zip into the other side.

Of all the different operations necessary, this was probably the most tricky, and I took no pictures of the procedure. It didn't work brilliantly the first time, mainly because I didn't follow the instructions exactly to the letter, but I had to undo it again anyway, because I'd made it too small. Better the second time, and that's as far as I got in the holiday week.

Day ??

Coming back from holiday to the real world, the dress took a back seat for a month or so, while I moved into my new weekday accommodation and acclimatised to the new lifestyle. But the sleeves and the hem still remained to be finished. The sleeves are stitched into a tube first, then the outside edge (armhole) needs finishing. The instructions assume a jersey fabric, but I felt the need to prevent it fraying by creating a hem. I could have done an invisible hem by hand, but I don't think the machine version is too bad.

Then one of the most fiddly operations - fitting and stitching the sleeves into their sockets. It didn't go too badly, I'm pretty sure I sewed them in the right way round, it all looked OK. So, time to try the almost-finished dress on.

Disaster! It appears that the one place where the stretchy jersey fabric was needed was the sleeves. Both my arms got stuck with the dress half on and the sleeves not much further than my elbows, and it was a devil of a job to extricate myself. Eventually the garment and I were separated, and I could survey the scene.

A couple of options are possible. I could split the sleeves along the outside, which would be fairly difficult to do, or I could remove them and create new ones, which would also be difficult. So I did nothing, for quite a long time.

Day ???

A long time later, following much thought, discussion and borrowing a T-shirt from Lola II that had the sort of sleeves we were looking for, I returned to the dress on our Yorkshire holiday in September.

I found that the T-shirt template wasn't going to work unless I unpicked the sleeve to use it as a template, but as the T-shirt was still a viable garment, I decided not to do that. What I did was to copy the pattern piece onto newspaper (it would have been tissue paper but I forgot to bring any), then split it and re-drew it in a way that I hoped would fit the same armhole but wouldn't need stretch jersey to work.

And it did! So the dress is nearly complete, with only the hem to finish. I can't do that without Lola II, because I will need her to model it and check that the skirt is the same length all the way round.

Days ???? and ?????

When I met up with Lola II after the holiday, we spent some time with me lying on the floor measuring the height of the hemline. It shouldn't have been necessary, but it's been a while since I did any dressmaking before this marathon effort, and the hemline definitely wasn't straight. That took ages.

I knew I'd be seeing her again this weekend, and all that was needed was to sew the hem and a bit at the front, so in between getting to weekend home from weekday home and setting off again for school reunion, I managed to haul out the sewing machine for the hem and then sew the front bit by hand.

Finished! It was fun. I really enjoyed it, and it brought back the satisfaction of creating something both beautiful and practical by hand. I'm going to do it again, but I have so many more pressing things on the agenda, it might be some time before I get round to this little project.

Lola 2013
Model wearing the dress I'm making
Burda 7082

Friday, 1 November 2013

An account of the past week or two

Pink flower
National Botanic Garden of Wales, May 2013
Let's start with some good news. Here are some bad things that haven't happened: the boiler hasn't broken down. The car hasn't needed any attention for nearly a week. There have been no work-related disasters.

My list of everyday tasks expands and contracts but never goes away. There has been progress of sorts - we have a date for installation of a new boiler, I have a certificate to prove I am not a criminal, and I have even managed to get proof of previous employment in the NHS back in the 1990's. This is useful because the amount of annual leave that one is entitled to depends on duration of employment, and it doesn't matter when that employment took place, so I should get a few more days holiday as a result.

On the down side, I haven't had any firm offer of employment so I haven't been able to give my notice in, and it is now looking as though I will therefore have to work through Christmas; I am nowhere near dealing with the Will or the Power of Attorney that I have been determined to set up for several years now, and there are some other jobs that look like they will be pushed further and further into the future. Income tax self-assessment form? Forget it.

The employment situation becomes ever more complicated. Why is it never straightforward? I got a call last thing on Friday as I was driving home last week, saying that there were more hours available to add to the 20 hours in one of the prospective new jobs, and then the voicemail message was cut off. An exciting prospect - perhaps this would be enough to make up a full time job together with the one day I've been offered by the other employer?

I had to wait until Monday to get more details. It took nearly a whole day of phoning and leaving a message, followed by not being able to answer the phone when it rang, then leaving another message, then being with a patient again when the return call came through, and so on throughout the day. Eventually we managed to find a time when both of us could speak, and of course the extra hours turned out to be on the same day as I had been offered for the one-day job.

Pros: four days with one employer is better than three with one and one with another, and it would cut out all the travel. Cons: the one day job would be doing education for people with Type 2 diabetes which is something a bit different that I'd actually like to do; I've said I'll take the one day job and don't like to mess people around; the extra hours tacked on to the 20-hour job would have to be taken on trust because that offer can't be put in writing. Watch this space.

I have been given the extension to the deadline for my Masters module that I asked for, and spent the whole of last weekend working on it. Really and truly, the whole weekend, except for a couple of hours watching La Vie En Rose, a biopic of the life of Edith Piaf, and a trip to the shops for provisions. I was able to do this due to the absence of Mr A, who is on a Bulgarian Biking Bonanza for a week. He returns very soon, and I await the thrilling tales of excitement and adventure. As far as I know, he hasn't broken anything, but I doubt that he would mention it if he had - he would just return home in plaster as a lovely surprise.

There is more to do for the stupid Masters module, which is taking up a disproportionate amount of leisure time, to the extent that I have decided to use work time to do it as well. Studying as a full time student was wonderful; combining it with a full time job is not so much fun. Just a couple more weeks of pain and it will be over - I do wonder whether I can be bothered to put myself through this for all the other modules necessary for the degree, but I imagine when the memory of this module has faded I shall miss the learning experience.

I am doing a fair bit of learning through everyday work, because I always want to make sure I'm on top of the game. A chance remark by one of the nurses set me thinking about the effect of caffeine on control of blood sugars in diabetes, and I chanced upon a recent paper which investigated just that. In case you're interested, it concludes that caffeine is bad for blood glucose control in Type 2 diabetes, and probably also in Type 1 and gestational diabetes. I'm not sure whether the paper is freely available because I accessed it through my university account, but if you're interested then look for "Whitehead N. & White H. (2013) Systematic review of randomised controlled trials of the effects of caffeine or caffeinated drinks on blood glucose concentrations and insulin sensitivity in people with diabetes mellitus. J Hum Nutr Diet." Or ask me, and I'll email it to you.

Speaking of gestational diabetes, those ladies keep on coming. I have had to deal with a glut of interpreters recently, some of whom have been truly awful, along with some very difficult patients who have been struggling both to understand what is being asked of them and to put it into practice. But some good news to finish with: at the end of today's clinic there was a lovely smiley lady whose interpreter hadn't arrived, but whose blood sugar record was near perfect and who indicated (with the help of family present) that she actually felt much better having made the recommended changes to her diet. That hardly ever happens, but so nice when it does!

Wednesday, 23 October 2013

What I've been reading

Image of the book cover

A Handful of Dust
by Evelyn Waugh

narrated by Andrew Sachs
"After seven years of marriage, the beautiful Lady Brenda Last is bored with life at Hetton Abbey, the Gothic mansion that is the pride and joy of her husband, Tony. She drifts into an affair with the shallow socialite John Beaver and forsakes Tony for the Belgravia set."
Evelyn Waugh can write such dry comedy that it came as a surprise to find this book not funny at all. A sad story of a marriage breakdown, tragic death and imprisonment, and most characters so self-obsessed and selfish. Most of the time I was listening I didn't think I liked it, but he is such a good writer and Sachs such a good narrator that, despite everything, I would class this as a good book. I wouldn't suggest anyone read it for laughs, though.


Image of the book cover

The Call of the Wild
by Jack London

narrated by B. J. Harrison
"Buck is stolen away from his comfortable life as a pet in California and sold to dog traders. Surrounded by cruelty, Buck’s natural instincts and behaviour begin to emerge as he works as a mail carrying sled dog, scavenging for food, protecting himself against other dogs and sleeping out in the cold snow."
This is a splendid book, shorter than I remember, but perfect for the car journey. Nothing more to say!


Image of the book cover

Type 1 Diabetes in Children, Adolescents, and Young Adults: How to Become an Expert on Your Own Diabetes
by Ragnar Hanas
"This practical, easy-to-read book tells you everything you need to know to take good care of your diabetes. Its strengths lie in its ability to connect with the reader, to explain and to make the reader understand medical knowledge in a clear and concise manner."
This enormous book has taken me a full nine months to read, and as I reached the last pages I knew that if I were to start at the beginning again, I would get just as much out of it as the first time through. I will do that at some point, but after nine months of hard slog I think I will give it a break and do more leisure reading until the New Year.


Image of the book cover

Less Than Angels
by Barbara Pym

narrated by Patience Tomlinson
"Less Than Angels follows the loves, works and hopes of a group of young anthropologists. Catherine Oliphant is a writer and lives with handsome anthropologist Tom Mallow. Their relationship runs into trouble when he begins a romance with student Deirdre Swann, so Catherine turns her attention to the reclusive anthropologist Alaric Lydgate, who has a fondness for wearing African masks."
Anthropology is an acquired taste, I imagine. This is a gentle story, sauntering through the narrative with hardly any sense of forward motion, so that I became quite impatient for something to happen. With patience, though, I came to recognise the characters and their personalities, and realised I was reading a book that required no effort and presented no challenge. Which is fine, once in a while.

Saturday, 19 October 2013

Hypoglycaemia treatments


Hypoglycaemia, or a 'hypo', happens when the level of glucose in the blood falls too low. It is not caused by diabetes, because the effect of diabetes is the opposite: high blood glucose levels, or hyperglycaemia. Hypos in people with diabetes are caused by the treatment of hyperglycaemia, not by the diabetes itself.

Very few people who are not diabetic will ever experience hypoglycaemia, because the systems that manage glucose homeostasis are very sensitive to blood glucose level, and keep the concentration very steady between about 4 and 7 mmol/L. But in diabetes, these systems are pretty much messed up along with the pancreatic beta cells. Not only is the insulin response defective, but responses to other hormones that regulate glucose can be blunted too.

In someone with a fully functioning pancreas, receptors in the beta cells of the pancreas islets respond to rising levels of blood glucose with a corresponding and synchronous release of insulin. This facilitates the transport of glucose out of the bloodstream and into cells around the body for use in generation of energy, or into storage in the form of glycogen or fat. As the level of blood glucose falls, the secretion of insulin tails off but a different hormone, glucagon, is released from alpha cells in the same islets. Glucagon stimulates the secretion of glucose into the blood by the liver, either from stores or by the creation of new glucose from scratch.

In someone with diabetes, the matching of blood glucose and insulin is no longer finely tuned and synchronous, but rough and ready and very much asynchronous. When the blood glucose level falls too far or too fast, the level of insulin cannot be unconsciously adjusted down because it is coming from subcutaneous fat depots or an insulin pump rather than the minutely adjustable pancreatic beta cells. Due to the presence of insulin, the glucagon response is not as effective as it should be, and glucose may continue to be removed from the circulation rather than pumped into it.

This is a gross simplification of the many complex hormonal pathways involved in glucose metabolism, but it will do. People with diabetes who inject insulin or use medications that stimulate the pancreas to secrete insulin can't turn their insulin off automatically when they don't need it any more, and are therefore at risk of hypoglycaemia.

Most systems in the body can use glucose or fatty acids to supply their energy, but the brain depends on glucose, although it can utilise ketone bodies (a by-product of fat metabolism) if necessary. When blood glucose concentration falls, the brain signals its displeasure by provoking the nervous system to put out a series of escalating warnings, culminating in stress hormones such as adrenaline and cortisol, in order to generate a flood of glucose to fuel 'fight or flight'. This is what is responsible for the hypo warning signals such as sweating, tingling of the lips or extremities, irritability, dizziness or unsteadiness, which help a person with diabetes to realise that blood glucose is dropping. Hypo unawareness, which I referred to in the post about islet transplantation, is so dangerous because the diabetic person is unable to detect low blood sugar until it is too late.

If untreated, hypoglycaemia can lead to impairment of cerebral function (confusion, drowsiness, inattention), convulsions and unconsciousness. In most cases the glucagon response kicks in and the liver eventually secretes a load of glucose into the blood. A hypo is not pleasant to experience, and there is always an underlying fear of more serious consequences.

The generally accepted definition of a hypo is a blood glucose level less than 4 mmol/L ('Make 4 the floor'), and if this happens, then treatment is advised. If the person is using an insulin pump, then it also makes sense to suspend insulin delivery until blood glucose has stabilised.

First line treatment is to eat or drink something that contains 10-20g of fast-acting carbohydrate, ideally in the form of easily accessible glucose. Energy drinks such as Lucozade are very handy, as are sweets such as jelly babies, fruit pastilles, jelly beans, wine gums or Haribo - these all contain glucose or glucose syrup in their ingredients. Sucrose takes a little longer to be broken down and converted into glucose, but sugary fizzy drinks such as cola still work. There is some argument about whether fruit juice is suitable as a first-line treatment because its sugar is in the form of fructose, which has a longer metabolic pathway than sucrose, but real-life trials suggest that it works just fine. There are also dextrose tablets that are designed to provide fast-acting glucose, but these are fairly unappetising, which can be a good thing - you may fancy a quick snack of jelly beans, but you are unlikely to eat dextrose tablets for fun.

The quantity of carbohydrate is important, because too much will send blood glucose too high, potentially leading to a need for correction downwards and a roller-coaster ride for the next few hours, or even days. The aim is to raise the blood glucose level back above 4 mmol/L very quickly, but ideally not above 7 or 8 mmol/L. To find out if this is the case, the second stage of hypo treatment is to wait about 15 minutes and test again. If the blood glucose level is still below 4 then it's a good idea to repeat the dose of fast-acting carbohydrate, wait another 15 minutes, test again, and repeat a third time if necessary. If blood glucose is still too low after three attempts, it's time to call the paramedics.

In most cases, one treatment will be enough to bring blood glucose back up again. At this point, the game is not over, because whatever caused the hypo in the first place may still be present, so the second line treatment is to eat or drink something that contains 10-20g of medium- or long-acting carbohydrate. If it's a mealtime then the meal would do, but otherwise it could be a starchy snack such as toast, biscuits, crisps, chocolate, fruit, popcorn or yogurt. Milk falls into this category because lactose follows an even longer pathway than fructose or sucrose before being converted to glucose.

The above paragraphs presuppose that the individual is conscious and alert enough to eat or drink. If the person is conscious but not alert and there is someone to assist, there are glucose gels that can be squirted into the mouth as first-line treatment. If the individual is not conscious then nothing should ever be put into the mouth - time to call the paramedics.

There is one other self-help option: an injection of glucagon, which can be administered by a partner or family member who has been shown how to do it. It is not as straightforward as, say, an insulin injection, because glucagon is not stable in solution so has to be prepared by mixing two components on the spot - not easy to manage when your loved one is unconscious or convulsing. But you should have called the paramedics before starting on the path to the glucagon injection, so they should be there to help very soon.

Part of the support and information we give to people with diabetes is how to deal with hypos. We may cover the many and varied reasons why hypos might occur, discuss the law as it applies to diabetes and driving, and I have even given advice about what to do about hypos underwater when scuba diving. But we were especially challenged by one patient with Type 1 Diabetes who does not read, write or speak English.

When I asked colleagues if we had anything that might help, I was sent some fairly crappy illustrations of hypo treatments, and I wanted to do better. 'Crowd-sourcing' using Facebook turned up a photographically oriented friend who volunteered his daughter to help out. I produced a specification for the items and quantities that I wanted photographed, and after some prompting, a terrific set of pictures were the eventual result. I have had them printed and laminated, and plan to use them either with those who need visual rather than written information, or as a teaching aid. I think they're great!

Tuesday, 15 October 2013

Many job opportunities

Two geese swimming in a lake
Munich, March 2013
Following responses to the last blog post, here is a brief update as to my comings and goings: I have acquired a new job, and maybe will get one or two others, and very nearly kept the one I already have.

A permanent Diabetes Dietitian job was advertised much closer to home, the only catch being that it is only 20 hours a week. After much consideration and discussion with family and employers, I applied, with the verbal assurance that my current 35-hour job could probably be tailored to accommodate me if I were to be offered the new job. The interview went well, especially as one of the two interviewers was my previous boss and had seemed very encouraging when I had asked whether she thought I should apply.

I was offered the job, which was very pleasing, and I went back to talk to my current employer about reducing my hours to suit. Oh dear, despite previous assurances, it wasn't quite that simple, because of non-negotiable commitments like the multi-disciplinary ante-natal clinic. If new job needed me on a Wednesday and current job also needed me on a Wednesday, then an irresistible force had met an immovable object and I was caught in the middle. After a bit more thinking, I have gone ahead and accepted the new, closer, permanent but part-time job. We are now negotiating over whether I am who I say I am, and whether I am a criminal. Well, not exactly, but nearly.

In the meantime, another post was advertised, also part-time and about 15 hours and in the same location as I am currently based (i.e. about 60 miles from home). Perfect - except that the advertised date and time for the interview were impossible for me to attend, because I had a clinic with patients booked in and nobody who could cover. Luckily, they have agreed to accommodate me at an alternative time, which they are under no obligation to do, so that interview will be happening this week. It is not quite a regular job because it involves delivering courses which might not be scheduled in the time I have available every week.

The third job is part of a European project which I think I have briefly mentioned before. They are happy to take me on in principle, delivering some of the group weight management sessions, but clearly want to see the outcome of all these other employment options before committing to employing me.

Meanwhile I have been trying to finish the module I'm doing towards an MSc in Advanced Dietetic Practice, and for the first time in my career had to ask for an extension to the deadline because I just can't fit everything in. The pressure of keeping all the plates spinning has also had an effect on my organisational ability, because I have had terrible trouble with all the documentation that I need to prove I am qualified and not a criminal and am actually who I say I am. It has taken two weeks for me to assemble everything in the same place.

And there have had to be trips at weekends, to London for a family do and get-together with friends, to Cambridge for a 30th anniversary dinner, the car needs another few things sorting, I really must revisit my Will which is dangerously out of date, I have played in a badminton match for a team in my weekday home, and the boiler is about to blow up and Mr A and I can't seem to find the time to make the necessary decisions about its replacement. He has had an exam and is about to have a job interview as well.

We often fret about our inefficiencies while appreciating that we are extremely lucky really, and there is nothing truly bad about our situation - as long as we can sort the boiler out before it breaks down for good.

Tuesday, 8 October 2013

Talk to me

Apples with hearts on their skins

My creative juices are waning. I am at low ebb. The tide of my imagination is way, way out to sea, and most evenings I want to retreat into some sort of cushioned cocoon and be warm and dry and quiet until morning, when the alarm drives me out into the cold. I am tormented by my unfinished case study, preying on my mind like a hungry maggot. I have started waxing poetic, and it's not pretty.

I would like to reach out to you, my readers. My blog statistics show that you are few (about 30, I think) and I think I know most of you by name. I need your help, advice, ideas, I want to extract all the goodness from your brains and use it to fuel my ambitions.

What am I talking about? Well, this has been a monologue for too long. In my previous incarnation as Student Lola, people commented. People I didn't know, but came to know, through their thoughts and views. As Dietitian Lola I am less promiscuous, I hardly comment on other peoples' blogs although I read them assiduously. In return, I receive few comments except through email and Facebook. This is OK.

But tonight I am weak, I crave company. I particularly yearn to know who is out there, especially if you have been silent up to now. I am braced for disappointment (like the time nobody came to my leaving party), so I am resilient, I will cope if you all remain silent. But I would very much like to hear from you.

What you can do for me is to tell me stuff. What do you find interesting? What do you like reading about? I'm not promising to fulfil your requests, oh no, if you want to read about the pros and cons of generic MP3 players or whatever happened to Opal Mints, I'm not the one to satisfy you. But if it's bordering on the realm of Lola Life - dietetics, diabetes, living away from home, working in the blasted NHS ('blasted' as in the Shakespearean heath), modest holidays in ordinary parts of the UK - then give me a hook to hang a blog post on and I may be inspired.

Or you could tell me what you like about my blog. Don't bother telling me what you don't like, because it's my blog and I do what I like. Don't be gushing or complimentary - if nobody read a single post I would still be writing them - but feel free to come out of the shadows, 'de-lurk', and shout something across the river running between us. And please, please, even if you don't have a formal online persona, do stick a name on the end - it doesn't have to be your real name, just make something up, it's fine. I am listening.

Wednesday, 2 October 2013

Pancreatic islet research

Lots of little pink flowers
National Botanic Garden of Wales, May 2013
Last week I visited the Islet Research Laboratory (IRL) in Worcester. I was assisted in this endeavour by the local Diabetes UK group, who had arranged a minibus to take a select few on this jolly trip. I have written about this group before, and suffice to say that most of the group did not exhibit behaviour significantly different from what I experience at their meetings. But the quality of the material presented by the researchers made up for any shortcomings of the party.

There are a very few centres in the country where this type of work is done. The islets in question are the Islets of Langerhans, which are the structures within the pancreas that contain insulin-secreting beta cells. The research team extract clumps of islet cells from cadaveric donor pancreata* by dissolving away the tissue around the islets, and then infuse them (sometimes on several occasions) into the hepatic portal vein of the recipient. The islets are transported to the liver and lodge in the tissue there, and somehow a blood supply is created from nowhere (vascularisation) to nourish them and to transport away the insulin that they manage to secrete. The fact that any of this works seems to me to be a miracle, much like throwing mortar and bricks randomly into house foundations might cause a habitable bungalow to emerge.

Although the techniques are still experimental, islet transplantation is approved for patients within the NHS. Recipients are very few (208 worldwide, 34 in the UK), partly because donors are very few, and partly because the selection criteria are so stringent. Most qualify due to severe hypoglycaemia unawareness, which can be utterly debilitating, leading to incapacitating hypoglycaemia with no warning. Others might be suitable recipients because they are already taking lifelong immunosuppressant medication following a kidney transplant.

The success rate of islet transplants is improving, measured by independence from insulin injections, but only 10% of transplant recipients are still insulin-independent after 5 years. It seems, however, that even though they have to return to insulin injections, some recipients recover their awareness of hypoglycaemia, which is a huge bonus. The researchers at IRL are following a number of strands of research: improving the yield of islets from donated pancreata (they only get about 50% yield at the moment), improving the vascular development and survival of implanted islets, and enhancing the immune protection of islets. They are also thinking about different sites for implantation - the pancreas is deemed too 'brittle' for implantation, which is why the liver is used, but there are other options that may be more successful, such as the intestinal submucosa.

Extraction of islets is quite brutal, so it makes sense to try to improve their 'health' before transplantation. It has been found that they survive better if held in a rotational suspension rather than allowing them to settle in culture. Next, ways to enhance vascularisation include stimulating secretion of vascular endothelial growth factor (VEGF) through incubation of islet cells with various drugs that not only increase VEGF expression but have also been shown to up-regulate beta-cell insulin secretion (the 'glitazones' or thiozolidinedione family).

Four experimental results
Fluorescence immunostaining for insulin (red – TRITC) and VEGF (green – FITC) in human islets maintained in (a) SC, (b) SC TZD, (c) RC and (d) RC TZD.TZD: thiazolidinedione; SC: static culture; RC: rotational cell culture; TRITC: tetramethylrhodamine isothiocyanate; VEGF: vascular endothelial growth factor; FITC: fluorescein isothiocyanate.
The immuno-protective angle seems to have arisen by one of those chance thoughts that the senior researcher seems to have had while doing a crossword or brushing his teeth or something - how is a developing foetus protected from the immune system of the mother? This has resulted in a series of experiments using adult stem cells from the amniotic membrane, which they collect from the nearby hospital following donations from women having caesarian sections. Sticking some of these cells in with the islets (nothing sophisticated, just mix them together) seems to have resulted in some useful fusing of the different cells, and may lead to a new line of research.

Progress is slow in research, and while I thoroughly approve of what they do, I can't imagine doing it myself - hardly any human contact, tens of years before results of experiments are any practical use. They also struggle for funding, ethical approval of research, and lack of donor material. Research labs are only third in line for any pancreas donation - first are medical centres that do whole pancreas transplants, and second are those that perform islet transplantations on people rather than just doing research. So IRL ends up with the pancreases that nobody else wants.

We all sang rousing songs in the minibus on the way back (no, of course we didn't) but I was mystified by those of the party, and there were several, who had been on this trip more than once. The rate of progress meant that aside from the benefit of tea and biscuits and sitting down for an hour or so, there would have been little change since the last time they were there. But then, this group contains individuals that are like none I have ever met before.

* by far my best moment of the evening came when the lead researcher first used 'pancreata' as the plural of pancreas.

Saturday, 28 September 2013

A tough week

Bikes racing in the park
Victoria Park, Leamington Spa, April 2013
My feet have hardly touched the ground for a week. Getting back from holiday led to a concentrated effort to get some of the more pressing jobs done around the house on Sunday, although there is plenty left to do. I was also anticipating a very full work schedule for this week, and copious amounts of preparation did seem to calm my frayed nerves, which enabled me to deal with everything.

Monday

I managed to navigate successfully to a Community Centre in the city to deliver the first session of my first Structured Education course. Structured Education describes evidence-based courses for groups of people with diabetes, delivering curriculum-led content designed to empower people to manage their diabetes more effectively. It is an intervention that, according to NICE, should be offered to anyone with diabetes, on the basis that the evidence suggests they those completing the course will be healthier, will need less time and resources, and therefore cost the NHS less money.

There are a number of different, validated Structured Education courses, and I guarantee I will be writing more about them in future. They are invariably known by an acronym or abbreviation: DAFNE, JUGGLE, BERT1E, EDWARD, T2ONIC, DESMOND and X-PERT - and there are more. Some are licensed nationally (and internationally), some have been developed by one diabetes centre in order to avoid paying licensing fees. In order to qualify for delivery within NICE guidelines, they must collect and collate evidence to demonstrate that they do in fact deliver positive results in terms of better diabetes management.

We deliver the course in pairs - one Diabetes Specialist Dietitian and one Diabetes Specialist Nurse. I was also being observed by my team leader to make sure I followed the teaching plan as documented (some of the other courses are very much more rigorous in their educator qualifications and peer review). Nine participants plus three carers were expected, and I was daunted by the prospect of such a large group, but as for all events of this sort, not everyone turned up. It went well, and I would almost go as far as to say that I enjoyed it.

Tuesday

On a different university campus I attended a preliminary meeting that introduced several Dietitians and Fitness Instructors to a European research project. It is a multi-centre, multi-national, 3-year project with the primary objective of discovering how two different dietary interventions affect the progression of people in a pre-diabetic state (with Impaired Fasting Glucose and Impaired Glucose Tolerance) to Type 2 diabetes. Secondary end points, no less important, incorporate two different exercise programmes alongside the dietary interventions, and also include assessing weight loss, CHD risk factors, quality of life and more.

The dietary interventions involve two diets that have previously been studied in other European projects (Diabetes Prevention Study and DioGenes): high protein and low glycaemic index (GI) compared with moderate protein and moderate GI. The hypotheses to be proved or disproved are a) that a high protein, high GI diet will be superior in preventing Type 2 diabetes compared with moderate protein, moderate GI diet, and b) that high intensity physical activity will be better than moderate intensity. I have provisionally put myself forward to conduct the dietetic aspect of the group sessions required within the project, but there are many barriers to my involvement, not least being that I am working full time at the moment, and I may be moving away from the region before the three years of the project are up.

Wednesday

The regular ante-natal clinic. I didn't have a great deal to do this time, but I was pleased that my thoughts about the treatment for one person I saw turned out to be supported by the more experienced members of the MDT. If blood glucose readings show high fasting levels first thing in the morning, this suggests adjustment to medication - if your blood glucose is on target when you go to bed but high in the morning, there isn't a lot of scope for fixing things with dietary intake.

I also went to see the convener of the Masters module. The date is approaching when the case study has to be handed in and I'm rather suffering from the pressure of it. It doesn't help that I can't do a great deal on my work PC because it uses such old technology and has various restrictions that prevent effective academic work, and I haven't had any Internet access at home all week because of some fault that can't be rectified easily because the landlord rather than the tenants has the contract with the ISP. I did get some very useful advice on where to focus my efforts with the case study, and with only two weeks to go before the deadline the pain will soon be over.

I also took a trip to the Islet Research Laboratory in Worcester in the evening, but I'm saving that report for a separate post.

Thursday

I attended a 'cross-site' dietetic meeting where Dietitians from the four corners of the Trust gathered to discuss various matters of import, and some other stuff. While we all sit under the umbrella of Dietetics, different disciplines are scattered in many places: Dietitians dealing with inpatients, home enteral feeding, paediatrics, hospital catering and diabetes all reside in different areas as well as being separated over the two hospital sites.

Some of the meeting was useful and interesting; some was not. The most interesting part was a discussion about Prescribing. At present, Dietitians are not legally able to prescribe Prescription Only Medicines (POMs), although we can prescribe nutritional supplements and tube feeding products which come under the heading of 'Borderline Substances.' Following a long drawn out process, Physiotherapists and Podiatrists have achieved a change in the law to allow them to prescribe (after a suitable Masters-level qualification has been awarded), and the BDA is following in their footsteps to try to bring about the same change for Dietitians.

If/when this comes about, it will make a great deal of difference in many dietetic settings. Most pressing is parenteral (intravenous) nutrition, where Dietitians make all the decisions about what should go into the parenteral feed and at what rate and for how long it should be administered, but have to find a doctor or a pharmacist to sign and take responsibility for the prescription, despite knowing nothing about its import. There are many other inpatient situations where it would make a big difference for the timeliness and efficiency of treatment if the Dietitian were able to prescribe, but in my line of work it would mean that a Dietitian could initiate and modify diabetes treatment. This would include tablets, injectable medications and insulin.

At present, it would be illegal for me to make or even to recommend any changes to the administration of a patient's insulin. We get round this by making sure that all I do is discuss what might be done and suggest that the patient decides whether to make a change or not. For example, repeated low blood glucose levels in the early hours of the morning in the absence of other factors might suggest that the basal rate of insulin overnight is too high. I could ask the patient what they thought they might do about that. Decrease the basal rate? That sounds like a good idea.

There are four defined levels of prescribing rights, starting at a Patient Specific Direction which allows a non-prescriber to supply and administer a specific dose of a named drug via a specified route for a named patient. Next up is the Patient Group Direction (PGD), which allows for a wider range of options to supply and administer specific drugs to classes of patients. The diabetes service in my Trust is working to draw up a PGD - it isn't entirely straightforward. What we hope to gain in future is firstly 'Supplementary Prescribing', which is fairly limited but allows prescribing of POMs according to a clinical management plan agreed by doctor, patient and prescriber. The end goal is to become 'Independent Prescribers', where no permission is needed from anyone.

Both supplementary and independent prescribing allow for complete access to the entire formulary of medicines available for prescription in the UK. It is not surprising, therefore, that there is significant work to be done to elicit approval of prescribing rights for Dietitians, including the amendment of an Act of Parliament. It is a worthy goal, but even if achieved it would only be available to a very few of the most senior Dietitians, not least because of the cost and difficulty of the Prescribing qualification, and the burden of such serious responsibility.

Friday

A much easier day ends a week in which my weekday house suffered the breakdown of the fridge freezer (it was replaced but all my frozen food was lost) and no Internet access. I have had to spend significant time after work and in the Medical Library during the week in order to research my case study and do all the other online tasks that are essential in this modern world. I am not optimistic that home Internet service will be resumed next week, but you never know.


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