PROFESSIONAL CONFERENCE NEWS, CAMPAIGNING, RESEARCH, NETWORKING
CENTRE OF EXCELLENCE A WEEK IN THE LIFE OF IPSWICH FOOT CLINIC
NEW LOOK WHY DIABETES UK IS REBRANDING
For healthcare professionals Spring 2012
DIABETESUPDATE SPOTLIGHT ON FOOTCARE PREVENTION, NOT AMPUTATION
STEM CELLS PROMISE OR HYPE FOR DIABETES? NETWORKS IMPROVING DIABETES SERVICES NHS REFORM MOVING TOWARDS OUTCOMES
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IN THIS ISSUE... “This rebranding exercise is far more than just a change of colour scheme and a new logo. It goes straight to the heart of who we are and what we do.”
• Calls to curb preventable amputations • Alzheimer’s drug for diabetes • Scottish government announces insulin pump investment • NICE approves Bydureon • Diabetes Week 2012, and more…
11 RESEARCH FOCUS • The risk of birth defects among women with diabetes • Health benefits of exercise linked to ‘self-eating’ • Vitamin D and diabetes, and more…
PUTTING FEET FIRST In March, Diabetes UK launched its major footcare campaign to reduce diabetes-related amputations by 50 per cent over five years
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FEATURES
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S STEP
LATEST
4 NEWS
14 COMMENT
TO HEALTHY
FEET
STEM CELLS TO THE RESCUE Stem cell research promises much in terms of renewing and repairing the human body. What might this mean, in the future, for people with diabetes?
REGULARS
29TALKING MEDICINE DIGEST 16 CLINIC
32 AT YOUR SERVICE
36 CARE DELIVERY
Under-reporting of diabetes in The challenges of delivering care to young hospital admissions may have adults with diabetes in research serious implications and service planning
A week in Ipswich Foot Clinic – showcasing the multidisciplinary approach to diabetes footcare
Wakefield diabetes network is delivering improvements to local services
INSERTS
FACT FILE
Driving and diabetes
Driving and diabetes
WALLCHARTS Insulins
What are the changes?
The most important change is that a Group 1 driver (car/motorcycle) who has had two or more episodes of hypoglycaemia requiring assistance from another person at any time (including when sleeping) in a year, must inform the DVLA, and will be advised not to drive. The same applies to a Group 2 driver (bus/lorry) with one or more episode(s) of hypoglycaemia requiring the assistance of another person in the previous year.
What is a reportable hypoglycaemic episode?
Hypoglycaemia requiring assistance from another person at any time constitutes an episode for reporting purposes. The requirement of assistance includes: • admission to Accident and Emergency • paramedic treatment • assistance from someone who has to administer glucagon or glucose because the person cannot do so themselves.
DIARY DATES 17 APRIL 2012 A New Strategy for NHS Procurement: Securing the Future of NHS Services Manchester Conference Centre, Weston Building, Sackville Street, Manchester M1 3BB Laura Lyons, Public Service Events • 01782 613924 • llyons@publicservice.co.uk • www.publicserviceevents.co.uk/211/ a-new-strategy-for-nhs-procurement
5–9 MAY 2012 International and European Congress of Endocrinology Fortezza da Basso, Viale Filippo Strozzi 1, 50129 Firenze, Florence, Italy BioScientifica Ltd, Euro House, 22 Apex Court, Woodlands, Bradley Stoke, Bristol BS32 4JT • 01454 642240 • 01454 642222 (fax) • ice-ece2012@bioscientifica.com • www.ice-ece2012.com
19 APRIL 2012 Healthy Lives, Healthy People: Improving UK Public Health Central London Inside Government, 22 Long Acre, Covent Garden, London, WC2E 9LY • 0845 666 0664 • 020 7550 5966 (fax) • enquiries@insidegovernment.co.uk • www.insidegovernment.co.uk/health/publichealthy/#agenda
12–15 MAY 2012 European Diabetes Epidemiology Conference The Village Hotel, Langdon Road (Off Fabian Way), SA1 Waterfront, Swansea SA1 8QY Liz Irvine • 01792 513430 (fax) • EDEG2012@ swansea.ac.uk • edeg.intelliopen.hu
20 APRIL 2012 18th Bart’s International Symposium: Diabetes Therapy 2012 The Great Hall, North Wing, St Bartholomew’s Hospital, London EC1A 7BE Stephanie Cunningham • 020 7882 2482 • 020 7882 2186 (fax) • stephanie.cunningham@qmul.ac.uk 20–21 APRIL 2012 Clinical Pharmacy Congress ExCeL London, One Western Gateway, Royal Victoria Dock, London E16 1XL Closer Still Media Healthcare Ltd, George House, Coventry Business Park, Herald Avenue, Coventry CV5 6UB • 01635 588483 • www.pharmacycongress.co.uk/ 23–25 APRIL 2012 RCN Annual International Nursing Research Conference Grand Connaught Rooms, 61–65 Great Queen Street, London WC2B 5DA Kathryn Clark, Conference and Events Manager, RCN Events • 020 7647 3585 • kathryn.clark@rcn.org.uk • www.rcn.org.uk/development/ researchanddevelopment/rs/research2012
Recent changes to the Driver and Vehicle Licensing Agency (DVLA) medical standards will have a significant impact on drivers with diabetes and those who complete medical reports. Nikki Joule, Senior Policy Officer at Diabetes UK, offers guidance on implementation and interpretation of the new standards It does not include another person offering or giving assistance, in circumstances where the person was aware of his/her hypoglycaemia and able to take independent action. Therefore, on reporting, great care is needed in eliciting an exact history of each episode. The Association of British Clinical Diabetologists (ABCD) (Gallen et al, 2012) recommends that primary care teams should consider specialist referral for patients who have suffered a single hypoglycaemic attack requiring assistance, especially where a second episode might result in loss of employment.
24 APRIL 2012 South London Health Innovation and Education Cluster (HIEC) Seminar: Recognising Depression in People with Diabetes 6th Floor Tower Wing, Guy’s Hospital, London SE1 9RT Aaron Hamilton, HIECluster Relationship Manager • 020 3049 4129 • aaron.m.hamilton@kcl.ac.uk • https://slondonhiec.org.uk/workstreams/ diabetes 26–27 APRIL 2012 Association of British Clinical Diabetologists Spring Meeting The Met Hotel, King Street, Leeds LS1 2HQ Elise Harvey, Red Hot Irons Ltd, PO Box 2927, Malmesbury SN16 0WZ • 01666 840589 • eliseharvey@redhotirons.com • www.diabetologists.org.uk/Shared_Documents/ ABCD_meetings/next_meeting.htm
Reporting severe hypoglycaemia
People may not proactively inform their doctor about hypoglycaemia, but reports may be sent from the ambulance team or Accident and Emergency to the person’s GP. If health professionals are informed that a patient has required treatment to manage hypoglycaemia, ABCD suggests that they are offered an appointment to explore the frequency and severity of these episodes. For Group 1 drivers, with two episodes requiring the assistance of another person within the previous year, the
EDITOR Susan Aldridge update@diabetes.org.uk
Code 6434
A focus on outcomes, rather than targets, is central to NHS reforms. What does this mean for diabetes services?
16 TALKING CLINIC The management of foot problems in diabetes
FACT FILE 10
NHS REFORMS – MOVING ON
15–16 MAY 2012 NICE Annual Conference The International Convention Centre, Broad Street, Birmingham B1 2EA Emap Limited, Greater London House, Hampstead Road, London NW1 7EJ • 0845 056 8339 • conferences@emap.com • www.niceconference.org.uk 15–18 MAY 2012 Diabetes Counselling Course Knuston Hall, Irchester, Northampton info@diabetescounselling.co.uk • www.diabetescounselling.co.uk. 23 MAY 2012 Northern Ireland Conference – New Horizons in Diabetes Care Hilton Templepatrick Hotel & Country Club, Castle Upton Estate, Templepatrick BT39 0DD Northern Ireland Florence Findlay White, Diabetes UK Northern Ireland, Bridgewood House, Newforge Business Park, Newforge Lane, Belfast BT9 5NW • 028 9066 6646 • florence.findlaywhite@ diabetes.org.uk • www.diabetes.org.uk/ In_Your_Area/N_Ireland/Professional-conferences 24 MAY 2012 12th Annual Plymouth ‘Diabesity’ Symposium on Obesity, Diabetes and the Metabolic Syndrome Postgraduate Medicine Centre, Derriford Hospital, Plymouth PL6 8DH Kerry Godley-McAvoy • 01752 763498 • 01752 792471 (fax) • Kerry.Godley-McAvoy@phnt.swest. nhs.uk • estore.plymouth.ac.uk/browse/extra_ info.asp?compid=1&modid=2&prodid=268&depti d=9&catid=30 24–27 MAY 2012 49th ERA-EDTA Congress Palais Maillot, Palais de Congrès, 2 Place de la Porte Maillot, Paris, France Via Spolverini 2, 43126 Parma, Italy • +39 521 989078 • +39 521 959242 (fax) • registrations@ era-edta.org • www.era-edta.org 30 MAY 2012 Ensuring the Effective Development and Delivery of Diabetes Services Central London Inside Government, 22 Long Acre, London WC2E 9LY • 0845 666 0664 • 020 7550 5966 • enquiries@insidegovernment.co.uk • www.insidegovernment.co.uk/health/diabetes
DIABETESUPDATE
EDITORIAL ASSISTANT Kate Flagg kate.flagg@diabetes.org.uk
14 JUNE 2012 One Day Essentials: Diabetes Manchester Profile Productions Ltd, Northumberland House, 11 The Pavement, Popes Lane, London W5 4NG • 020 8832 7311 • 020 8832 7301 (fax) • rcgp@ profileproductions.co.uk • www.rcgp.org.uk/ courses__events/one-day_essentials/diabetes_ manchester.aspx 17 JUNE 2012 RPS Medicines Safety Symposium Royal Institute for British Architects (RIBA), 66 Portland Place, London W1B 1AD Rachel Flower, Royal Pharmaceutical Society, 1 Lambeth High Street, London SE1 7JN • Rachel.Flower@rpharms.com • www.rpharms.com/conferences/medicines-safetysymposium.asp?intlink=hp_meds_safety_symp 18 JUNE 2012 13th Scottish Conference of the Diabetic Foot Journal: The Next Dimension of Diabetic Foot Care Hilton Glasgow Hotel, 1 William Street, Glasgow G3 8HT SB Communications Group, 1.3 Enterprise House, 1-2 Hatfields, London SE1 9PG • 020 7627 1510 • 020 7627 1570 (fax) • bookings@sbcommunicationsgroup.com • www.diabeticfootjournal.co.uk/eventsdetail. php?id=507 19 JUNE 2012 One Day Diabetes Update for GPs and Practice Nurses Stadium of Light, Sunderland SR5 1SU Diabetes UK Northern & Yorkshire, Sterling House, 22 St Cuthbert’s Way, Darlington DL1 1GB • 01325 488606 • www.diabetes.org.uk/ In_Your_Area/Northern__Yorkshire/Professionalconferences/ 23–26 JUNE 2012 ENDO 2012: the 94th Annual Meeting and EXPO George R. Brown Convention Center, 1001 Avenida de las Americas, Houston, Texas 77010 USA ENDO 2012 Registrar, c/o Experient, PO BOX 4088, Frederick, Maryland 21705-4088 • +1 301 694 5243 • +1 301 694 5124 (fax) • endo@experient-inc.com • www.endo-society.org/endo2012
DIARY DATES
17 April to 27 June 2012
27–28 JUNE 2012 Commissioning Conference 2012 Olympia Conference Centre, Hammersmith Road, London W14 8UX James Hall, Closer Still Media • 020 7348 5254 • j.hall@closerstillmedia.com • www.commissioningshow.co.uk 27–29 JUNE 2012 Heart UK 26th Annual Conference: Metabolic Syndrome, Obesity and Pre-Diabetes Newcastle Civic Centre, Barras Bridge, Newcastle upon Tyne NE1 8PP Natasha Dougall, Wheldon Events & Conferences, 93 Watling Street, Bridgtown, Cannock, Staffordshire WS11 0BG • 01543 503322 • 01543 466890 (fax) • wheldonevents@ btconnect.com • www.heartuk.org.uk
020 7424 1000 | info@diabetes.org.uk | www.diabetes.org.uk
A charity registered in England and Wales (215199) and in Scotland (SC039136). ©Diabetes UK 2011
DESIGNER/ART EDITOR John Clarkson
Diabetes Update is produced by Diabetes UK for all healthcare professionals with an interest in diabetes. Healthcare professional members of Diabetes UK receive Diabetes Update as a membership benefit. For more on receiving Diabetes Update, contact the Diabetes UK Supporter Services team on 0845 123 2399 or email supporterservices@diabetes.org.uk. ADVERTISEMENTS AND ARTICLES Articles in Diabetes Update written by freelance contributors do not necessarily represent the views of Diabetes UK. Diabetes UK policy statements are always clearly identified as such. Diabetes Update welcomes original contributions from healthcare professionals. All potential submissions should be made in writing for editorial consideration and should include a synopsis of the suggested feature or issue. All submissions should be sent to: Diabetes Update, Diabetes UK, 10 Parkway, London NW1 7AA or update@diabetes.org.uk. Products and services advertised in Diabetes Update are not necessarily recommended by Diabetes UK. Any comments regarding advertised services or products, or enquiries regarding future advertisement bookings, should be addressed to: Claire Barber, Display Sales Executive, Ten Alps Publishing, One New Oxford Street, High Holborn, London WC1A 1NU, 020 7878 2319, Claire.Barber@tenalps.com
Spring 2012 | DIABETESUPDATE | 3
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DIABETES UK 2012 PROFESSIONAL CONFERENCE HIGHLIGHTS More than 500 new research studies were presented at Diabetes UK’s Professional Conference 2012, held at the Scottish Exhibition & Conference Centre, Glasgow from 7–9 March. With around 3,000 delegates, the Professional Conference is one of the largest health conferences in the UK.
CALLS TO CURB PREVENTABLE AMPUTATIONS Diabetes UK has launched a campaign to bring an end to the thousands of potentially preventable amputations in people with diabetes, as new research has once again highlighted the unacceptably poor levels of footcare for people with the condition. ‘Putting Feet First’, launched at the Diabetes UK Professional Conference 2012, highlights the fact that people with diabetes are over 20 times more likely to have a lower-limb amputation than those without the condition, and that about 80 per cent of the 6,000 diabetes-related amputations in England every year could be prevented through high-quality diabetes footcare. A new report from the National Diabetes Information Service, presented at the Professional Conference, found that amputation rates are 10 times higher in some parts of England than in others. Meanwhile, a report from NHS Diabetes highlights the shocking cost to both patients and the NHS of poor-quality diabetes footcare: around £650m is spent on foot ulcers or amputations each year, and around 7 per cent of people with diabetes currently have, or have had, a foot ulcer, which can lead to amputation.
The ‘Putting Feet First’ campaign demands that everyone with diabetes has access to the high-quality footcare already available in some parts of the country, and aims to reduce diabetesrelated amputations by 50 per cent within five years. Diabetes UK is calling for healthcare professionals to support the campaign by making sure they understand the footcare that people with diabetes should be receiving – and the potentially devastating
consequences of this not happening. The charity is also raising awareness of the issue so that people with diabetes understand how important it is to look after their feet and check them regularly. Barbara Young, Chief Executive of Diabetes UK (pictured), said: “The sad fact is that there are large parts of the country where diabetes foot care is not good enough. Quality of care makes a big difference to amputation rates. Foot ulcers can deteriorate in a matter of hours, so failing to refer someone quickly enough can literally be the difference between losing a foot and keeping it. “Every amputation that results from poor healthcare is a tragedy. It is a scandal that needs to be brought to an end.” For more on the campaign and the footcare that people with diabetes should receive, see ‘Putting Feet First’, page 20, and visit www.diabetes.org.uk/putting-feetfirst. • Holman N, Young R and Jeffcoate W (2012). Variation in the recorded incidence of amputation of the lower limb in England. Published online on 7 March 2012: www. diabetologia-journal.org
Young adults receiving poor diabetes care Only a fifth of young adults aged 16 to 24 with diabetes receive all the health checks recommended by the National Institute for Health and Clinical Excellence (NICE), according to research presented at the Diabetes UK Professional Conference. The study analysed data from the 2009–10 National Diabetes Audit (NDA) to identify that those aged 16 to 24 are least likely of all age groups in England to receive the health checks and services they need. Diabetes UK has urged the NHS to do more to stop young adults with diabetes falling through the gap between paediatric and adult healthcare services. The study also found that although under-55s make up nearly a quarter (24 per cent) of people with diabetes, the same
demographic accounts for more than 60 per cent of end stage kidney disease in those with Type 1, and 15 per cent of those with Type 2 diabetes. More than one in 10 of all heart attacks and 15 per cent of major amputations in people with the condition occurred in this same age group. Data from the study also show that adults under 55 years old are less likely to achieve their target blood glucose levels than older people, with only half of those with Type 2 diabetes achieving the average measurement of blood glucose (HbA1c) treatment target. Lead researcher Dr Bob Young, from Salford Royal Hospital, said: “This study not only shows a gap in care for young people, but also highlights the negative outcomes that this can have in the way of serious
health problems. Care quality for younger people with Type 1 and Type 2 diabetes is poor. Systems of care for young and working-age people with diabetes should be specifically targeted for improvement.” Through its 15 Healthcare Essentials campaign, Diabetes UK aims to empower people with diabetes to take control of their care and influence the NHS to improve. The charity wants all people with diabetes to use the checklist of the 15 essential services that they should receive, or have access to, and to speak to their healthcare team if they identify any gaps in their care. Visit www.diabetes.org.uk/15-essentials for more on the campaign and to download a simple patient checklist.
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UP FOR AN AWARD The Diabetes UK Type 2 Diabetes Research award is presented for research contributing to the advancement of the understanding of Type 2 diabetes and its treatment. Shortlisted this year were:
BMI AND DIABETES A study for the Scottish Diabetes Research Network, presented by Jennifer Logue, University of Glasgow, sheds new light on the relationship between body mass index (BMI) and mortality in Type 2 diabetes. Previous research has given conflicting results over whether BMI is important in determining the life expectancy of an individual with diabetes. The researchers recorded BMI at diagnosis of Type 2 in a group of 106,640 participants and related it to all-cause and cause-specific mortality, using the BMI range 25–30 as a reference. Risk of all-cause mortality was higher among those with BMI 20–25 and among those with BMI 45–50. Mortality risk was lowest around BMI 30, which is five points higher than is found for the general population. The findings suggest more attention should be focused on those patients with Type 2 diabetes who are underweight.
Telephone service success An out-of-hours telephone support service for young people with Type 1 diabetes and their families could save the NHS £60,000 a year. Guidelines say that children with Type 1 should have access to specialist support 24/7. However, limited resources mean there may be gaps in provision. The East of England Paediatric Diabetes Network has sought to remedy this by piloting a service offering telephone advice between 5pm and 9am, and at weekends, to young people and their families. Analysis of the 16-week study showed there were 193 calls from 99 patients. Most calls were about hypoglycaemia, hyperglycaemia, ketonaemia and insulin problems. Seven clinicians and seven nurse specialists took the calls and, between them, saved 63 hospital attendances and 36 bed days, adding up to a yearly saving of £59,588, when the costs of the service are taken into account.
COGNITIVE DECLINE MARKER In a second short-listed presentation, PhD student Markéta Keller, University of Edinburgh, reported that a molecule involved in inflammation, interleukin-6 (IL-6), may act as a marker for cognitive decline in older adults with Type 2 diabetes. Her work is derived from the Edinburgh Type 2 Diabetes Study, which is investigating the effects of various risk factors on cognitive impairment in older adults with Type 2. Interleukin-6 was measured in a group of more than 1,000 adults aged 60 to 75 along with assessment of seven cognitive domains, including memory, verbal fluency and attention. Testing was repeated four years later. Increased IL-6 levels were associated with decline in non-verbal reasoning, which would affect a person’s problem-solving and forward-planning abilities and, therefore, have a severe impact on daily living. Ms Keller said: “Interleukin-6 has a direct effect on the brain, causing neuroinflammation and neural death.” People with diabetes are known to be at increased risk of cognitive decline and it is possible that therapies targeting IL-6 could be preventive. However, further research is needed to see whether IL-6 causes cognitive decline or whether it is merely associated with it. Analysis of a number of other inflammatory markers measured in the Edinburgh study is ongoing.
ALZHEIMER’S DRUG FOR DIABETES? Diabetes UK has part-funded research by a team at the University of Dundee, which has found that therapies known as BACE inhibitors, currently in clinical trials for Alzheimer’s disease, could also have a role in both prevention and treatment of Type 2 diabetes. The enzyme ß-secretase (BACE) is already known to play a role in the deposition of amyloid plaque in the brain in Alzheimer’s disease. Previously the Dundee team showed that BACE is also involved in the metabolism of glucose. In this new study, mice fed a high-fat diet to induce obesity and Type 2 diabetes were given either a BACE inhibitor or placebo. The former group became leaner within days and their insulin sensitivity improved significantly. “Our preliminary data suggest that BACE
inhibition could be a novel therapeutic target for prevention and treatment of Type 2 diabetes associated with obesity,” noted lead investigator Paul Meakin. This work was shortlisted for the Nick Hales Young Investigator Award, which is supported by Cambridge University NHS Foundation Trust.
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GOVERNMENT INACTION BLAMED FOR THE “SCANDAL OF EARLY DEATHS” The Government’s failure to match its words on diabetes healthcare with decisive action is responsible for the “scandal of early deaths and preventable complications” in people with diabetes, according to Barbara Young, Chief Executive of Diabetes UK. Speaking on BBC News on 21 February, ahead of an edition of Radio 4’s File on 4 on diabetes care, Barbara Young (pictured) called for the Government to make diabetes a much higher priority and to bring an end to the current situation where people with diabetes die an average of between 10 (for Type 2) and 20 (for Type 1) years earlier than the rest of the population. One of the reasons for this is that too few of them have access to all the health checks and services recommended by the National Institute of Health and Clinical Excellence. Barbara Young said: “The Government often says the right things but the fact is
that we are treading water when it comes to delivering quality diabetes healthcare. The stark fact is that people are dying and suffering dramatically reduced quality of life as a result of lack of political will. “Perhaps the most frustrating thing is that this is one of the few problems facing the Government that does not require more
SCOTTISH GOVERNMENT ANNOUNCES INSULIN PUMP INVESTMENT Diabetes UK Scotland has welcomed a Scottish Government announcement to invest more than £1m in delivering insulin pumps, after many years of campaigning by the charity and patient groups. All eligible under-18s with Type 1 diabetes will now have access to life-changing insulin pumps under plans announced on 27 February by the Scottish Health Secretary Nicola Sturgeon (pictured). Funding of at least £1m has been allocated to NHS Boards to help them deliver pumps to under-18s who need them, as well as tripling the number of pumps available to all people in Scotland. Nicola Sturgeon said: “Insulin pumps mean freedom from having multiple insulin jabs a day – giving Scotland’s youngest diabetics a normal childhood. By the end of March 2013, this treatment will be made available to the 480 children and teens struggling with Type 1 diabetes who could benefit from it. “Over the next three years, NHS Boards will also increase the number of insulin pumps available to all Scots to 2,000, tripling the current amount.” The youngest person in Scotland with an insulin pump, five year old Daisy Slatter, with Nicola Sturgeon
investment. A colossal amount of money is already being spent on diabetes – about 10 per cent of the NHS budget – but too much of it is being used to treat the complications of diabetes rather than to prevent those complications developing in the first place. “Healthcare professionals are constantly telling us how frustrated they are with the constraints the system places upon them and we want the Government and the NHS to give them the tools they need to provide the excellent care that people with diabetes deserve. It is time to stop just talking the talk on diabetes healthcare and start walking the walk.” To find out more about Diabetes UK’s campaign on the 15 essential health checks and services which all people with diabetes should be receiving on a regular basis, visit www.diabetes.org.uk/15-essentials
DRIVING UPDATE The Driver and Vehicle Licensing Agency (DVLA) is testing a redrafted form (DIAB1) that people are required to fill in when applying, or reapplying, for a driving licence. The new form explains more clearly what people are expected to report, following concerns about the definitions of ‘severe hypoglycaemia’, and the criteria used to assess fitness to drive. It is hoped that the redraft will ensure that fewer people will have their licences needlessly revoked, and reduce the delays that people experience in applying and reapplying for licences. The new form – introduced at the second meeting of the working group set up by Transport Minister Mike Penning MP, which includes Diabetes UK and Diabetes Voices campaigners – is being tested further among people with diabetes. Once the new form is finalised, Diabetes UK will produce guidance for people with diabetes going through the application process, along with the charity’s position statement. Diabetes UK and the Association of British Clinical Diabetologists have already produced guidance for healthcare professionals to help clarify the changes to the driving licence standards (see ‘Fact file’, inside this issue of Update). Further work with the DVLA to ensure that the process is fair, transparent, safe and efficient is ongoing. The charity is also liaising with colleagues in Europe to monitor the implementation of the changes. For more details, visit www.diabetes.org.uk/ new-driving-standards
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FreeStyle InsuLinx can say a lot about your patients.
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FreeStyle InsuLinx translates blood glucose and individual patient data into accurately calculated insulin dosing suggestions* for your patients. The on board FreeStyle Auto-Assist software allows time – saving access to tailored patient information for you. For In Vitro Diagnostic Use Only. * Data on file, Abbott Diabetes Care 2012
Ask your Abbott Diabetes Care representative about FreeStyle InsuLinx or for further information please visit
www.abbottdiabetescare.co.uk Blood Glucose Monitoring System
© 2012 Abbott Photographs contained herein are for illustrative purposes only. Not actual patients. FreeStyle and related brand marks are trademarks of Abbott Diabetes Care Inc. in various jurisdictions. ADCMDP120003
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GPS TO ‘PRESCRIBE’ SMARTPHONE APPS
Quality in Care awards
Health Secretary Andrew Lansley has called for GPs to direct patients to free or cheap smartphone apps that help patients and doctors better manage healthcare. A list of apps was created following a consultation exercise in which more than 500 apps were nominated and voted for by the public. Diabetes UK welcomes the fact that the Diabetes UK Tracker app for iPhone and iPod Touch is one of the apps recommended by the Department of Health initiative. The app provides the user with a place to log blood glucose, blood pressure and blood fat levels; and results can be visualised across days and weeks to help recognise trends. It also allows the user to record their feelings, share their data with their healthcare team, and save specific records as ‘talking points’ for healthcare appointments.
The second Quality in Care (QiC) Diabetes programme was launched at the Diabetes UK Professional Conference 2012, to once again recognise good healthcare practice in diabetes in the UK. Supported by Diabetes UK, NHS Diabetes and Sanofi, QiC Diabetes 2012 comprises both an awards event, to be held at Sanofi’s Guildford headquarters on 18 October 2012, and subsequent opportunities for finalists to explain why their efforts were successful to a wider healthcare audience, including presenting at Diabetes UK’s Professional Conference. Entries are invited for initiatives and programmes launched between January 2008 and December 2011, from anyone working in the diabetes arena. The entry deadline is 25 May 2012. Simon O’Neill, Director of Care, Policy and Intelligence at Diabetes UK, said: “Diabetes UK is delighted to continue its support of QiC Diabetes. The standard of entries in the first year was outstanding and has enabled us to share and learn from best practice in the field of diabetes care. We look forward to seeing even more examples of excellence through the second QiC Diabetes programme.”
The free Diabetes UK Tracker app is available free from the iTunes App Store.
PORTABLE KNOWLEDGE The pocket-sized Clinical Pocket Reference: Diabetes has been comprehensively updated to reflect the latest developments in core knowledge and best practice in diabetes management, with emphasis on patient self care, new therapeutic approaches and current views on blood glucose monitoring. Authored by Anita Thynne, Sue Cradock, Michael Cummings, Lisa Skinner, (Academic Department of Diabetes and Endocrinology, Queen Alexandra Hospital, Portsmouth) and Francesca Arundel (West Sussex Primary Care Trust), the pocket reference provides a brief introduction to the main clinical features of diabetes, followed by overviews of daily management and self care, acute care, and continuing care and complications. The final pages are devoted to key transient issues for patients with diabetes: steroid therapy, surgery, fasting, pregnancy and travel. All sections are fully referenced to enable further study of each topic covered. Readers’ discount Professional members of Diabetes UK can receive a 15 per cent discount and purchase Clinical Pocket Reference: Diabetes (second edition) for just £8.50 (RRP £9.99). Postage is free. To take up this offer, visit www.clinicalpocketreference.com and use the code ‘CN2011’ when you have placed the book in the shopping basket.
SANOFI UPDATE Following a shortage, a new supply of Sanofi’s Apidra SoloStar and Apidra cartridges, for use with the ClikStar pen, became available at the beginning of February. The temporary shortage was due to a technical incident at a manufacturing site, which interrupted production. Sanofi has been working closely with the Department of Health and the supply chain to try to ensure that supplies are available with the minimum of disruption. However, as Sanofi will be receiving deliveries on a weekly basis initially, the company asks that healthcare professionals limit individual prescriptions to no more than three months supply in the first instance. Subsequent prescriptions can be written as usual. As previously communicated Apidra OptiSet and Apidra cartridges for OptiClik presentations were discontinued at the end 2011 and as such no further supply of Apidra OptiSet and Apidra cartridges for OptiClik presentations will be made available. None of the other Sanofi insulin products (Lantus, Insuman) have been affected. Apidra Sanofi Medical Information line: 0800 281973.
For further details, including 2011 winners, categories and how to enter, visit www.qualityincare.org/awards/diabetes/ qic_diabetes_2012.
Analogue insulin Diabetes UK has updated its position statement on the use of analogue insulin. The charity recommends that all insulin analogues should be available to people with diabetes in the same way as human or animal insulin. However, the decision of which insulin is most appropriate should be made between the person with diabetes and their healthcare team. It should follow National Institute for Health and Clinical Excellence guidance that human insulins should, in general, be tried as first-line treatment, with analogues being introduced if optimal control cannot be attained. Diabetes UK would like to see pharmaceutical companies addressing the issue of cost to ensure that new and novel therapies are affordable in the current climate, and are supported by robust evidence of superiority to established therapies. Read the position statement at www.diabetes.org.uk/analogue-insulin.
8 | DIABETESUPDATE | Spring 2012
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H h a d
T a
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Help your patients detect hypoglycaemia with automatic low pattern detection.
The glycaemic self-management system suitable for Type 1 and Type 2 patients on intensive insulin therapy.
OneTouch® Verio®Pro is the first meter from OneTouch® with a High and Low Pattern Messenger that is always searching for low blood glucose patterns and automatically notifies your patient when they occur. Easy to use, it sends clear, easy to understand messages so they can consider if therapy adjustment is needed. Patients on intensive insulin therapy prefer to use a meter like OneTouch® Verio®Pro.*
For further information please call: OneTouch® Customer Care on 0800 279 4142 (UK) quoting code AE170 Lines open 8.30am-6pm Mon-Fri, 9am-1pm Sat
www.LifeScan.co.uk *71.3% of 101 subjects in the OneTouch® Verio®Pro High and Low Patterns Tool Product Claims and User-Experience Study (2011) said they would prefer to use a meter with messages compared with 9.9% of subjects who said they would prefer to use a meter without messages. Data on file. LifeScan, LifeScan Logo, OneTouch®, OneTouch® Verio®Pro are trademarks of LifeScan Inc. © 2012 LifeScan, Ortho-Clinical Diagnostics. AW 098-837A 12-005
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NEWS
NICE APPROVES BYDUREON The National Institute for Health and Clinical Excellence (NICE) has issued its final guidance on the use of Bydureon (prolongedrelease exenatide) as a treatment option for people with Type 2 diabetes. Bydureon is recommended for use in triple-therapy regimens (in combination with metformin and a sulphonylurea, or metformin and a thiazolidinedione) in people with Type 2 diabetes whose blood glucose levels are not well controlled and have other risk factors, including a body mass index (BMI) of 35 or above. It can be used in patients with a BMI below 35 if treatment with insulin has presented problems. Bydureon in dual-therapy regimens (in combination with metformin or a sulphonylurea) is recommended as a treatment option for people with Type 2 diabetes only if the patient is intolerant of
ARE YOU READY TO HELP YOUR PATIENTS MAKE THE DIABETES CONNECTION? Diabetes Week 2012 – Diabetes UK’s annual awareness and fundraising drive – runs from 10 June to 16 June this year and is calling on healthcare professionals to get connected and get involved. Using the theme ‘make a connection’, Diabetes UK is aiming to use Diabetes Week 2012 to connect with more people living with the condition, more people at risk of developing Type 2, and to connect more people with diabetes with each other, with the health services they need and with the care and support that is provided by Diabetes UK. Healthcare professionals can get involved by downloading a Diabetes Week pack online from mid April. The pack includes a variety of posters that can be displayed in clinics and GP surgeries to help raise awareness among patients and help those affected by, and at risk of, diabetes learn more about the services available from Diabetes UK. Download a Diabetes Week 2012 pack at www.diabetes.org.uk/diabetesweek
either metformin or a sulphonylurea, or a treatment with metformin or a sulphonylurea is contraindicated, and if the person is intolerant of thiazolidinediones and dipeptidyl peptidase-4 (DPP-4) inhibitors, or a treatment with thiazolidinediones and DPP-4 inhibitors is contraindicted. NICE recommends that treatment with Bydureon should only be continued if tests show a beneficial effect after six months. For details, visit http:// publications.nice.org.uk/ exenatide-prolongedrelease-suspension-forinjection-incombinationwith-oralantidiabetictherapy-ta248
Foot of the Bed innovation The diabetes footcare team at Ipswich Hospital has developed a simple, yet effective, way of ensuring that more diabetes inpatients receive foot assessments. The ‘Foot of the Bed’ (FoB) check includes a risk list, daily heel check and the Ipswich Touch Test, a simple neuropathy test. Over two weeks, 167 nurses and healthcare assistants were trained in FoB and passed the training on to nurses and healthcare assistants. Before the introduction of FoB, only 27 per cent of inpatients at Ipswich were receiving their foot assessments. Ten months into the initiative, the figure had risen to 80 per cent. Diabetes specialist nurses validated the FoB form and found that it identified all patients with neuropathy. See also ‘Care Delivery’, page 36.
Peer support Diabetes UK has launched a new support scheme for people living with diabetes called Peer Support. Healthcare professionals are being encouraged to refer people patients to the scheme, which connects people with diabetes with specially trained peers who will be able to offer emotional support. All volunteers have diabetes themselves and are on hand to talk through issues such as recent diagnosis, adjusting to an insulin pump, complications and relationships. The service is completely confidential, safe and secure. Peer Support is currently a pilot scheme which is expected to grow dramatically over the next six months. The Peer Support helpline can be contacted by calling 0843 353 8600 during open hours (see below) or by visiting www.diabetes.org.uk/peer-support at any time for the email service and further information. Service open hours for telephone support are: Wednesday: 12–3pm; Friday: 9–12 (midday); Sunday: 7–10pm.
GET INVOLVED Diabetes UK has a wide range of fundraising events coming up in 2012 and is calling out for as many people as possible to take part to help raise vital funds. Without supporters’ fundraising efforts, the charity could not deliver the range of products and services that it provides for people with diabetes, their friends, family and carers. Even a small amount of sponsorship money can make a difference.
Running, walking, cycling and swimming are great ways to raise funds while improving fitness, and there are events held across the UK and as far afield as Paris, New York, Kilimanjaro and Rajasthan. For those who would prefer something less active, there are coffee mornings, charity lunches, concerts, quiz nights and themed parties. And, of course, people are also invited to think up their own unique challenges. If you would like to help raise funds for Diabetes UK visit www.diabetes. org.uk/fundraise for a list of events.
10 | DIABETESUPDATE | Spring 2012
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Dr Richard Elliott brings you the latest developments in diabetes research and the next round of funding application deadlines
RESEARCH FOCUS
THE RISK OF BIRTH DEFECTS AMONG WOMEN WITH DIABETES A study funded by Diabetes UK has shown that pregnant women with diabetes are almost four times more likely to have a baby with a birth defect than women without diabetes. The findings also reveal that the mother’s blood glucose level at the time of conception is the most important factor in predicting the risk of such defects. It is already known that diabetes in pregnancy is associated with a higher risk of various complications but this project, led by researchers at Newcastle University and the Regional Maternity Survey Office, provides further evidence to support and quantify this link. The study involved an investigation of the recorded outcomes of 401,149 pregnancies, including 1,677 pregnancies in women with diabetes, between 1996 and 2008 in the north of England. The analysis suggested that around 7 per cent of pregnancies in women with Type 1 or Type 2 diabetes are affected by a major congenital anomaly (compared to around 2 per cent in women without diabetes). UK medical guidance already addresses this risk. The researchers and Diabetes UK stress that the vast majority of pregnancies in women with diabetes do not involve a birth defect. Nevertheless, the results have prompted the charity to urge women with diabetes who are considering becoming pregnant to ensure they understand the importance of careful planning.
“Pregnant women with diabetes are nearly four times more likely to have a baby with a birth defect” Dr Iain Frame, Director of Research for Diabetes UK, said: “The real message from this study is that the blood glucose level of the mother is important to the risk. This study offers clear evidence that although women with diabetes might still have a higher risk of a birth defect, they can still do something positive to reduce that risk by carefully monitoring their blood glucose level and trying to reduce it if it is high. “We need to get the message out to women with diabetes that if they are considering becoming pregnant, then they should tell their diabetes healthcare team,
who will make sure they are aware of planning and what next steps they should be taking. Blood glucose control continues to be important throughout pregnancy and should be closely monitored to ensure the best result for the baby – this is why women should be as prepared as possible beforehand. “It also highlights the importance of using contraception for women with diabetes who are sexually active but not planning to become pregnant. This is because as well as high blood glucose levels increasing the risk of birth defects, some medications taken by people with Type 2 diabetes can cause problems in the developing foetus, and higher doses of folic acid are needed for women with diabetes to reduce the risk of complications such as spina bifida.” Dr Ruth Bell, the study’s lead researcher, said: “The good news is that, with expert help before and during pregnancy, most women with diabetes will have a healthy baby. The risk of problems can be reduced by women taking extra care to have the best possible glucose control before becoming pregnant. Any reduction in high glucose levels is likely to improve the chances of a healthy baby.” The original article, in Diabetologia, can be downloaded at www.springerlink.com/ content/0012-186x186x/?k=Bell
NEW LINK BETWEEN KILLER T-CELLS AND TYPE 1 Researchers in Cardiff and London have, for the first time, visualised the mechanism that leads killer T-cells to destroy insulinproducing beta cells in the pancreas. It is hoped that this new insight into the autoimmune attack that causes Type 1 diabetes will help scientists to devise new ways of preventing, or even halting, Type 1. The exact mechanism by which the immune system destroys the body’s capacity to make insulin in people with Type 1 is not fully understood, but increasing evidence points toward rogue killer T-cells. Professor Andy Sewell from Cardiff University and researchers from King’s College London isolated a T-cell from a patient with Type 1 diabetes. They then used state-of-the-art X-ray crystallography experiments to view the interaction of the cell’s surface receptor with a fragment of insulin presented on the surface of a beta cell.
T-cells (red, left) attacking a beta cell, revealed by groundbreaking experiments that shed light on the mechanism of Type 1 Their findings show that the T-cell receptor recognised the beta cell via an abnormal and highly focused mode of binding. The researchers believe that this
unusual binding allows rogue killer T-cells to survive the culling process that would normally eliminate such cells when they begin to attack the body’s own tissues. “This first sight of how killer T-cells make contact with the cells that make insulin is very enlightening, and increases our understanding of how Type 1 diabetes may arise,” said Professor Mark Peakman of King’s College London, the study’s coauthor. “This knowledge will be used in the future to help us predict who might get the disease and also to develop new approaches to prevent it. Our aim is to catch the disease early before too many insulin-producing cells have been damaged.” The study was published in Nature Immunology in January and the paper can be accessed at www.nature.com/ni/journal/ vaop/ncurrent/full/ni.2206.html Spring 2012 | DIABETESUPDATE | 11
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RESEARCH FOCUS
British and French researchers have found new evidence to suggest that people who carry rare genetic mutations in a receptor for the ‘body clock’ hormone melatonin have a much higher risk of Type 2 diabetes. Melatonin controls the body’s cycle of waking and sleeping and affects drowsiness and body temperature. It is also known to regulate the release of insulin. Previous studies have shown that people who work night shifts have a higher risk of Type 2 diabetes and heart disease. Meanwhile, volunteers who had their sleep disrupted repeatedly for three days temporarily developed the symptoms of diabetes. People with common variations in the gene for MT2 (a receptor for melatonin) are also known to have a slightly higher risk of Type 2 diabetes. The research team, led by Professor Philippe Froguel, examined mutations in the MT2 gene in thousands of individuals and then tested their effect on the MT2 receptor in human cells in the lab. They identified four rare mutations that rendered the receptor completely incapable of responding to melatonin and led to a six-fold increase in the risk of Type 2.
The researchers now believe that genetic variations such as these may disrupt the link between the body clock and insulin release. It may be that this leads to abnormal control of blood glucose and thereby contributes to the development of diabetes. Cataloguing these variations should help scientists to assess a person’s risk of diabetes more accurately and could lead to the development of personalised treatments. Dr Iain Frame, Director of Research at Diabetes UK, said: “Genetic studies like this one are useful as they can help us understand how a person’s genetic makeup can influence their risk of developing Type 2 diabetes.” “Though we are still at an early stage, the more we understand about the effect of these genetic differences, the more likely it is that we will be able to design new drugs or apply existing drug treatments for people with Type 2 diabetes.” The study was published in Nature Genetics in January and the original article can be found at www.nature.com/ng/ journal/vaop/ncurrent/full/ng.1053.html
HENNING DALHOFF / SCIENCE PHOTO LIBRARY
BODY CLOCK RECEPTOR LINKED TO TYPE 2
Artwork showing how the hormone melatonin (blue spheres) is secreted in the brain and helps to control the body’s biological clock. Melatonin is produced naturally by the pineal gland (purple). Secreted at night, melatonin helps induce sleep and set the biological rhythms of the body. When light enters the eye (left), melatonin secretion shuts down.
Health benefits of exercise linked to ‘self-eating’ A study by researchers at the University of Texas Southwestern Medical Center in Dallas suggests that the health benefits of exercise might derive from the ability of the body’s cells to ‘devour’ themselves. Exercise conveys a wide range of health benefits and protects against many different illnesses, including heart disease and dementia. It also protects against diabetes by increasing glucose uptake. However, the cellular mechanisms underlying this process are unclear. Dr Beth Levine and her team used genetically modified mice to test the theory that exercise improves health by promoting a process known as ‘autophagy’. Sometimes referred to as a ‘housekeeping’ pathway, autophagy (from the Greek word for ‘self-eating’) is the process by which cells scrap and recycle abnormal, surplus or degraded proteins and other cellular components in order to respond to external stresses and produce extra energy. To develop their theory, the researchers focused on one specific health benefit of exercise: the prevention of abnormalities in blood glucose levels related to a high-fat diet. They first established that exercise tended to stimulate autophagy in mice.
However, mice that were genetically The study was published in the journal incapable of increasing autophagy in Nature – the original article is available at response to exercise failed to experience www.nature.com/nature/journal/v481/ the typical benefits of exercise on blood n7382/full/nature10758.html glucose metabolism. In comparison, the early signs of diabetes were reversed in mice that had not been genetically modified. The researchers conclude that exerciseinduced autophagy appears to help cells fine-tune their uptake of blood glucose and Dr Levine suggests that drugs which boost autophagy could potentially be used to mimic these effects. “Our finding that exercise fails to improve glucose metabolism in autophagydeficient mice strongly suggests that autophagy is an important mechanism by which exercise protects against diabetes,” she says. “It also raises the possibility “Autophagy that activation of is an autophagy may important contribute to other health mechanism benefits of exercise, by which including protection exercise against cancer, protects neurodegenerative against diseases and ageing. diabetes”
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RESEARCH FOCUS
RESEARCH APPLICATION DEADLINES 1 June Diabetes UK Project Grants – Project Grants provide support for high-quality, diabetes-related research. Support may be requested for up to five years. There is no limit to research expenses that may be requested. However all requests must be fully justified. 1 June Diabetes UK Equipment Grants – Equipment grants enable the purchase of a specific large item of multi-user equipment necessary for diabetesrelated research projects. Throughout the year The European Foundation for the Study of Diabetes – Albert Renold Travel Fellowships for Young Scientists (up to €7,000, £5,828 ) enable young scientists to travel and work at other institutions for up to three months to learn different scientific techniques related to diabetes research. Either the home or the host institution must be based in Europe or an associated country. Throughout the year Diabetes UK – Small Grants (up to £15,000) enable researchers to undertake small research projects or pilot studies related to diabetes. Applications can be submitted anytime.
It’s never too late to learn It is sometimes thought that if a person has had diabetes for a long time, they will have developed ingrained habits, and be resistant to change. Jackie Elliott, of the University of Sheffield, and co-workers in Glasgow and Nottingham, set out to challenge this view. They looked at whether the outcomes from the Dose Adjustment for Normal Eating (DAFNE) programme depended upon how long a person had had diabetes. A total of 479 people with diabetes were recruited from the DAFNE research database from 10 centres around the country. Their age range was between 17 and 74 and duration of their diabetes from one to 55 years. Biomedical and psychosocial data were collected both at baseline and 12 months after completion of the DAFNE programme. At one year follow up, HbA1c had decreased only modestly, which is in line with what other studies have found on the impact of DAFNE and an issue that needs addressing separately. However, there were significant decreases in the number of hypoglycaemic episodes from 393 to 99 on average. Meanwhile, the percentage of those experiencing episodes of diabetic ketoacidosis decreased from 9.5 per cent to 2.5 per cent as a result of DAFNE training. Diabetes distress, as measured by the Problem Areas in Diabetes questionnaire, and anxiety and depression, were also reduced as a result of taking the DAFNE programme, so participants’ quality of life increased. None of the results were influenced by the duration of diabetes. Those who had been living with diabetes for many years had as much to gain from DAFNE as those who had only been recently diagnosed. “It is not just those with short-duration diabetes who can be taught not to have hypos,” observed Ms Elliott. Therefore, long duration of diabetes should not be a barrier to offering the individual structured education programmes such as DAFNE. These findings relate to just the first 479 subjects and more data is now being analysed.
RESEARCH OPPORTUNITIES FOR PATIENTS Diabetes UK-funded researchers at the University of Dundee are currently recruiting people with Type 1 diabetes or Maturity Onset Diabetes of the Young (MODY) aged 16 or older who are living in Scotland. The researchers need help to develop a ‘bioresource’ of blood, urine and DNA samples from 10,000 people with Type 1 and MODY that will be used to improve the study of both conditions and could lead to the development of new treatments. Contact Bridget Shepherd at b.z.shepherd@dundee.ac.uk or 01382 632 353 for further information. Researchers at the University of Oxford are recruiting people with Type 2 diabetes aged 50 or older with a history of heart disease, stroke or poor circulation to an international trial of a drug that lowers blood glucose. The study, being led
by Professor Rury Holman, will test whether adding the drug sitagliptin to existing diabetes care can reduce the likelihood of cardiovascular problems. Visit www.diabetes.org.uk/ international-therapy-trial for further information and details of how to register. University of Southampton researchers are looking for people aged over 18 who have diabetes and depression to help improve a questionnaire that is designed to explore how people make sense of and manage both conditions. Participants should visit www. isurvey.soton.ac.uk/2776 to complete the survey. For further details or to obtain a hard copy of the survey, call Jenny McSharry, University of Southampton on 023 8024 1047 or email jem1d08@soton.ac.uk
VITAMIN D AND DIABETES New research at Aberystwyth University’s Department of Sport and Exercise Science aims to find out if there is a link between low levels of vitamin D and Type 2 diabetes. An increasing body of research links low levels of vitamin D with a number of medical conditions, including multiple sclerosis, depression, Type 1 diabetes and cardiovascular disease. The study, involving 150 volunteers over a year, is being lead by Ffion Curtis, of the Physical Activity in Ageing, Rehabilitation and Health research group. She said: “The number of people with Type 2 diabetes is increasing dramatically world-wide. At the same time people’s lifestyles are changing; they are spending less time out in the open and as a consequence see less sunlight which is essential for the synthesis of to vitamin D. “The aim of our study is to establish whether the lack of vitamin D is leading to more people developing this form of diabetes. If this is the case, it may then be possible to advise people on how they can manage the condition without medication, or prevent its onset, possibly by taking vitamin supplements or eating foods high in vitamin D.” In the same department, Fergus Guppy is researching the relationship between glucose control and bone health, and the role exercise can play in managing the conditions. He is adopting X-ray imaging methods of assessing bone health alongside blood markers of bone turnover. The use of both methods will enable a fuller understanding of the response in bone and glucose control to exercise and to examine any relationships between the two conditions. www.aber.ac.uk/en/sportexercise/research/health/ diabetes/vitamind
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COMMENT SIGNS
AND ACTION
Early diagnosis is crucial for good
FRIDAY 25 MAY management of Type 2 diabetes. Once you have treatment and CHANNELS the condition is under control,
LF GO CHALLENGE
LOOK OUT FOR THE SIGNS
any symptoms you previously experienced will normally disappear. However, in Type 1 diabetes symptoms will appear more
suddenly and dramatically. CHANNELS GOLF CLUB How do you know if you have diabetes? TAKE ACTION
RAISE
Type 2 diabetes develops gradually. Sometimes it takes years to realise something is wrong, and first signs may be barely noticeable.
S FUND VITAL
Everyone experiences different
Watch out for these FORsymptoms. changes in your body: ETES DIAB • blurred vision H ARC RESE • excessive thirst
• genital itching or regular episodes of thrush • passing more urine than normal, especially at night • slow healing of cuts and wounds • unexplained weight loss. If you have any of these, ask your doctor about a diabetes test.
S ES 300 ACR UL OF BEAUTIFUL PARKLAND
Think you have Type 2 diabetes, or are at high risk of developing the condition? Then make an appointment to see your GP or practice nurse at once. Do not wait.
S 18 HOLES
Y AY DA 1D
The sooner you find out if you have diabetes, the sooner you can get the right care that will reduce your risk of serious ill health or complications. You will also learn how to manage your diabetes and make changes to your lifestyle. We can also help you. Call the Diabetes UK Careline on 0845 120 2960 for support and information or email careline@diabetes.org.uk.
holes of golf, rolls upon arrival, 18 Tea/coffee and bacon day, a two course meal in the evening nal services on the per team of four. professio Entry fee just £240 www.diabetes.org.uk and competition prizes! A charity registered in England and Wales (215199) and in Scotland (SC039136). © Diabetes UK 2012
/channels2012
at www.diabetes.org.uk
MEASURE UP FOR A HEALTHY LIFESTYLE
THE
WELL WALK
IF YOUR
WAIST
GET
ELL STAY W WELL
IS BIGGER THAN THIS You could be at risk of Type 2 diabetes. ROUNDHAY PARK, LEEDS Sunday 24 June 2012, 11am
Help yourself to stay healthy by joining
us on this four mile walk.
Entry fee adults £5, children £2, family of four £12 For more information: Telephone 01325 488606 Email northyorks@diabetes. org.uk or visit www.diabetes.org.uk/wellwalklee ds
Book diabetes.org.uk 250) email: louise.rout@ CM8 2TL. 501 390 (fax: 01376 505 Station Road, Witham, For details call: 01376 Floor, 8 Atlantic Square, Diabetes UK Eastern, Ground For information on how to take care
www.diabetes.org.uk
of your feet and Diabetes UK’s Putting
A charity registered in England and
Feet First campaign visit
Wales (215199) and in Scotland (SC039136).
RAISING OUR PROFILE Diabetes UK has a new brand and a new logo. Our strapline ‘care.connect. campaign’ encapsulates our vision for people with diabetes. Louise Ansari, Diabetes UK’s Director of Communications, explains
This rebranding exercise is far more than just a change of colour scheme and a new logo. It goes straight to the heart of who we are and what we do
D
iabetes health professionals are only too well aware that they are dealing with a serious, misunderstood and growing condition. Diabetes currently affects 3.7 million people in the UK, with a further 7 million at risk. That is more than 10 million people that we need to connect with. We have a tough challenge on our hands as we aim to ensure that diabetes is taken as seriously as cancer and heart disease. We believe that the Diabetes UK re-branding will help us to raise our profile and improve the impact of the work that we do in caring for and campaigning on behalf of everyone affected by or at risk of diabetes. Evidence has suggested that the previous brand did not clearly communicate to people who we are, what we do and why they should connect with us. We therefore decided to introduce a more assertive brand, to improve public awareness of both the charity and the condition and to ensure that we appear relevant to everyone affected by or at risk of diabetes. Of course, times are tough and uncertain. All medical and health charities are having to work harder for support. We believe it is more important than ever before to raise the profile of diabetes and Diabetes UK. Inevitably, you may have concerns about the cost of this process. That is why we intend to carry out the re-branding exercise in as cost-effective a way as possible. The new brand is to be phased in gradually and we will use up existing stocks of materials until they run out. Diabetes UK’s new brand has been developed in consultation with people with Type I and Type 2 diabetes, and many other stakeholders, including healthcare professionals, parents of children with Type 1, supporters, volunteers and staff. Central to the new logo (see above) is the strapline ‘care.connect.campaign’. This is designed to communicate clearly, at a glance, who we are and
what we do. We provide care so that people can manage their diabetes effectively, we connect people with diabetes with one another and the services they need, and we campaign and fund research in order to create a better future for people with diabetes and those at risk. Barbara Young, Diabetes UK Chief Executive, said: “This re-branding exercise is far more than just a change of colour scheme and a new logo. It goes straight to the heart of who we are and what we do. The number of people living with diabetes is set to reach 5 million by 2025. An unacceptably high number of these will develop severe and even life-threatening complications including heart disease, stroke, blindness, kidney disease and amputation. A tough challenge like this needs a strong brand.” Becoming a more visible organisation through the new brand will help drive our campaigns during 2012. First, Diabetes UK intends to continue its work with The Driver and Vehicle Licensing Agency to influence its policy on driving and nocturnal hypoglycaemia. We will also be ensuring that as many people as possible understand the 15 healthcare essentials they should be receiving. We will focus our work with the NHS on places where these standards are not being met. We will also be keeping a clear focus on the distinctive needs of people with Type 1 and Type 2 diabetes. And we are committed to addressing the issues that are important to parents of children with Type 1. Diabetes UK will be launching a major campaign to get a better deal for children with diabetes. Finally, the complications of diabetes are a risk for everyone, whether they have Type 1 or Type 2. This is why we have just launched a major campaign to ensure that all people with diabetes get the regular foot care and services they need in order to reduce the risk of devastating amputation.
14 | DIABETESUPDATE | Spring 2012
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MD_D00
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TALKING CLINIC
Photo: Crown Copyright
Rachel Berrington: Louise, can you remind us why the foot is such a problem area for people with diabetes?
THE MANAGEMENT OF FOOT PROBLEMS IN DIABETES Foot problems present a major threat to some people with diabetes and account for 20 per cent of the total cost of diabetes care in the UK. However, 80 per cent of amputations arising from foot problems are preventable with appropriate care. Here, consultant podiatrist Louise Stuart discusses management of the foot in diabetes with senior diabetes specialist nurse Rachel Berrington
Louise Stuart: First of all Rachel, it’s important to say that not all people with diabetes develop problems with their feet and that the majority of foot problems that occur in diabetes are preventable and treatable. However, foot ulcers are more common in people who have diabetes. There are as many as 70 amputations occurring each week in England alone, many of which could have been avoided if only early intervention had been sought. There are two main reasons why foot ulcers are more common when you have diabetes. Firstly, sensation in the foot may be reduced or, more specifically, the person may have neuropathy. This is a condition that develops over time and can be accelerated when glycaemic control is poor. Once you have established that your patient has neuropathy it can be quite challenging getting him or her to recognise that they have sensory loss. It is then crucial that you explain the risk of developing foot problems as a consequence of this loss of feeling. Many people with diabetes are not actually aware of lost sensation, as it happens gradually. So it is the responsibility of the healthcare professional who has identified the neuropathy to explain the implications to their patients and have a full discussion with them. I often see people who remember having their foot tested for sensory loss, but really have no idea what the result of the test was or what living with sensory loss may mean. When our patients can’t feel pain they do not recognise injury to the foot and continue walking about on it. Then, what starts as a simple wound very quickly deteriorates to an infected wound needing urgent specialist attention. RB: And the second reason for foot problems in diabetes? LS: The reduced blood supply to the foot is the other main cause of foot ulcers in diabetes. As you are probably aware, peripheral arterial disease is four times as common in people who have diabetes. Disease of the foot due to ischemia and/or neuropathy, often presenting with infection, can take months to heal and the proper management of such problems is specialist
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territory. In short, proactive organised management is required. RB: Yes, because delays in access to expert attention do often lead to devastating consequences for people with diabetes, increasing the likelihood of delayed healing and even amputation. How can we best avoid this? LS: All people with foot ulcers should have access to a structured foot care service that is able to provide expert assessment and
IN CONVERSATION
management of foot problems. If you identify a foot ulcer you really do need to take prompt action. As the National Institute for Health and Clinical Excellence recommends, refer patients with acute foot problems, such as new ulcers or sudden swelling or discolouration to the foot, to a multidisciplinary foot team (MDT) within 24 hours wherever possible. RB: If a nurse or GP were to ask us about the key to good management of the foot in diabetes, what do you think we should be telling them?
Louise Stuart is a consultant podiatrist for Pennine Acute NHS Hospital Trust, where she leads the community arm of a busy multidisciplinary diabetes foot care service, working in partnership with the hospital team. She is an enthusiastic member of the diabetes world and is committed to improving the delivery of care for people with diabetes. For the past eight years Louise has worked closely with Diabetes UK in developing national improved standards of foot care for people with diabetes. Nationally Louise represents diabetes foot care on Diabetes UK’s Council for Healthcare Professionals. She also chairs Foot in Diabetes UK, which is a multidisciplinary national specialist interest group representing more than 2000 healthcare professionals involved in the care of people with diabetes-related foot complications. Louise has contributed to the delivery of the National Minimum Skills Framework for the commissioning of diabetes foot care services and, more recently, has been involved in the development of national guidelines for the specialist management of diabetes foot-related complications. In June 2008 Louise was awarded an MBE for services to allied health professionals. Rachel Berrington is a senior diabetes specialist nurse working within the University Hospitals of Leicester NHS Trust, where she has led the multidisciplinary foot clinic across two sites for the past four years and is a key member of the inpatient foot outreach team. Rachel is a dedicated and passionate member of the team, striving to improve better care and outcomes for inpatients and outpatients with active diabetic foot disease. An experienced diabetes educator, Rachel delivers Dose Adjustment for Normal Eating (DAFNE) and lecturies on the Diabetes MSc module. She is also a member of the Foot in Diabetes UK committee and, in 2010, become an independent nurse prescriber, which has enhanced her role within the multidisciplinary foot team. Rachel is currently leading on the implementation of casting for diabetic foot guidelines.
LS: In a nutshell? Make sure patients know their level of foot risk and are able to contact an expert for help in the event of a problem. To
When our patients can’t feel pain they do not recognise injury to the foot and continue walking about on it expand on that, I’d say encourage your patient to check their feet daily. In cases where the patient can’t actually get to their feet, I always suggest they use a mirror to aid the foot inspection. Alternatively, a spouse or carer should inspect the foot for them. However, I’ve found that just asking people to inspect their feet really does not mean a great deal. You need to spell out exactly what they should be looking out for. So, for example, stress that they should look for any areas of redness, any infection or new breaks in the skin, or ulceration to the foot. Patients should also watch out for changes to the shape of the foot or any new increased swelling or heat. In these instances, he or she should seek professional advice without delay.
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TALKING CLINIC
And, of course, it is extremely important to advise the patient not to use corn plasters or attempt home DIY with razor blades or scissors to remove corns or hard skin. RB: Good advice. I would add that advice about wearing shoes that fit properly is also important. What do you say to your patients about their foot risk status? LS: I always make sure that people with diabetes know what their foot risk status is. Put simply, this is the chance of them developing a problem with their feet as a result of having diabetes. Being aware of this is really the key to looking after your feet if you have diabetes. It is so important to advise your patients to have their feet assessed as part of their overall diabetes review. I’d say to any healthcare professional caring for someone with diabetes, please encourage patients not to miss their appointments for this review and really drive home the importance that they must reschedule their appointment if it is not convenient. They should take the foot review as seriously as they do their retinal screening appointment. The foot review should take place at least once per year. RB: What should take place at the allimportant foot review? LS: It’s vital that the foot review should include an examination of the foot and, silly as it may sound, the shoes and socks do need to be removed. I have heard of instances where the patient has kept stockings and socks on during the foot review. In my experience people with diabetes all too often have their annual foot review but are not informed, or do not understand what the results of the review mean. If people with diabetes are not sure what their risk status is, they should be encouraged to ask the person undertaking the review to explain their findings. Typically, the annual foot review is completed by the GP or the practice nurse at the local surgery. RB: And if the person with diabetes is found to be at risk of a foot problem? LS: People with diabetes, once risk assessed should be classified as low risk, increased risk, high risk or as presenting
with active foot disease. Their managment depends on their risk status. So if you have a patient who is low risk, with no risk factors present (which means no loss of sensation, no signs of vascular disease or other risk factors), he or she should continue to have their annual foot screen and be given written, as well as verbal, education regarding foot care. For your patients with a greater risk but no active foot problem, you need to make sure they are being reviewed regularly by a foot protection team (FPT). If necessary the FPT will refer your patients to the multidisciplinary team. In the case of patients with a new or existing foot problem, you need to ensure that that you involve the MDT in the care of your patient as soon as possible. With a new ulceration or problem this should be within 24 hours, thereby ensuring the patient
It is so important to advise your patients to have their feet assessed as part of their overall diabetes review
receives the care to which he or she is entitled. This approach does work because in centres, such as Ipswich, where a dedicated specialist multidisciplinary team has been implemented, amputation rates have been reduced significantly. In my opinion, the key to managing active foot disease is to have prompt expert multidisciplinary input working seamlessly with the FPT. RB: Louise, which foot care services do people with diabetes need access to, in your opinion? LS: They should be referred automatically for expert advice if needed. They also need to see a healthcare professional who is able to educate and promote awareness, and they should be receiving an in depth assessment of the foot with structured individualised advice. I would also recommend that you make sure they are given contact details of who to get in touch with at the first sign of any new problem with the feet to ensure prompt specialist attention. For example they would need to take action if they notice a new cut,
infection or unexplained swelling to the foot. The NICE Quality Standard 10 recommends referral within 24 hours in such cases. RB: Can you tell us a bit more about the foot protection team? Healthcare professionals will probably have heard the term but may be unsure what an FPT is and what it does LS: The term ‘foot protection team’ was first introduced in the NICE clinical guidance for the management of foot problems in Type 2 diabetes in 2004. It is now clearly defined in the National Minimum Skills Framework 2011 and also referred to in the more recent 2012 NICE foot care guidance for in patient care. Basically the foot protection team is a group of healthcare professionals who have the specialist expertise in assessing and managing diabetes-related foot disease. The FPT really does need to work hand in hand with the multidisciplinary team but, ideally, the two teams would be composed of the same individuals. It really is essential that the FPT can provide a first point of access for patients needing advice or care in the community. The team can then facilitate the patient’s journey appropriately, according to their level of need. RB: How do we make sense of all the guidance that now exists for preventing and managing diabetes and foot disease? LS: That’s a great question. As you know, there were four new pieces of national guidance in 2011 alone! Help is on the horizon though. Diabetes UK is launching a Foot Care Pathway in March 2012 called ‘Putting Feet First’, which will provide a clear and concise summary of the services needed, from prevention of foot disease to treating active foot disease, including pathways of care for management of the person whose foot disease has been treated. The Pathway will be available for patients, commissioners and healthcare providers across the UK. I would strongly recommend healthcare professionals use the Pathway to help them provide gold-standard care for all patients irrespective of where they are seen. All the relevant guidance is pulled together in this document, showing how everything can be brought together in a single integrated pathway.
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KEY POINTS
RB: Finally, Diabetes UK is starting a foot campaign in spring 2012. What can we expect? LS: Diabetes UK’s foot campaign Putting Feet First aims to put diabetes and foot disease on everyone’s radar and will really support the improvement of foot care services for people with diabetes and help reduce amputations. I am very excited about this campaign which will not only raise awareness of foot problems for people with diabetes but will make the organisation of foot care services and implementation of all guidance a much greater priority across the UK. Watch this space! Neuropathic pain. NICE Clinical Guideline 96: www.nice.org.uk/nicemedia/ live/12948/47949/47949.pdf • Putting Feet First: www.diabetes.org.uk/ Documents/Reports/Putting_Feet_ First_010709.pdf • Type 2 diabetes – foot care NICE Clinical Guideline 10:www.nice.org.uk/CG10 • Putting Feet First: National Minimum Skills Framework: uk/sitestat.com/diabetes/ website-uk/s?Feet-skills-framework&ns_ type=pdf • See also ‘Putting feet first’ pages 20-22
• Neuropathy and reduced blood supply to the foot are the two main reasons why foot problems occur in diabetes. • The key to good management of foot problems in diabetes is making sure patients are aware of their level of foot risk. • People with diabetes should be encouraged to examine their feet every day and be told specifically what to look out for. • The annual review of the foot is an essential. Higher-risk patients should be under the care of the foot protection team. All people with diabetes should know where to go when problems develop.
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FEATURE
In March, Diabetes UK launched its major foot care campaign to reduce diabetes-related amputations by 50 per cent over five years, by bringing an end to preventable amputations. Nikki Joule, Senior Policy Officer at Diabetes UK, explains
P
oorly controlled diabetes is serious and costly; it can lead to foot disease and amputations. Clearly, amputation brings with it significant social and economic costs. However, 80 per cent of amputations are potentially preventable through access to good-quality structured care and improved awareness among people with diabetes about their risk status and what action to take. Through ‘Putting Feet First’, Diabetes UK hopes to make a significant difference to the long-term quality of life of thousands of people who have diabetes now and those who will be diagnosed in the future. The charity is campaigning so people with diabetes do not develop preventable foot problems which otherwise result in pain, depression, reduced independence, lost limbs and death. The goal is to halve the number of amputations over the next five years. Diabetes UK also wants to put an end to the widespread geographical variations in standards of footcare for people with diabetes.
What Diabetes UK will do
Diabetes UK will raise awareness about the seriousness of the condition and the impact of diabetes on feet among people with diabetes, healthcare
professionals and the public. Over the next year the charity will be providing campaign materials to healthcare professionals and people with diabetes. Information about the campaign, including standards and good practice guidance, will be developed and disseminated to healthcare professionals and managers of services across the UK. Information for people with diabetes about how to look after their feet and what good care looks like will be distributed throughout 2012 together with a campaign pack outlining information about what to do if they are not getting the care expected. Diabetes UK will be working together with healthcare professionals, managers and decision makers, supporting increasing numbers of people with diabetes to have their voices heard through Diabetes Voices. As well as an increase in awareness, a dramatic improvement in standards of care is needed. This means that people with diabetes should have annual foot checks, and need to know how to look after their feet. The check should include an examination of skin, circulation and nerve supply. A healthcare professional should have a discussion about the results with the person with diabetes – including talking about the level of risk. It is a sad fact
10 STE PS
S P E T S
PUTTING FEET FIRST
10
FEET TO HEALTHY
that in 2009–2010 nearly a third of people with Type 1 diabetes did not get a foot check and less than half (45 per cent) of people with any type of diabetes had their risk clearly explained to them. It is also known that there is a very wide geographical variation in terms of numbers of people who are getting all their annual checks, including foot checks. Recent evidence shows a wide variation in amputation rates across England: some localities carry out less than one amputation per year per thousand people with diabetes, others carry out more than five amputations per thousand. The way that services are organised can have an impact on amputation rates. Diabetes UK wants to ensure that people with diabetes can access foot protection services in the community and multidisciplinary teams made up of healthcare professionals with specialist expertise in assessment and management of foot disease, as set out in key guidance. At the moment, nearly one quarter of hospitals in England do not have a multidisciplinary team. People with diabetes should have access to these teams, in all areas. Crucially, people with ulcers should be referred to specialist care within 24 hours – for this could
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FEATURE
It is a sad fact that in 2009-2010 nearly a third of people with Type 1 diabetes did not get a foot check and less than half (45 per cent) of people with any type of diabetes had their risk clearly explained to them mean the difference between losing or keeping a foot. To achieve this it is important to ensure close co-ordination between different groups of healthcare professionals involved in diabetes and foot care. Such co-ordinated management is not yet widespread. Diabetes UK will engage with GPs, managers and local decision makers to promote high-quality diabetes integrated footcare services. The models of care that should be in place will be promoted. Meanwhile, poor care outcomes will be highlighted, using indicators available publicly and by feedback from people with diabetes. The charity will also engage locally to promote examples of good practice in footcare services. It will be calling for key decision-makers to prioritise diabetes footcare services and deliver improved services across primary and
specialist care in all areas. Furthermore, Diabetes UK wants to see improved access to specialist podiatrists as part of multidisciplinary teams and better education and training on diabetes and footcare for staff working in primary care. Work is being developed in all these areas. In addition, there will be a number of parliamentary and media events throughout this first year of the campaign and beyond.
What you can do
Please join with Diabetes UK to help ensure that all NHS staff looking after people with diabetes know about footcare, how to do foot checks, inform people with diabetes about their risk status and refer to specialist care appropriately as part of their overall diabetes care. GPs, practice nurses,
ward staff and healthcare assistants can all support effective self-management to prevent future amputations. You can ensure that people with diabetes understand the importance of checking their feet and that they know how to look after them. You can also help to ensure that people with ‘medium’ and ‘high’ risk feet have timely access to the skills of trained staff working in the community and in specialist teams. Healthcare professionals working in primary, community and specialist care can work together with people with diabetes within diabetes networks to plan, monitor and make changes to improve the quality of diabetes footcare services and ensure that they meet national standards. Find out about the work happening in your region to support improvement through NHS Diabetes Foot Care Networks.
THE FACTS Amputations – The number of amputations is rising, although the prevalence rates appear stable (owing to the increasing number of people diagnosed with diabetes). In England around 6,315 amputations were performed in 2009/10. Based on this, in 2014/15 more than 7,000 amputations will be performed in England . However, up to 80 per cent of amputations are preventable. Mortality – The five-year mortality rate for major amputations is 39–80 per cent and for foot ulcers is 44 per cent. Disease of the foot in diabetes is associated with more deaths than the four most common cancers. Foot checks – between 15 and 32 per cent of people with Type 2 and Type 1 diabetes respectively are not receiving foot checks. In Scotland only 59.5 per cent of people with Type 1 diabetes and 78 per cent with Type 2 received any form of foot check in 2009–10. Ulcers – Around 85 per cent of diabetes-related non-traumatic amputations are preceded by ulcers. Only two-thirds of ulcers eventually heal and patients who have had a foot ulcer are at increasing risk of further ulceration. Lack of awareness of risk – In 2007, one in two people with diabetes reported that they did not realise having the condition puts them at more risk of having an amputation. Social impact – Disease of the foot in diabetes is associated with social deprivation. The quality of life of those with foot disease is reduced through increased discrimination, impact on social relations and intimacy, as well as reduced independence through lack of mobility impacting on ability to work. Economic cost – the annual cost of diabetic foot ulcers to NHS England is estimated at £600–700m and the annual cost of amputation is estimated at £50–64m.
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FEATURE
PUTTING
A footcare pathway for people with diabetes
FEET
Check their feet every day
Annual Foot Review
FIRST
Be aware of loss of sensation Look for changes in the shape of their foot Not use corn removing plasters or blades
Foot examination with shoes and socks/stockings removed • Test foot sensations using 10g monofilament or vibration • Palpate foot pulses
• Inspect for any deformity • Inspect for significant callus • Check for signs of ulceration
• Ask about any previous ulceration • Inspect footwear • Ask about any pain
DIABETIC FOOT RISK STRATIFICATION AND TRIAGE/IDENTIFICATION OF RISK STATUS DEFINITION
ACTIVE
HIGH
MODERATE (INCREASED*)
LOW
ADVISE THE PATIENT TO:
Know how to look after their toenails Wear shoes that fit properly Maintain good blood glucose control Attend their annual foot review
ACTION
Presence of active ulceration, spreading infection, critical ischaemia, gangrene or unexplained hot, red, swollen foot with or without the presence of pain, painful peripheral neuropathy, acute Charcot foot*
Rapid referral to and management by a member of a Multidisciplinary Foot Team (see over). Agreed and tailored management/treatment plan according to patient needs. Provide written and verbal education with emergency contact numbers. Referral for specialist intervention when required.
Previous ulceration or amputation or more than one risk factor present eg loss of sensation or signs of peripheral vascular disease with callus or deformity.
Annual assessment or 1–3 monthly according to need* by a specialist podiatrist or member of a foot protection team*. Agreed and tailored management/treatment plan by a specialist podiatrist or the FPT* according to patient needs. Provide written and verbal education with emergency contact numbers. Referral for specialist intervention if/when required.
One risk factor present eg loss of sensation or signs of peripheral vascular disease without callus or deformity.
Annual assessment or 3–6 monthly according to need* by a specialist podiatrist or member of a foot protection team*. Agreed and tailored management/treatment plan by podiatrist or the FPT* according to patient needs. Provide written and verbal education with emergency contact numbers. Referral for specialist intervention if/when required.
No risk factors present eg no loss of sensation, no signs of peripheral vascular disease and no other risk factors.
Annual screening by a suitably trained Healthcare Professional. Agreed self management plan. Provide written and verbal education with emergency contact numbers. Appropriate access to podiatrist if/when required.
These risk categories relate to the use of the SCI-DC foot risk stratification tool.
Risk status should be documented and the patient informed.
* NICE Guidance
Produced by the Scottish Diabetes Foot Action Group
www.diabetes.org.uk A charity registered in England and Wales (215199) and in Scotland (SC039136). © Diabetes UK 2012
Diabetes UK’s new footcare pathway for healthcare professionals Diabetes UK also wants people with diabetes in hospital to have their feet checked. Less than one-third had their feet examined at any time during an admission to hospital. In fact, disturbingly, two in every 100 people with diabetes developed a new foot complication during their hospital stay. Over a quarter (26.8 per cent) of hospitals in England have no inpatient podiatry service. It is well known that complications of diabetes happen because of raised blood glucose, cholesterol and raised blood pressure levels over a long period of time. It is essential that the NHS promotes good diabetes management and delivers best practice guidance and person-centred care planning as set out in the Year of Care programme.
Diabetes UK is calling for:
1. People with diabetes to be more involved in their own care – they should know how to look after their feet, what risk they have of developing a complication, and what care they should get from the health service. A ‘touch the
Diabetes UK will engage with GPs, managers and local decision makers to promote high-quality diabetes integrated foot care services toes test’ guide has been developed so people can get a friend to carry out a check on their feet. 2. Local health services to deliver the integrated foot care pathway – that means providing the right treatment at the right time and in the right place for all people with diabetes: • Set up referral within 24 hours for those with ulcers to a multidisciplinary specialist footcare teams. • Ensure appropriate referral to a foot protection team that has specialist expertise in assessment and management of disease of the foot. • Create local ‘foot’ networks to
join up and improve footcare for people with diabetes. 3. Healthcare professionals to understand the risk of diabetic foot disease, talk about this with people with diabetes, provide annual foot screening (both in primary care and in hospital), and refer quickly to specialists when necessary. 4. Improved delivery and monitoring of diabetic foot care as part of the implementation of the national Diabetes Action Plan. As well as this, the indicators in Quality Outcomes Framework (QOF) should require that GPs tell people about their foot risk level and refer to specialist care when appropriate. For more information about the Diabetes UK foot campaign, visit www. diabetes.org.uk/putting-feet-first The annual foot check is one of Diabetes UK’s 15 healthcare essentials. Visit www.diabetes.org.uk/15-essentials For a referenced version of this article, visit www.diabetes.org.uk/pmupdate16
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SCIENCE PHOTO LIBRARY
FEATURE
Stem cell, coloured scanning electron micrograph
STEM CELLS TO THE RESCUE Stem cell research promises much in terms of renewing and repairing the human body. What might this mean, in the future, for people with diabetes? Dr Eleanor Kennedy reviews the field
F
rom more conservative headlines claiming ‘Treatment could mean diabetics produce their own insulin’ to the merely hysterical ‘Stem cells could finish diseases’, it would appear, at least in the media spotlight, that enormous progress is being made in stem cell research. But how much has actually been delivered? The advent of stem cells is relatively recent, considering all the advances in cell biology that have occurred since the invention of the microscope. Clinically, the first stem cells to be routinely used were in bone marrow transplants. And,
although initially unsuccessful because of the lack of understanding of the immune system, these transplants are now used routinely to treat certain leukaemias and aplastic anaemia. Then, in 1998, James Thomson’s team at the University of Wisconsin in the USA isolated and grew stem cells from human embryos for the first time. In the same year, a team of researchers led by John Gearhart at Johns Hopkins University, again in the USA, identified stem cells from human germ cells. With stem cells technically available both from human embryos and from human
germ cells, a whole new branch of scientific endeavour was born.
Stem cells 101
Scientists now distinguish several types of stem cell: Embryonic stem (ES) cells are formed post-fertilisation and preimplantation. As the fertilised egg divides during this period, the so-called inner cell mass forms. Post-implantation, this inner cell mass rapidly begins to differentiate into any of around 200 identified different cell types that occur in the body. However, if the inner cell Spring 2012 | DIABETESUPDATE | 23
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FEATURE
mass is removed before this time, then the cells are able to proliferate indefinitely, given the correct culture conditions. Professor Timothy Kieffer from the University of British Columbia Vancouver explained: “Embryonic stem cells are relatively easy to maintain in culture, have the ability to expand to virtually unlimited numbers, and have the advantage of being able to form cells of any tissue. Thus one source of ES cells could serve as a precursor to any cell type that might be needed to treat a given disease.” There is an important caveat, however. He continued: “As the cells are foreign, when introduced into a patient to treat disease, some form of immuno-isolation or immunosuppression will likely be needed to protect the cells from immune attack.” Embryonic germ (EG) cells are, in many ways, very similar to ES cells. Prof Kieffer explained: “The main difference between the two is in the tissue source from which these cells are derived. Embryonic germ cells give rise to the gametes – the eggs and sperm. While ES cells are derived from the inner cell mass of a blastocyst or early stage embryo prior to implantation, EG cells
‘Removing Barriers to Responsible Scientific Research Involving Human Stem Cells’ overcoming the previous administration’s restrictions on stem cell research in the USA which paved the way to a rather more conducive regulatory environment. However, even in countries where more restrictive policies range from permitting research on imported ES cell lines only, to permitting research on a limited number of previously established stem cell lines, disaster can still strike. Recently, Europe’s largest stem cell transplant clinic was closed indefinitely following the death of a baby who had received an injection of stem cells. The XCell Centre in Germany had been charging patients up to £20,000 for stem cell injections despite a lack of proof that they were effective.
cells in clinical trials. Similarly, patients with Parkinson’s disease and other neurological disorders may benefit from stem cell therapies. A recent study has indicated that dopaminergic neurons could successfully be derived from iPS cells in vitro. And stem cell therapies are already in phase I trials for macular degeneration. But what about Type 1 diabetes? Is there sight of a stem cell-based cure on the horizon? Islet cell transplantation is still moving ahead but, with the obvious limitations in the amount of tissue available, new sources of islet tissue are being sought. Running in parallel to this research, there is work on generating beta cell-like cells from stem cells, which would theoretically overcome the need for islet transplantation. Dr Ortwin Naujok from Hannover Medical School in Germany knows that it is an exciting field of research but recognises that there are still obstacles. “The challenges are to make a pure population of cells. We’re able to produce populations of beta cells but these are mixed with other cell types that may differentiate differently. Until a time when we can ensure 100 per cent pure cell populations, any therapy would run the risk of cell proliferation and, potentially, tumour formation,” he said. Dr Ludovic Vallier, formerly a Diabetes UK/MRC Fellow, from the Cambridge Stem Cell Institute, is actively working on the generation of pancreatic progenitors, which could be used for cell-based therapy. He is optimistic about the future for ES cells. “Nowadays we’re getting much more consistency among labs on cell lines and cell culture protocols. We can now encourage ES cells to differentiate into cells that secrete insulin at physiologically relevant glucose concentrations. And, when these are transplanted into mouse models that have diabetes, we can effectively reverse the condition.” However, he is cautious about raising people’s expectations. “Animal models of diabetes are great at allowing researchers to show a proof of principle and that’s what we and others have done. However, using the same approach in patients represents a major challenge and we still have a long way to go.”
Stem cells and Type 1
Commercial interest
Induced pluripotent stem (iPS) cells are ‘stem cells’ that can be generated from other cells taken from the body, such as skin. Considerable work is ongoing to characterise how these iPS cells compare and differ from ES cells, to answer the question if they could be used instead of ES cells as a source from which to derive cells for transplant.
The legal perspective
In the UK, the use of embryos in stem cell research requires permission from the Human Fertilisation and Embryo Authority. Licences are granted in accordance with the Human Fertilisation and Embryology (Research Purposes) Regulations (2001). In other countries with similar guidelines, research applications dealing with ethically sensitive human stem cell research are reviewed appropriately. In Canada, for example, the Stem Cell Oversight Committee ensures that research proposals are in accordance with stem cell guidelines developed by the Canadian Institutes of Health Research. Meanwhile, in 2009 President Barack Obama issued an Executive Order,
We can now encourage ES cells to differentiate into cells that secrete insulin at physiologically relevant glucose concentrations are obtained later in foetal development and thus may not be ethically acceptable for use.” Adult stem cells are derived from a range of tissues and organs in the body. Until relatively recently, it was widely held that adult stem cells – or somatic cells as they are sometimes called – could only form the particular cell type of the tissue that they were isolated from, eg adult stem cells located in the liver could only form hepatocytes. It is now accepted that the programmability of these cells may be considerably greater than was first anticipated. Importantly, the pancreas itself appears to contain such stem cells, leading to speculation about their potential use in diabetes research. It is important to temper this enthusiasm with a dose of reality though. “It’s true that these cells have the ability to renew themselves, while also being differentiated into cells of their corresponding tissue. However, in many tissues, their identification remains really elusive. And isolating and expanding them in culture is also a major challenge.” said Prof Kieffer.
Despite this setback, advances in stem cell technology, although perhaps slower than some had hoped for or even anticipated, are being made. Patients with cardiovascular disease are showing improvement following the use of stem
Perhaps unsurprisingly, thanks to the slower than expected move into clinical trials, commercial interest in stem cell research has stuttered over recent years. The biggest casualty of this has been Geron. The poster boy of the
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FEATURE
STEM CELL RESEARCH MILESTONES 1956 First bone marrow transplants performed in human patients 1961 The existence and properties of transplantable stem cells in mouse bone marrow are established 1978 First in vitro fertilisation baby born 1981 Successful cultivation of mouse embryonic stem cells from explanted inner cell mass cells 1982 First methodology developed for targeted genetic modification in embryonic stem cells 1996 Dolly the sheep is cloned by cell nuclear replacement techniques. Primate embryonic stem cell lines are derived 1998 First human embryonic stem cell lines are derived from human blastocysts 1999 Researchers transplant dopaminergic neural stem cells cultures derived from a patient with Parkinson’s disease resulting in a 40–50% improvement in certain motor tasks in the recipient 2002 Researchers demonstrate that adult somatic stem cells can differentiate into unrelated cell types, such as nerve and blood cells 2003 Researchers generate the UK’s first human embryonic stem cell line 2006 First induced pluripotent stem cells generated by reprogramming adult mouse skin cells 2010 Adult cells reprogrammed directly to neurons, cardiac muscle and blood cells
Californian biotech sector, Geron had positioned itself as a leader in stem cell therapies, pioneering work on their use in spinal injury. In November 2011, however, Geron pulled out of a phase I clinical trial to establish first-in-man safety of the company’s new stem cell therapy in four patients. Naturally, this has left the world wondering where stem cell therapy goes from here.
for patients considering stem cell tourism. These acknowledge that ‘the scale of media coverage for early-stage stem cell research has raised the hopes of many patients afflicted with currently incurable diseases and disabling conditions’ and recognises that ‘Numerous clinics around the world are exploiting patients’ hopes by purporting to offer new and effective stem cell
the stem cell field is becoming more dependent on the deeper pockets of industry to fund it - a strategy that may not be sustainable in the long term Professor Greg Korbutt at the University of Alberta commented: ”The reason Geron closed its stem cell research isn’t because of the science. It’s more about the funding.The company had invested millions of dollars in its stem cell programme but the therapies were taking longer to get to market than the company had envisaged. It’s important to stress that this type of work does take considerable investment.” According to Geron the ‘current environment of capital scarcity and uncertain economic conditions’ have encouraged it to refocus on its cancer programme. But all is not lost commercially. “There are still some companies working in the field but the costs involved are driving them to seek partnership with some of the bigger pharmaceutical companies,” Prof Korbutt concluded. This means that the stem cell field is becoming more dependent on the deeper pockets of industry to fund it – a strategy that may not be sustainable in the long term.
Stem cell tourism
While some wait for a stem cell revolution, others are more impatient. With every news story about advances in stem cell technology comes the surrounding hype that the media can foster. And, with that, comes hope for people with diseases and conditions. Stem cell tourism is a growing industry as people actively seek to go abroad for treatment. Prof Kieffer explained: “It’s a growing problem. Increasing numbers of patients around the world are travelling to countries for stem cell therapies, which are expensive. Moreover, they’re largely unproven and even risky.” He added: “This practice will continue until these countries develop policies and laws to stop it without proven safety and efficacy.” The International Society for Stem Cell Research (ISSCR) has issued guidelines
therapies for seriously ill patients, typically for large sums of money and without credible scientific rationale, transparency, oversight, or patient protections. The ISSCR is deeply concerned about the potential physical, psychological, and financial harm to patients who pursue unproven stem cell-based “therapies” and the general lack of scientific transparency and professional accountability of those engaged in these activities.’ Diabetes UK also has a position statement on stem cells. It states ‘..some clinics in countries like Mexico, China and India are offering untested and unproven stem cell therapies to people with diabetes and other conditions, often in exchange for considerable sums of money. Diabetes UK does not recommend that people travel abroad to receive such therapies, as novel medical treatments in many foreign countries are not regulated as carefully as they are in the UK and could be harmful to health.’
The future
With many countries now actively engaging in stem cell research, progress will be made. Powerhouses like China and Singapore are funding enormous programmes in this area to deliver new therapies to those who need them. “There needs to be more cross-working among international groups to ensure continued consistency in the field.” said Dr Vallier, adding: “However, we cannot promise miracles. Clinical trials will be long and complex and it will take time before we can be sure of any real and viable stem cell-based alternative for people with diabetes.” For people with Type 1, the stem cell field offers great hope, though treatments based on insulin-producing cell are still some years away. For a referenced version of this article, visit www.diabetes.org.uk/ pmupdate16 Spring 2012 | DIABETESUPDATE | 25
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Illustration: Clare Nicholas
FEATURE
NHS REFORMS – MOVING ON A focus on outcomes, rather than targets, is central to the NHS reforms. John Fellows, Senior Policy Officer at Diabetes UK, explains how the three different levels of outcomes may affect diabetes services
A
t the time of writing, the Health and Social Care Bill – which reforms the NHS in England – is back in the House of Lords, and also the news. The first day of Report Stage in the Lords coincided with The Times quoting an ‘unnamed Downing Street source’ saying that the Secretary of State for Health, Andrew Lansley, ‘should be taken out and shot’ for the substance of the Bill and the failure to communicate the reform policies. This quote follows the move to oppose the entire Bill from clinical representative organisations such as the British Medical Association, the Royal College of Nursing and the Royal College of General Practitioners. Dropping the Bill (or at the least the section relating to Monitor and competition) is also the Labour Party’s
position. The unnamed source reflects exasperation within the Coalition Government that it is expending political capital on health, one of the two areas (the other is international development) where the Coalition’s programme did not impose a reduction in departmental funding. With briefings, seemingly from Number 10, taking place against Andrew Lansley, it looks as if it will be a difficult few months for the Secretary of State. However, it is still likely that the Health and Social Care Bill will be passed and will gain Royal Assent in April or May 2012. For there are legislative options open to the Coalition Government that would allow it to force the Bill through the House of Commons should it wish to do so. As the Bill going through Parliament remains the likely
outcome, Diabetes UK has been taking a pragmatic approach, seeking to amend the Bill. The organisation is working in alliance with other leading health charities to improve duties on, for example, collective patient and public engagement.
All change
The Bill is primarily a reform of the commissioning organisations in the NHS, with primary care trusts and strategic health authorities being replaced by clinician-led clinical commissioning groups (CCGs) and, at a national level, by the NHS Commissioning Board. However, even before the Bill has received Royal well under way, with existing organisations ‘clustering’ their responsibilities and staff. This has led to
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FEATURE
Diabetes in Adults was one of the first Quality Standards and these statements have been used to develop the indicators for the Commissioning Outcomes Framework uncertainty within the NHS, as commissioning structures are changing and staff capacity has been reduced while there has not been an accompanying growth in the new organisations. This is because the Bill that creates them has not yet been passed and the date (April 2013) when the new bodies will become responsible for budgets and commissioning services is still some way off. The lack of available detail about the new commissioning organisations and how they will work have led to concern among the clinical representative organisations. A further source of uncertainty is that the reforms are happening at the same time as the service-level reorganisations taking place due to funding constraints in the English NHS. While the Coalition Government is committed to maintaining spending on health, this is in the context of a service that has enjoyed an average of 7 per cent growth in funding this century until 2010/2011, which now (due to inflation) is likely to experience either no growth or a slight reduction in funding (according to the leading health economist Professor John Appleby). The health service has long known that there would be a reduction in funding and, from 2009, the NHS has been aware that it would have to deliver £20bn of ‘efficiency savings’ in lieu of any growth in funding. How this efficiency drive has worked in practice has been a cause for concern. For example, the 2010 Diabetes UK Diabetes Specialist Nursing Work Force Survey demonstrated that some areas are saving money by leaving specialist nurse posts unfilled. This has led to further uncertainty in the NHS, as expressed by Diabetes UK Chief
Executive Barbara Young in the House of Lords on 8 February: “Patients are telling me that we are seeing the fragmentation of responsibility for the commissioning of healthcare and that services are suffering as a result of the financial squeeze; for example, diabetes specialist nurses are disappearing and patient education is being cut. The things that are important for the quality of care are being removed.”
From targets to outcomes
Despite the general air of uncertainty surrounding the Bill, an emphasis upon outcomes is one element that will definitely be in place. What are outcomes, where do they fit and, most importantly, how will they work for diabetes? Moving from a system of targets to one of outcomes was a key feature of Conservative policy when in opposition. The Labour Government had introduced, for example, ‘access targets’ around waiting times and waiting lists. With the formation of a Coalition Government, the Conservative policy to remove these targets, with the rationale that they distorted clinical priorities, became the Coalition Government’s policy. Since publication of the original White Paper in July 2010 it has been known that there would be an overarching NHS Outcomes Framework and that, below this, Quality Standards from the National Institute for Health and Clinical Excellence (NICE) would be used to inform commissioning. As new details emerge, we are beginning to see how the system will fit together.
The mandate
The Health and Social Care Bill legislates that the Secretary of State will, before the start of any financial year, write ‘the mandate’ to the NHS Commissioning Board, specifying the amount of money that the Board would have available for the year and the improvements in outcomes that it must deliver for this outlay. The overall outcomes that the NHS Commissioning Board must deliver are described in the NHS Outcomes Framework. The mandate will (after consultation in 2012) set the levels of improvement that the Commissioning Board must deliver against some of
Table 1: NHS Outcomes Framework Indicators relevant to Diabetes Domain 1: Preventing people from dying prematurely Potential years of life lost from causes considered amenable to healthcare Domain 2: Enhancing quality of life for people with long-term conditions Health-related quality of life for people with long-term conditions Proportion of people feeling supported to manage their condition Unplanned hospitalisations for chronic ambulatory care sensitive conditions (defined as diabetes, asthma and epilepsy) Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s Domain 3: Helping people to recover from episodes of ill health or following injury Effective recovery from illnesses and injuries requiring hospitalisation Domain 4: Ensuring that people have a positive experience of care Patient experience of primary care i) GP services, ii) GP out of hours services Responsiveness to inpatients’ personal needs Children and young people’s experience of healthcare Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm Incidence of medication errors causing serious harm these outcomes. There are 60 indicators in total, 10 of which are directly related to diabetes. These relevant national indicators are shown in table 1 (above).
Commissioning Outcomes Framework
The NHS Outcomes Framework, and the above diabetes-related indicators, set out the national indicators that the Secretary of State will use to assess the performance of the NHS Commissioning Board in improving outcomes. The NHS Commissioning Board will then, in turn, develop a Commissioning Outcomes Framework to assess the performance Spring 2012 | DIABETESUPDATE | 27
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FEATURE
of CCGs to deliver local improvements that will contribute to the national indicators. These indicators are to be developed by NICE. Draft indicators were released by NICE in February so it is now possible to begin to see what the system will look like in practice. At the same time, NICE has been tasked with creating a library of Quality Standards, which describe in short statements what high-quality care will look like for a range of conditions. Diabetes in Adults was one of the first Quality Standards and these statements have been used to develop the indicators for the Commissoning Outcomes Framework. These are the indicators that NICE thinks can be improved through good commissioning. The Quality Standards are in draft form at present, and they will go to the NHS Commissioning Board after consultation for it to choose the indicators that will be used. The diabetes in children standard will be progressed from April 2012. From April 2013, healthcare professionals working in a service commissioned by a CCG will find that it will be looking to the service to deliver these improved outcomes. For diabetes the proposed indicators for the Commissioning Outcomes Framework are shown in table 2 (right). The third piece of the puzzle for diabetes outcomes is the Public Health Outcomes Framework. Just as the NHS will set its strategic direction in terms of improvements in outcomes, so the public health and adult social care systems will be set up in a similar way. The pause in the Health Bill, and the report of the Future Forum that followed it, led to the recommendation that the Outcomes Frameworks for these areas should ‘align’ so that they share outcomes and responsibilities at appropriate points. Table 3 (left) lists diabetes-related indicators
Table 2: Draft diabetes indicators in the Commissioning Outcomes Framework Domain 1: Preventing people from dying prematurely Myocardial infarction, stroke and end stage kidney disease in people with diabetes Domain 2: Enhancing quality of life for people with long-term conditions Single marker of all nine basic care processes performed People with newly diagnosed diabetes who are offered structured education within three months of diagnosis People with established diabetes who are offered structured education People with newly diagnosed diabetes who start structured education People with established diabetes who start structured education People with newly diagnosed diabetes who complete structured education People with established diabetes who complete structured education People with established diabetes whose structured education has been reviewed and reinforced within the last 15 months Readmission rates of people admitted with diabetic ketoacidosis within 12 months following discharge Rates of complications associated with diabetes Rates of lower limb amputation Emergency admissions: diabetic ketoacidosis in people with diabetes Emergency admissions: hypoglycaemia in people with diabetes Domain 3: Helping people to recover from episodes of ill health or following injury People with diabetes with a new diagnosis of foot ulceration requiring urgent medical attention who are seen by the multidisciplinary foot care team within 24 hours of referral Domain 4: Ensuring people have a positive experience of care Patient experience of diabetes services
What are outcomes, where do they fit and, most importantly, how will they work for diabetes?
Table 3: Diabetes indicators in the Public Health Outcomes Framework Gap between the employment rate for those with a long-term health condition and the overall employment rate Number of QOF-recorded cases of diabetes per 100 patients registered with GP practices (17 years and over) The proportion of those offered screening for diabetic retinopathy who attend a digital screening event Take up of the NHS Health Check programme – by those eligible Mortality from causes considered preventable Emergency readmissions within 30 days of discharge from hospital Preventable sight loss
in the Public Health Outcomes Framework. These outcomes, in the different frameworks, will be used in the new system to manage the performance of the CCGs and the NHS Commissioning Board. Beyond the likely Royal Assent of the Health and Social Care Bill in April/May 2012, the political debate is likely to shift towards the outcomes that the NHS in England is delivering. The NHS Outcomes Framework can be viewed at www.dh.gov.uk/prod_consum_ dh/groups/dh_digitalassets/documents/ digitalasset/dh_131723.pdf
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MEDICINE DIGEST
DIABETES UNDERREPORTING Recording diabetes in hospital admissions data is important for research and planning services. A new study from the Scottish Diabetes Research Network Epidemiology Group has found widespread under-reporting of diabetes in hospitals. Linkage with the Scottish national diabetes register could make admissions data more accurate
H
ospital admissions data are a key resource for service planning and research. With the increase in the prevalence of diabetes, reliable data on hospital admissions for people with diabetes are more important than ever in understanding the condition’s impact on secondary care. High-quality data are also needed to assess the impact of initiatives to prevent diabetes and its complications. For instance, the Organisation for Economic Co-operation and Development (OECD) Health Care Quality Indicators use diabetes-related lower extremity amputation as a measure of the quality of diabetes care. Previous research suggested that discharge statistics for a single hospital in Scotland considerably underestimated diabetes as a cause of hospital admission. It is not clear whether diabetes recording has improved since then or, indeed, whether these findings were typical of hospitals in Scotland and elsewhere. Therefore, the Scottish Diabetes Research Network Epidemiology Group has carried out a study to check how far hospital admissions data throughout
Scotland reflect the true impact of the condition in secondary care.
Database linkage
The Scottish Care Information-Diabetes Collaboration (SCI-DC) dataset is the national electronic diabetes register. It has existed since 2000 and contains population-based data for more than 99.5 per cent of people diagnosed with diabetes in Scotland. The database is populated, and updated daily, with demographic and clinical data relevant to primary and secondary diabetes care. In this study, data were extracted from the SCI-DC database in May 2008 and linked to the Scottish Morbidity Record hospital episodes by the NHS National Services Scotland Information Services Division. This linked dataset, which contained no patient identifiable information, was analysed to discover the proportion of hospital inpatient admissions mentioning diabetes for those people in the SCI-DC database. Spring 2012 | DIABETESUPDATE | 29
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MEDICINE DIGEST
If an individual was present in the diabetes register then, ideally, this fact would have been recorded in hospital admission data. The aim of the study was, therefore, to see how far actual hospital admission records deviated from this ‘gold standard’. The study also allowed for testing of the completeness of the SCI-DC database by noting the number of individuals who were not registered, yet had a hospital admission record that did mention diabetes. The analysis of the hospital data was also stratified to include the impact on completeness of service-related factors (NHS Board, hospital and speciality), year of hospital admission (between 2000 and 2007) and patient factors such as age, sex, co-morbidity and socioeconomic status. For people diagnosed with diabetes, the percentage of admissions coded with a co-morbidity of diabetes was calculated for selected primary diagnoses, namely: cerebrovascular disease, coronary heart disease, chronic kidney disease, circulatory disease, peripheral vascular disease and cancer. The proportion of admissions for lower extremity amputation mentioning diabetes among those in the SCI-DC database was also calculated.
Completeness and under-reporting
The researchers found that, in 2007, there were 1,517 people in Scotland having at least one hospital admission mentioning diabetes but who were not included on the register. This amounts to just 0.6 per cent of the 231,391 people with diabetes in Scotland. The national diabetes register in Scotland therefore has a very high level of completeness. It is an extremely valuable information resource which, in this study, was linked to the hospital admission data to describe the completeness of diabetes recording in the latter. There were 78,559 hospital admissions during 2007 for people on the diabetes register. When admission data for these people was examined, only 59.3 per cent of admissions actually mentioned diabetes as either a primary or secondary diagnosis.
diagnosis of diabetes as a co-morbidity was missed in 41 per cent of hospital admissions
The completeness of recording of diabetes on hospital admission varied from 44 to 88 per cent for mainland NHS Boards and from 35 to 89 per cent for large general hospitals. Diabetes was more likely to be recorded in medical compared to surgical specialities. There was an improvement over time, from 2000 to 2007, in recording of diabetes in accident and emergency admissions. For other specialties, the trend remained flat.
Variation in under-recording
Patients with a primary diagnosis of cardiovascular and coronary heart disease were more likely to be recorded with a co-morbidity of diabetes than those with other diagnoses. The figures were 70.5 per cent and 69.7 per cent respectively,
compared to 66.4 per cent for chronic kidney disease and 41.4 per cent for cancer, with little variation over time. Among those on the diabetes register admitted for a lower extremity amputation, 73.7 per cent of admissions mentioned diabetes as the primary diagnosis. This last indication of incompleteness is particularly concerning, given the importance of amputation data in the OECD assessment of the quality of diabetes care. There was little difference between men and women in the percentage of admissions mentioning diabetes. Nor was there any variation according to socio-economic status. However, the proportion of hospital admissions records mentioning diabetes did decrease with age. For those aged 0–19 years, at least 90 per cent of admissions mentioned diabetes but this fell to below 60 per cent for those aged 55 or more. The more co-morbidities were mentioned, the more likely was the recording of diabetes. For people on the diabetes register, the average length of hospital stay was approximately 1.3 times longer among those where diabetes was also recorded on their hospital admission (11.8 days compared to 8.9 days, in 2007). However, the average length of hospital stay for all inpatients in Scotland in 2007/2008 was 5.4 days. This means that average length of stay for people with diabetes is overestimated if only records that mention diabetes are used for these estimates. However, the proportion of bed days accounted for by people with diagnosed diabetes increases from 10.8 per cent if only records mentioning diabetes are used, to 14.9 per cent when all hospital admissions among people with diabetes are counted.
Coding variation
It should be noted that, overall, the quality of coding of primary diagnosis in hospital admissions in Scotland is accurate. A review has found it to be at a level of 88 per cent, which is close to the 90 per cent target level. However, coding for other conditions, including diabetes, is less accurate. Most recording errors are under-recording, either because diabetes is not mentioned on the clinical discharge summary or because the coders do not record the diagnosis. This study shows that diagnosis of diabetes as a comorbidity was missed in 41 per cent of hospital admissions. This is so even when the existence of diabetes is likely to play an important role. Thus more than 30 per cent of admissions for coronary heart disease do not mention diabetes. The problem is not unique to Scotland. The DiabetesE fifth national report, which included 82 per cent of primary care trusts in England, found that 39 per cent of hospital providers did not identify and code people with diabetes in an appropriate way. Variation in the recording of diabetes between hospitals and clinical specialities is likely to arise from a combination of factors, including differences in training, seniority of staff completing discharge summaries and local variations in resources assigned to clinical coding. Better quality data among the paediatric population might result from a combination of a lower number of co-morbidities and a higher number of insulin users. However, it is not clear whether variations in completeness of coding actually reflect existing differences in the quality of diabetes care between hospitals and specialities.
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Implications of under-reporting
Using hospital data alone in Scotland will considerably underestimate the actual number of hospital admissions for people with diabetes. This is so even when the diagnosis is likely to be diabetes-related, such as heart disease. With diabetes coding levels for lower extremity amputations, most of which are likely to be diabetes-related, being only 74 per cent, it is likely that rates of such amputations are being underestimated. This study calls into question the validity of using hospital admissions data on its own for diabetes-related performance and quality assessments.
linking with high quality data means the true cost of diabetes can be estimated more accurately
Furthermore, some diabetes research studies rely upon hospital admissions data. One example is a cohort study of the link between overweight and the risk of developing diabetes. The authors of that study acknowledge that the data might result in underestimates of the true incidence of diabetes. Another study compared trends in admissions among people with or without diabetes for heart disease and claimed that coding inaccuracy was unlikely to impact their results. However, the authors of the current study believe that under-recording of the secondary diagnosis (diabetes) may have affected the conclusions of this earlier study. These findings also suggest that routine data overestimate the mean length of hospital stay associated with diabetes but underestimate the number of bed days. A study of prolonged inpatient hospital stay for people with diabetes found excess diabetes length of stay to be between one and 1.2 days. This could be an overestimate because of reliance on the coding of diabetes on discharge summary alone. Finally, under-recording of diabetes may also influence the Charlson index, which is a weighted index used to classify co-morbidity. If diabetes and other co-morbidities are not recorded, the index is likely to provide inaccurate estimates. Given these low levels of recording, it may be better to find alternative ways of recording co-morbidities. This new study provides evidence that linkage to a diabetes register provides a much more accurate data source for measuring hospital admissions among people diagnosed with diabetes than hospital admissions data alone. Linking with high-quality data means that the true cost of diabetes can be estimated more accurately, which will enable better planning and monitoring of health services than if hospital data of current quality is used. This is a digested version of Anwar H, Fischbacher C, Leese G et al (2012). Assessment of the under-reporting of diabetes in hospital admission data: a study from the Scottish Diabetes Research Network Epidemiology Group. Diabetic Medicine 28;1514-1519 • To download the original referenced article, go to http://onlinelibrary.wiley.com/ doi/10.1111/j.1464-5491.2011.03432.x/full
Animal insulins remain a perfectly acceptable alternative to ‘human’ insulins for the treatment of diabetes mellitus and, indeed, some patients prefer them.1 Reference: 1. International Diabetes Federation Position Statement – Animal, Human and Analogue insulins. March 2005. www.idf.org. Consult Summary of Product Characteristics, particularly in relation to side-effects, precautions and contra-indications, before prescribing. Legal category POM Adverse reactions should be reported. Reporting forms and information can be found at www.yellowcard.gov.uk. Adverse reactions should also be reported to the Drug Safety and Information Department at Wockhardt UK (Tel: 01978 661261).
Further information is available from: Wockhardt UK, Ash Road North, Wrexham, LL13 9UF Tel: 01978 661261 Fax: 01978 660130 www.wockhardt.co.uk HP08/11 May 2011
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AT YOUR SERVICE
NETWORKS WORK Wakefield District Primary Care Trust’s diabetes network has improved service delivery and is highly valued by healthcare professionals and patients alike. But could such examples of good practice be swept away by health service reform? Katie Simon, Service Improvement Manger at Diabetes UK, reports
N
etworks are currently a hot topic in the NHS and are being used as a tool to drive up the quality of care. Diabetes UK is championing the use of local networks as a method of service improvement where ‘communications between diverse, but related, organisations manage the flow of public services across the whole area, sharing resources, such as equipment, technology, knowledge and expertise’ (Addicott et al, 2007). This year, the charity will carry out research to ascertain the factors that make an effective local diabetes network and how Diabetes UK can support the NHS to make sustainable improvements at a time when resources are limited. Networks currently exist patchily across England, as they are not mandatory. However, Diabetes UK regional managers are supporting local diabetes networks across the country to promote transparency, improvement and integration of diabetes services.
The organisation believes that sharing of best practice is really valuable to support improvement in services. Effective local diabetes networks with engaged commissioners, primary and specialist care teams, public health and people with diabetes are key drivers for building relationships, setting the vision and improving the overall integration of diabetes services. With co-management support and leadership, local networks are essential to meet the aspirations of the NHS White Paper Equity and Excellence: Liberating the NHS. Janet Wilson, Diabetes Network Manager at Wakefield District Primary Care Trust (PCT), told Update how the establishment of a local network has improved diabetes services. The network covers 40 GP surgeries, one secondary care provider (Mid Yorkshire Hospital) and one PCT. Wakefield has a population of 350,000, including 17,500 with diabetes. There is also a monthly increase of around 120 people developing the condition in the network’s area.
Wakefield District Diabetes Network The current network existed previously as a District Diabetes Advisory Group (DDAG), but with the introduction of the National Service Framework (NSF) for Diabetes in 2003, this became a smaller network board with seven working groups themed by the 12 NSF standards (the working groups now all include people with diabetes). The following stakeholders sit on the board: • two lead GPs who were previous lead commissioners for their area • the Diabetes UK regional manager • a diabetes specialist nurse • two diabetologists • the network manager (Janet Wilson) • the head of public health • the network coordinator • the network facilitator • three practice nurses • the general manager from the secondary care provider • a paediatric consultant • chair of the local patient focus group.
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DiabetesE Module
2003
2007
DiabetesE Module
2010
Leadership
46%
66%
Leadership, Policy & Strategy
86%
Policy & Strategy
68%
55%
Productivity & Contracting
86%
Staff
56%
57%
Health Promotion & Prevention
90%
Clinical Information System
97%
92%
Clinical Leadership
90%
Clinical Indicators
56%
Nil return
Staff Development
100%
Prevention of Type 2 Diabetes
86%
79%
Patient Experience
78%
Identification of People with Diabetes
63%
100%
Children & Young People with Diabetes
89%
Initial Management
73%
69%
Adults with Diabetes
87%
Annual Review
47%
83%
Inpatient Care – Adults
84%
Metabolic Management
60%
91%
Prevention & Management of Diabetic Footcare
75%
Risk Factors for Cardiovascular Disease
51%
91%
63%
Hospital Admissions
49%
79%
Inpatient Management of Active Diabetic Footcare
Eye Screening
49%
95%
Kidney Screening & Management
56%
Retinal Screening & Management
52%
60%
Pre-Pregnancy
85%
Footcare & Lower Limb Amputation
60%
74%
Diabetes in Pregnancy
91%
Children & Young People with Diabetes
50%
87%
Pregnancy
26%
95%
Elderly
66%
52%
If there are agenda items needing expertise outside the network board, such as podiatry or dietetics, a specialist is invited to the meeting to share expertise. The network meets every quarter, while the seven working groups covering the 12 NSF standards meet more frequently, with progress reported to the network board every six months. When the DDAG reformed into a network board the new group needed to establish a baseline, so that there was an understanding of how services were currently performing. This information was gathered through the use of the DiabetesE online tool, which highlighted the PCT’s performance against the 12 NSF standards in a ‘traffic light’ system. Wakefield District’s performance ws rated as red and amber, which indicated gaps in diabetes services (figure 1). This information was shared with the themed working groups so
Figure 1 (left): DiabetesE module outcomes for Wakefield District PCT (2003 & 2007); Figure 2 (above): DiabetesE module outcomes for Wakefield District PCT (2010)
People with diabetes feature as key network stakeholders to maintain clear communication with NHS staff that smaller projects could focus on achieving their designated NSF standard. The DiabetesE tool provides action plans and guidance on how to measure progress and keeps projects on track. The PCT is now achieving green against all NSF standards, apart from one amber for kidney care (figure 2). Being able to measure progress using a quantitative method provided the network with evidence of improvement, as well as information to present to commissioners when requesting funding for additional service developments. The
Level 1-2
Primary care diabetes oral therapy. GLP-1 analogues, for ongoing monitoring and review due to non titration required
Level 3
Managing patients on insulin therapy
Level 4a
GLP-1 analogues initiation. Once initiated follow up after one month then refer back to level 1-2 if GLP-1 analogues fails would require insulin
Level 4b
Insulin initiation. Initiated and titrated then following year review under L3
Level 5
Hospital care
Figure 3: Wakefield District PCT, Local Enhanced Service Model
network also encouraged the use of the National Diabetes Audit and reported a 100 per cent submission rate for all GP surgeries. Mid Yorkshire Hospital will also be submitting activity this year.
Implementing the Local Enhanced Service (LES)
The network decided to implement a tiered model of diabetes care (figure 3). The overarching objectives of this model were (Nagi et al 2011): • improving the overall quality of diabetes care delivered in primary care • reducing variations in the deliveqry of diabetes care across GP practices • integrating primary care and specialist care • addressing existing health inequalities. For successful implementation, the following commitments were at the forefront of this redesign: • Build and strengthen existing relationships with all healthcare professionals. • Always ensure that the patient is involved in decision making. • Encourage mutual respect for all other stakeholder roles. All 40 GP surgeries were invited complete a survey to determine the level at which they were delivering diabetes care (figure 4). After this, there was a case note review of people with diabetes in the Wakefield District PCT area to establish Spring 2012 | DIABETESUPDATE | 33
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Prevention; Identification; Impaired Glucose Tolerance/Impaired Fasting Glucose; Diet-Controlled Type 2 diabetes
Type 2 on tablets; Annual review
Management of patients stabilised on insulin Annual review Type 1 and Type 2 diabetes
Initiation of Insulin Problem Patients; Unstable Diabetes; Annual review Type 1 and Type 2 diabetes
Gestational diabetes; Pre-conception care; Children and adolescents; Inpatient hospital care; Complex complications; Insulin pump; Carbohydrate counting; DAFNE
Practice level 1 Practice level 2 Practice level 3 Practice level 4 Primary Care Services
Specialist Care Service
Figure 4: Model used for self-assessment of the level of diabetes service provided by the GP practices and specialist teams (Nagi et al 2011) where patients should receive their care, according to clinical and social needs. The initial review was of patients with HbA1c levels of 86mmol/mol (10 per cent) and above. The main patient flows (figure 5) show which healthcare professionals needed to conduct the patient’s reviews. From the case note review patients were assigned to one of the following specialist primary care clinics: 1. A joint clinic led by the GP and supported by the diabetologist: • People with diabetes were informed about the joint clinics prior to the day. • Care plans were discussed and agreed by the people with diabetes at the appointment. • If care had always been provided by secondary care, their future appointments could be delivered at the surgery, with support of specialist team as required. • These clinics were also run at HMP Wakefield. • The GP was able to up-skill. 2. A joint diabetes nurse and practice nurse clinic:
Specialist Diabetes Services
• Those with particular needs that could be treated in primary care • The practice nurse was able to up-skill. • This clinic supported insulin initiation, titration and GLP-1 analogue starts. If people with diabetes had complex care needs, and could still be reviewed in primary care, GPs and nurses were provided with support and training by hospital teams to ensure quality care was delivered, and patients continued to receive their ongoing care from their local surgery. Dependent on the level of the surgery (figure 3) the assigned diabetologist and diabetes nurse would complete the following visits: Working at Level 2–3 Monthly visits Working at Level 3 Bi-monthly visits Working at Level 3–4 Bi-monthly visits Working at Level 4 Quarterly visits The visits were used for joint consultations, case note reviews, education or home visits for complex house-bound patients. Between visits, GPs and practice nurses could liaise with their diabetologist or DSN by
Patients Under Hospital Care
phone or e-consultation (SystmOne), if they had queries or concerns. Through this agreed LES, primary care was treating the majority of those with diabetes while increasing professional knowledge and skills. Meanwhile, capacity was increased in secondary care to deal with complex cases and focus upon other aspects of care, including vascular and retinopathy screening.
Patient feedback
The Wakefield District diabetes network always ensured that people with diabetes were at the forefront of the service redesign. This has continued and patients feature as key network stakeholders to maintain clear communication with NHS staff. Healthcare professionals in Wakefield were very satisfied with the new model of care. But were people with diabetes happy with the care that they were receiving and the new clinic system? This is what they had to say: “Smashing appointment” “Hope we’re lucky enough for this new service to continue!” “Brilliant service!”
Routine Primary Care Clinic
Structured Education All Practice Patients Joint GP & Diabetologist Clinic
Joint PN + DSN Clinic
Figure 5: Outcome of Patient Flows from a joint case note review based at the GP Practice as a part of Diabetes redesign (Nagi et al 2011) 34 | DIABETESUPDATE | Spring 2012
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;
ate
11)
Linking with high-quality data means that the true cost of diabetes can be estimated more accurately
HAVE YOU BROWSED THE DIABETES UK ONLINE SHOP RECENTLY? Did you know there is useful information, guidance and awareness materials to download in the Health Professionals section?
“Less worrying than a hospital atmosphere, less anxiety, a hospital appointment is a big appointment.” “Wouldn’t have wanted to go to a hospital even though I knew my control was worsening.”
The future
The planning and implementation of the redesign of diabetes care in Wakefield was successful, owing to the continuous support of the diabetes network and the shared vision of the healthcare professionals. This resulted in improving the delivery of integrated diabetes care and intermediate and long-term outcomes for people with diabetes. The new care model has proved very beneficial to healthcare professionals and patients alike. It is to be hoped that this popularity will make the new model sustainable. However, the network now faces an uncertain future with current NHS reforms. There is a lack of clarity over whether the network will continue and there is a concern that the ‘new world’ may fragment diabetes services. Diabetes UK is very concerned about the future of the local diabetes networks and supports them as a service improvement methodology. The Wakefield District case study is just one example of the success that an effective network can have on improving service delivery, patient outcomes and patient experience. They can promote transparency and integration as well as support and improve the commissioning, development and maintenance of diabetes services. Addicott R, McGivern G and Fairlie E (2007). The Distortion of a Managerial Technique? The Case of Clinical Networks in UK Health Care. British Journal of Management 18; 93–95 • Nagi, D and Wilson, J (2011). Integrating Primary Care and Specialist Diabetes Teams to deliver better Diabetes Care; The Wakefield Diabetes Service Re-design • Department of Health (2010). Liberating the NHS
You may be interested in: • Weight Creeping Up on You? – an A5 booklet to help people with diabetes manage their weight
• Diabetic Neuropathy – a booklet explaining how diabetes can damage the nerves of the body. Covers symptoms and pain relief Downloads are free. Profit on for-sale items all go to support Diabetes UK’s work. For more information visit www.diabetes.org.uk/onlineshop
Spring 2012 | DIABETESUPDATE | 35
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CARE DELIVERY
A WEEK AT IPSWICH DIABETES FOOT CLINIC Ipswich Diabetes Foot Clinic has pioneered the multidisciplinary approach to diabetes footcare. Dr Gerry Rayman, Head of Service at the Diabetes and Endocrine Centre, Dr Duncan Fowler and Neil Baker, Research Podiatrist at Ipswich Hospital NHS Trust, take time out to describe a week in their busy clinical diary
F
irst a little history. The Ipswich Diabetes Foot Clinic opened in 1986, following reports from clinics at Manchester Royal Infirmary and King’s College Hospital, London, which suggested that better outcomes could be achieved for people with diabetic foot ulcers if they were seen in clinics where specialists from different disciplines, with different perspectives and different skills, could share their experience. Our first attempt to achieve this was a weekly joint clinic, held in the general outpatients department. The clinic was led by a trainee in diabetes (author GR), working with an outpatient nurse with an interest in wound care, a community
podiatrist seconded for the morning and a vascular surgeon working alongside in an adjacent clinic. All those involved noted immediate patient benefits and were convinced that multidisciplinary team working was the way forward. Several years later, the author (GR) returned to Ipswich Hospital as a consultant, reviewed the service and concluded that a single weekly clinic with seconded community podiatrists was insufficient for the volume of foot disease being seen. What was required was a department with staff specialising in, and solely dedicated to, diabetic foot disease, delivering care in more than one scheduled outpatient clinic and
being available during the working week for those requiring urgent outpatient treatment, and those admitted to the hospital as emergencies. Multidisciplinary working, learning from each other and good contacts with – and education of – those in primary care to encourage early referral were believed to be key to reducing the burden of foot disease. Working closely with our vascular surgeons, and with their support and encouragement, the Foot Clinic became the first point of call for all diabetic foot disease. The proposed development had no funding stream, being relatively novel for a district general hospital. Undaunted, staff raised funds through various means,
36 | DIABETESUPDATE | Spring 2012
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CARE DELIVERY
including charity and pharmaceutical research, to employ a dedicated specialist diabetes podiatrist (author NB) and a diabetes specialist nurse to act as a patient advocate, and to review diabetes control, hypertension and lipid management. We believed that continued funding would result if we were able to demonstrate improved outcomes. To achieve this we developed a robust means for accurate auditing of amputation rates across the whole of the community served. Since 1997 we have seen a 75 per cent reduction in major amputation rates. The success and value of the service has been recognised by the hospital trust which now funds the podiatric and diabetes specialist nurse salaries. So where are we today? Very busy! Here is a brief outline of the working week of the multidisciplinary clinic staff.
Monday
As on all other days, the first task is to check the Diabetes Foot Hotline answerphone for messages from patients, community-based healthcare professionals, the Emergency Department and the wards. Today these included calls from several wards and the critical care unit asking for review of weekend admissions with foot problems, two GP calls for urgent appointments and several district nurse calls for advice. There are also calls from foot clinic patients about their appointments, transport or wound care. These enquiries are replied to throughout the morning alongside seeing the three new ‘semi-urgent’ patients booked from the previous week and two research patients. Katherine, the diabetes specialist foot nurse, also telephones all the wards to pick up any patients with
foot problems, including who have not been referred in via the hotline and to address any ward staff concerns. Several patients are identified, including one with a badly infected foot ulcer. Thus the hotline enquires and ward surveillance identify two patients that need to be seen today, one with a non-resolving infection and the other with a sudden onset of pain and gangrene in her big toe.
Since 1997 we have seen a 75 per cent reduction in major amputation rates The morning progresses with the research and new patients being attended to. The emergency GP referral patient has to be admitted, owing to severe infection resulting in digital vasculitis and the risk of gangrene of the big toe. The morning ends with a round up discussion of the patients identified with foot problems. Additionally, the podiatrist and diabetes specialist foot nurse join the diabetes consultants’ ward rounds to see existing foot patients jointly and to discuss the newly acquired foot patients. Monday midday sees the weekly meeting of all members of the diabetes team to discuss issues of the past or coming week. This week the meeting ends with one of the research specialist registrars running through his presentation for the forthcoming Diabetes UK Professional Conference. For foot clinic staff, the afternoon is spent visiting more wards, undertaking foot assessments in the specialist renal diabetes clinic and answering telephone
STEP-BY-STEP INSTRUCTION
TOUCH THE TOES
TEST
1
Reference guide
1
Step-by-step instruction
2
Recording the results
3
What the results mean and what to do
3
ABOUT THE TEST
REFERENCE GUIDE
Remove socks and shoes and rest the subject with their feet laying on a sofa or bed. Remind them which is their RIGHT and LEFT leg, pointing this out by firmly touching each leg, saying “this is your right” when the right leg is touched and “this is your left side” when the left is touched. If you face the soles of their feet their right is on your left (see reference guide, page 1).
The Touch the toes test* is quick and easy, designed to assess sensitivity in your feet, and can be done in the comfort of your own home. Why is sensitivity important? Sensitivity is an important way that the body can alert you to other problems. Sensations, like sharp pain or throbbing, can tell you when you may have damage to a part of your body. In the case of feet, pain could be due to a burn, blister or cut and because you feel it you can take prompt action and appropriate treatment. If sensation is impaired you may not realise if minor damage has occurred and left unknown and untreated the risk of infection is increased. Infections and ulcers are also painful – but not if that part of the foot also lacks sensation.
2
5
1
3
6 4
R
L
3
Ask them to close their eyes and keep them closed until the end of the test.
4
Inform them that you are going to touch their toes and ask them to say right or left as soon as they feel the touch and depending on which foot was touched.
5
Perform the touch, using your index (pointing finger) as shown in the photos and diagrams.
6
The pictures also show which six toes should be touched and the sequence.
7
So, start by lightly touching the tip of the toe marked 1 (right big toe) with the tip of your index finger. The patient will respond by saying “right” if they feel the touch.
Knowing if you have impaired sensitivity requires you to rely more on regular visual checking for discoloration or swelling for instance. It is important to remember that impaired sensation itself does not cause infection and ulceration. Please note that the Touch the toes test is not a substitute for your annual foot review by an appropriately trained person.
Subject’s right foot, your left side
Subject’s left foot, your right side
*Officially known as the Ipswich Touch Test which was designed by Gerry Rayman and the team at Ipswich Hospital
8
Record the result by circling ‘Y’ on the attached record sheet. If they did not respond, circle ‘N’.
9
Now move to the toe marked 2, the right little toe, record the result, followed by the toe marked 3, the left big toe etc.
2
Remember: If the touch has not been felt do not press harder, and DO NOT try again. You can only touch each toe ONCE; if not felt this must be recorded by circling ‘N’ on the diagram right. There is no second chance.
R
If the subject correctly says right or left, circle ‘Y’ on the diagram right.
WHAT THE RESULTS MEAN AND WHAT TO DO NORMAL SENSATION
3
L
L
4
If you felt the touch at all six or five of the six toes, as shown in the example below, then your sensation is normal and you are not at increased risk of developing a foot problem because of lack of sensation. However, you must continue having the more detailed foot checks that you should be receiving annually. Y
Y
N
N
5 2
Y
5
R
N
6
L
Y N
Y
N
R
1
Y
Y
N
N
2
N
6
L
Y
Y
N
3
R
5 2
Y N 1
Y N
3
4
Y N
6
L
10 Continue until all the six toes has been checked.
1
N
Y N
5
2
1
3
Y
Y
N
N
6 4
The touch must be light as a feather, and very brief (1–2 seconds): DO NOT press, prod or poke.
1
R
• The touch must be light as a feather, and brief (1–2 seconds): do not press, prod or poke tap or stroke the skin. • If the person did not respond do not attempt to get a reaction by pressing harder. They did not feel; this should be recorded as not felt. • You must not touch each toe more than once. If not felt do not repeat the touch, there is no second chance.
Y N
Y
Y N
Using the index finger, touch the tips of toes following the sequence from 1 to 6 shown in photos and drawings shown on page 2.
VERY IMPORTANT!
2
Tuesday’s hotline is not so busy. The diabetes specialist foot nurse’s morning is spent following up on ward patients, while the specialist podiatrist’s task is to remove a toe and a metatarsal from a patient seen the previous week with unresolving osteomyelitis, despite intensive and prolonged antibiotic treatment. The close working relationship with the vascular surgeons permits the patient to be added to the end of their routine operating list, with the procedure being undertaken by the podiatrist and a surgeon. He will be reviewed postoperatively tomorrow by the podiatrist and the diabetes team. Over lunch there is time is catch-up time with the diabetes specialist foot nurse to discuss the ward patients. In the afternoon the previously identified ward patients with foot problems are reviewed. Additionally, an orthopaedic patient with a spinal problem has been found to have reduced foot sensation using the Ipswich Touch Test (see panel) and a red heel, spelling the potential for a pressure sore. After confirmation of the problem, a special casted heel protector is constructed to help prevent further damage to her heel. The ward staff are informed of how to off-load and monitor changes in the heel skin at least twice a day. A patient found to have diabetes after she was admitted with a severe non-resolving foot infection is reviewed.
REMINDER
The test simply involves very lightly touching six toes, three on each foot as shown to find out how many of the touches are felt. Importantly the touch must be gentle, light as a feather and brief.
1
Tuesday
RECORDING THE RESULTS
HOW TO PERFORM THE TEST
About the test
queries. Two inpatients who were identified as having potential heel sores are visited after clinic to make protective heel casts. As at the end of each day the hotline is revisited, but there are no additional calls this time.
www.diabetes.org.uk
4
L
R Subject’s right foot, your left side
Subject’s left foot, your right side
IMPAIRED SENSATION If you did not feel when touched at two or more of the six toes, as shown in the examples below, then you are very likely to have reduced sensation and may be at risk of a diabetic foot ulcer. This needs to be confirmed by further testing. We suggest you visit your surgery and ask for a full examination of your feet. After that examination you should ask for the results of the assessment and then if it is abnormal you should be referred to a diabetes specialist podiatrist, foot protection team, or the diabetes foot clinic depending on the severity.
Y
Y
N
N
5 2
Y N
Y N 3
Y N
R
Y
1
Y
Y
N
N 3
Y
N
N
6
L
R
5 2
Y N 1
Y N
4
The Ispwich Touch Test has now been validated for home use by carers of those with diabetes-related foot problems. It is proving to be a powerful awareness and education tool. The study, from the Diabetes Research Unit at Ipswich Hospital, won the Diabetes UK Education and Self-management award at this year’s Professional Conference held in Glasgow.
Y N
6
L
4
A charity registered in England and Wales (215199) and in Scotland (SC039136). © Diabetes UK 2012
3
Spring 2012 | DIABETESUPDATE | 37
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CARE DELIVERY
Unfortunately, despite intravenous antibiotics, a deep-seated abscess requiring immediate surgical drainage has developed in the middle of her foot. The situation is explained to the patient and then the hunt is on to find an available vascular surgery colleague and operating theatre time. Fortunately, it goes well and by late afternoon the patient is back on the ward. Again, at the close of the day, messages left on the answerphone are replayed before leaving.
Wednesday
Today is an all-day clinic, with a list of more than 30 patients, most of whom are well known and require regular follow up and monitoring to assess the progress of their foot ulcers. Many of these patients are casted and require reassessment of their casts. Two community-based podiatrists work in this clinic as part of an integrated multidisciplinary foot team. The clinic requires a high degree of co-ordination,
all members of the team: a consultant diabetologist, specialist podiatrists, diabetes nurse, phlebotomist, healthcare assistant, receptionist and our very important volunteers, who act as porters and provide support, including tea making, to the patients and relatives. The clinic is a hive of activity as all the patients have complex foot ulceration that require multi-faceted approaches, including detailed medical assessments, medicines reviews, debridement, X-rays, infection control, off-loading strategies, education, diabetes monitoring, vascular assessments and assessment of lifestyle issues. Several of the patients in today’s clinic have osteomyelitis requiring detailed review. There are four new patients, all of whom will require a detailed general medical and foot assessments by a physician and podiatrist in a quiet clinic room away from the main treatment area. Attention is paid to including the patient and their carers in deriving and
it is this close cooperation between many different disciplines that defines our multidisciplinary team and has driven our success in improving the care of patients with foot disease as many patients arrive via hospital transport, with several having to go directly to the renal dialysis unit after their appointment with us. The clinic layout is open-plan, with three treatment areas and a separate treatment area for patients with MRSA. During today’s clinic, several patients require conventional foot X-rays, or initiation or change of antibiotic treatment. Some patients require a new plaster cast or review of an existing one. One of the new patients seen in today’s clinic is an 87-year-old lady with early dementia who lives in a care home. She has developed a pressure sore. The care home staff attended so we were able to explain to them why the pressure sore had developed, how a heel protector cast that we would construct would help and what they need to do to help protect the ulcer until the skin healed. A patient-held record book that outlines the agreed management plan is given to the care home. At the end of the day letters are written and the hotline is checked once again.
Thursday
Today is the ‘bumper’ multidisciplinary team clinic. Starting at 8.30am and finishing between 1 and 2pm, it is the busiest of the foot clinics, attended by
understanding the care plans. A long morning, with patients requiring antibiotics, X-rays, plaster casts and advanced wound care, finally draws to a close. One patient is admitted for intravenous antibiotics, an MRI and, depending on the result, surgery to drain a suspected mid-foot abscess. At the end of clinic, district and community nurses are updated on changes to dressings or therapies and to discuss other concerns regarding continuing patient care between hospital visits. In the afternoon a co-ordinated visit with one of the vascular surgeons increases suspicions that there is a deep-seated abscess in the patient admitted from the clinic that will require at least incisional drainage, if not more, later today. A consultant radiologist agrees to expatiate on the MRI prior to surgery to help direct the approach and extent of surgery required. This is explained to the patient, who is now septic, feeling very unwell and only too keen to be treated. The MRI scan clearly shows a collection of fluid in between some of the metatarsal bones. The problem is addressed that same afternoon when the fluid is drained by a vascular surgeon and the diabetes specialist podiatrist.
Friday
Friday is shoe fitting clinic day, which is attended by a visiting shoe fitter and podiatrists. There are 17 people for fitting but also two urgently referred patients to be seen in the ad hoc emergency clinic. For patients who have had a healed ulcer, previous amputation or foot deformity, and cannot be accommodated in ordinary shoes, a range of special footwear is available. We actively involve all of the patients in shoe choice, as compliance is essential. Kevin, our shoe fitter, arrives at 8.15am and sees the first patient 15 minutes later. There are two patients attending for their first shoe fitting. The rest are routine follow ups for resupply or evaluation of existing footwear. One of the new patients has a very deformed mid-foot resulting from a diabetes-related neuropathic fracture. This requires a plaster cast to be taken of the affected foot so that an exact shape last of the foot can be made on which to make a correctly fitting shoe. In between observing several patients walk up and down in their new shoes to check for problems, and explaining new patients’ requirements to Kevin, the podiatrist has been treating some ulcer patients and assessing the two new referrals neither of whom have any urgent needs. These will be reviewed with the consultant in next week’s Thursday clinic. In the afternoon, the joint vascular/ radiology/diabetes foot clinic meeting takes place. Here, the week’s angiograms, and other images, are discussed and treatment plans formulated. After the meeting, patients on the wards are revisited before the weekend. The wound of a patient who had surgery the previous day is reviewed by the diabetes consultant, vascular surgeon and podiatrist. It was agreed that vacuum-assisted closure therapy may be helpful in reducing oedema, stimulating granulation and wound closure. A tissue viability nurse will initiate and monitor the vacuum device over the weekend. On reflection, at the end of the day, it is this close co-operation between many different disciplines that defines our multidisciplinary team and has driven our success in improving the care of patients with foot disease. So there you have it – a busy week in our diabetes foot clinic. We continue to work on improving the service. For instance, we have recently had valuable discussion with primary care colleagues on improving foot screening in the community and strengthening the community-based podiatric service.
38 | DIABETESUPDATE | Spring 2012
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”
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A charity registered in England and Wales (215199) and in Scotland (SC039136). © Diabetes UK 2012
36-40 CD SA2.indd 39
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Control and care matter Trajenta® – suitable for your hyperglycaemic adult type 2 diabetes mellitus patients as monotherapy in metformin-inappropriate patients and add-on to metformin alone or metformin + sulphonylurea1
Efficacy – significant HbA
1c
reductions versus placebo2–4
– HbA1c reduction sustained over 102 weeks as add-on to metformin + sulphonylurea5
Generally well tolerated – Trajenta , studied in over 4,000 patients in clinical trials, ®
has an overall incidence of adverse events that is similar to placebo1
Different – the first one dose, once daily DPP-4 inhibitor excreted primarily via the bile requiring no dose adjustment1,6–11
Prescribe – Trajenta
®
5 mg once daily1
TRAJENTA® 5 mg film-coated tablets Prescribing Information (UK) Film-coated tablets containing 5 mg linagliptin. Indication: Trajenta is indicated in the treatment of type 2 diabetes mellitus to improve glycaemic control in adults: as monotherapy - in patients inadequately controlled by diet and exercise alone and for whom metformin is inappropriate due to intolerance, or contraindicated due to renal impairment; as combination therapy: - in combination with metformin when diet and exercise plus metformin alone do not provide adequate glycaemic control; - in combination with a sulphonylurea and metformin when diet and exercise plus dual therapy with these medicinal products do not provide adequate glycaemic control. Dose and Administration: 5 mg once daily. If added to metformin, the dose of metformin should be maintained and linagliptin administered concomitantly. When used in combination with a sulphonylurea, a lower dose of the sulphonylurea may be considered to reduce the risk of hypoglycaemia. Patients with renal impairment: no dose adjustment required. Pharmacokinetic studies suggest that no dose adjustment is required for patients with hepatic impairment but clinical experience in such patients is lacking. Elderly: no dose adjustment is necessary based on age however, clinical experience in patients > 75 years of age is limited. The safety and efficacy of linagliptin in children and adolescents has not yet been established. No data are available. Trajenta can be taken with or without a meal at any time of the day. If a dose is missed, it should be taken as soon as possible but a double dose should not be taken on the same day. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Warnings and Precautions: Trajenta should not be used in patients with type 1 diabetes
or for the treatment of diabetic ketoacidosis. Caution is advised when linagliptin is used in combination with a sulphonylurea; a dose reduction of the sulphonylurea may be considered. Interactions: Linagliptin is a weak competitive and a weak to moderate mechanism-based inhibitor of CYP isozyme CYP3A4, but does not inhibit other CYP isozymes. It is not an inducer of CYP isozymes. Linagliptin is a P-glycoprotein substrate and inhibits P-glycoprotein mediated transport of digoxin with low potency. Based on these results and in vivo interaction studies, linagliptin is considered unlikely to cause interactions with other P-gp substrates. The risk for clinically meaningful interactions by other medicinal products on linagliptin is low and in clinical studies linagliptin had no clinically relevant effect on the pharmacokinetics of metformin, glyburide, simvastatin, warfarin, digoxin or oral contraceptives (please refer to Summary of Product Characteristics for information on clinical data). Fertility, pregnancy and lactation: Avoid use during pregnancy. A risk to the breast-fed child cannot be excluded. A decision must be made whether to discontinue breast-feeding or to discontinue/abstain from Trajenta therapy taking into account the benefit of breast-feeding for the child and the benefit of therapy for the woman. No studies on the effect on human fertility have been conducted for Trajenta. Undesirable effects: Adverse reactions reported in patients who received linagliptin 5 mg daily as monotherapy or as add-on therapies (pooled analysis of placebo-controlled studies). The adverse reactions are listed by absolute frequency. Frequencies are defined as very common (≥1/10), common (≥1/100 to <1/10), uncommon (≥ 1/1,000 to < 1/100), rare (≥ 1/10,000 to
< 1/1,000), or very rare (<1/10,000), not known (cannot be estimated from the available data). Very common: hypoglycaemia (combination with/ add on to metformin and sulphonylurea). Uncommon: nasopharyngitis (monotherapy; combination with/add on to metformin); hypersensitivity (combination with/add on to metformin); cough (monotherapy; combination with/add on to metformin). Not known: nasopharyngitis (combination with/add on to metformin and sulphonylurea); hypersensitivity (monotherapy; combination with/add on to metformin and sulphonylurea); cough (combination with/add on to metformin and sulphonylurea); pancreatitis (monotherapy; combination with/add on to metformin; combination with/add on to metformin and sulphonylurea). Prescribers should consult the Summary of Product Characteristics for further information on side effects. Pack sizes and NHS price: 28 tablets £33.26. Legal category: POM. MA number: EU/1/11/707/003. Marketing Authorisation Holder: Boehringer Ingelheim International GmbH, D-55216 Ingelheim am Rhein, Germany. Prescribers should consult the Summary of Product Characteristics for full prescribing information. Prepared in September 2011.
Adverse events should be reported. Reporting forms and information can be found at www.yellowcard.gov.uk. Adverse events should also be reported to Boehringer Ingelheim Drug Safety on 0800 328 1627 (freephone).
References: 1. Trajenta® Summary of Product Characteristics, August 2011. 2. Barnett AH et al. Poster No. 823-P. The European Association for the Study of Diabetes 46th Annual Meeting, 20–24 September 2010, Stockholm, Sweden. 3. Taskinen M-R et al. Diabetes Obes Metab 2011;13:65–74. 4. Owens DR et al. Diabet Med 2011;28:1352–61. 5. Boehringer Ingelheim, data on file LIN11-06a. 6. Vincent SH et al. Drug Metab Dispos 2007;35:533–538. 7. Januvia (sitagliptin) Summary of Product Characteristics. Available at: http://www.medicines.org.uk/EMC/medicine/19609/SPC/JANUVIA+100mg+film-coated+tablets/ (accessed January 2012). 8. Galvus (vildagliptin) Summary of Product Characteristics. Available at: http://www.medicines.org.uk/EMC/medicine/20734/SPC/Galvus+50+mg+Tablets/ (accessed January 2012). 9. Onglyza (saxagliptin) Summary of Product Characteristics. Available at: http://www.medicines.org.uk/EMC/medicine/22315/SPC/Onglyza+2.5mg+%26+5mg+film-coated+tablets/ (accessed January 2012). 10. Deacon CF. Diabetes Obes Metab 2011;13:7–18. 11. Blech S et al. Drug Metab UK/TRJ/00159n Date of preparation: January 2012 Dispos 2010;38:667–678.
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19/03/2012 13:55 15/02/2012 10:11
DIABETESUPDATE
INSULINS Name
Manufacturer
Source
Delivery system
Taken
Rapid-acting
Onset, peak and duration (approximate hours) 0
NovoRapid
Novo Nordisk
Analogue
Vial, cartridge, prefilled pen
Just before / with / just after food
Humalog
Lilly
Analogue
Vial, cartridge, prefilled pen
Just before / with / just after food
Apidra
Sanofi
Analogue
Vial, cartridge, prefilled pen
Just before / with / just after food
Actrapid
Novo Nordisk
Human
Vial
30 mins before food
Humulin S
Lilly
Human
Vial, cartridge
20–45 mins before food
Hypurin Bovine Neutral
Wockhardt UK
Bovine
Vial, cartridge
30 mins before food
Hypurin Porcine Neutral
Wockhardt UK
Porcine
Vial, cartridge
30 mins before food
Insuman Rapid
Sanofi
Human
Cartridge
15–20 mins before food
Insulatard
Novo Nordisk
Human
Vial, cartridge, prefilled insulin doser
To be determined by the healthcare team
Humulin I
Lilly
Human
Vial, cartridge, prefilled pen
About 30 mins before food or bed
Hypurin Bovine Isophane
Wockhardt UK
Bovine
Vial, cartridge
To be determined by the healthcare team
Hypurin Porcine Isophane
Wockhardt UK
Porcine
Vial, cartridge
To be determined by the healthcare team
Insuman Basal
Sanofi
Human
Vial, cartridge, prefilled pen
45–60 mins before food
Humulin M3
Lilly
Human
Vial, cartridge, prefilled pen
20–45 mins before food
Hypurin Porcine 30/70 Mix
Wockhardt UK
Porcine
Vial, cartridge
To be determined by the healthcare team
Insuman Comb 15
Sanofi
Human
Cartridge
30–45 mins before food
Insuman Comb 25
Sanofi
Human
Vial, cartridge, prefilled pen
30–45 mins before food
Insuman Comb 50
Sanofi
Human
Cartridge
20–30 mins before food
Humalog Mix 25
Lilly
Analogue
Vial, cartridge, prefilled pen
Just before / with / just after food
Humalog Mix 50
Lilly
Analogue
Cartridge, prefilled pen
Just before / with / just after food
NovoMix 30
Novo Nordisk
Analogue
Cartridge, prefilled pen
Just before / with / just after food
Hypurin Bovine Lente
Wockhardt UK
Bovine
Vial
To be determined by the healthcare team
Hypurin Bovine PZI
Wockhardt UK
Bovine
Vial
To be determined by the healthcare team
Lantus
Sanofi
Analogue
Vial, cartridge, prefilled pen
Once a day, any time (at same time each day)
Levemir
Novo Nordisk
Analogue
Cartridge, prefilled pen, prefilled insulin doser
Once or twice daily (at same time each day)
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
32
34
36
Short-acting / neutral
Medium-acting
Mixed
Long-acting
Information supplied and checked by the manufacturers: Lilly 01256 315000, Novo Nordisk 0845 600 5055, Sanofi 08000 352525, Wockhardt UK 01978 661261
duration onset peak
Times are approximate and may vary from person to person. This is a guide only.
020 7424 1000 | info@diabetes.org.uk | www.diabetes.org.uk A charity registered in England and Wales (215199) and in Scotland (SC039136). Code 6434w. ©Diabetes UK 2012.
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