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Cambridge Diabetes Study Day - 6 February 2019

The supporting guidance and presentations from this event are on the 'Related Documents' tab to the right.

The Q&A is below (and also available as a download in the Related Documents tab).

STRUCTURED EDUCATION QUESTIONS

DESMOND

Is there a DESMOND course for patients who speak different languages?
There is currently no DESMOND course available in the area in other languages

NDPP

Those with gestational diabetes are being missed.  Could they be referred into the programme even if HbA1C is below 44mmols/mols
At present those with a diagnosis of gestational diabetes are not catered for in the NDDP unless when they have their annual HbA1C measured and it is above 44mmols/mols - then they can be referred into the programme like everyone else. This is something we can feed back to the national programme as it would be a good idea that they are included.

There is no alert for pre-diabetes or gestational diabetes on GP systems
If the patients are coded with the diagnosis of gestational diabetes or pre-diabetes then this goes into their problem list so each clinician can see, and also allows admin to do searches on patients that need annual HbA1c. The DPP have IT advisers that could answer the question for system one - Jo Fallon will have their contact details.

Dietitian Talk

Does low carb diet have adverse effect on Lipids?
If someone lost weight on a low carb diet that could reduce their cholesterol. However, if they replace the carbs with foods high in saturated fat, that could increase their LDL cholesterol. 

Are eggs ok?  Do they raise cholesterol?
Eggs are a source of dietary cholesterol but it is in fact saturated fat in the diet that raises cholesterol so eggs are fine (unless someone has familial hypercholesterolaemia where the few dietary sources of cholesterol would also need to be limited)

How do you get a voucher for the low carb app?
Currently the CCG do not commission a voucher scheme for the low carb app however this will be reviewed following the publication of the NHS Long Term Plan by the Diabetes Clinical Community.

Podiatry Talk

What do you see and not see?
We see people with diabetes who have a problem with their feet. These problems can be an ulcer, pain, swelling, deformity or combination of all. Many of these problems are driven by poor circulation, neuropathy and infection and are made more tricky by other medical, social and personal issues. We try and view problems in the feet in a holistic way as problems arising in the feet are so often another manifestation of wider systemic problems. We try not to be prescriptive and would much rather see someone once, reassure and discharge rather than see them late in the disease process, especially when a more timely intervention would have made a big difference. When you see a foot problem in a person living with diabetes ask “ Why has that problem occurred on that foot at this time and what processes have contributed to what I see in front of me?” It’s not good enough just to say “Because they have diabetes”- that offers no solutions. If in doubt, ask. 

One common question we get is whether we need to see people who have high risk feet ( e.g., absent pulses, confirmed neuropathy) but who currently have no active foot problems and are pain free. Such people should be able to access all the care they need in the community and should have access to appropriate footwear without needing to go through our foot clinic. However, we are happy to advise at any time.

Because we aim to be a reactive clinic that can deal with emergencies in a timely manner, we also do not need to see people whose only clinical need is good nailcare and chiropody. This should be accessible in the community.

Can you have an ischaemic foot even though you can feel pulse?
If you can feel and count 2 good pulses in the foot (much as you do at the radial pulse at the wrist) this is very reassuring.  However, feeling for pulses is just part of the assessment. Look at the whole foot and consider the nature and location of the lesion. If there is one pulse missing and there is a part of the foot likely to have previously supplied by that artery, this may warrant further investigation. For example, if there is an ischaemic looking lesion under the heel and only the posterior tibial (PT) artery is impalpable, then it may be that there is little cross filling from the other arteries and that the blocked PT is the culprit. This is the “angiosome” concept, referring to an anatomic unit of tissue fed by a source artery. 

Pulses can be tricky and if there is a clinical concern that ischaemia is driving a problem much better to seek help and a further assessment.

How do you score zero on sight (sinbad score)?
The SINBAD score focuses on the index lesion on the foot

Sinbad Score.jpg

As such, there is no measure of eyesight in the score.  However, inability to see a lesion is a worrying factor that must be taken into account when advising people with a high risk foot. If someone cannot check their neuropathic foot themselves, someone else ( carer, family, friend) needs to help. Further, asking someone with impaired vision to be vigilant to changes in appearance in a lesion is not going to be plan that is likely to succeed. 

The Diabetic Foot: Podiatry Perspective

What makes a good shoe?
This the Footwear Advice Leaflet from CPFT which summaries the features of a good shoe.  Remember to tell patients, it is not about cost!   I recommend one thumbs width from the longest toe when looking for the best fit/right size (my rule of thumb)!

Footwear Advice leaflet

Who do you contact out of hours?
Contact your foot protection team at your GP surgery, A&E or Out of Hours Surgery, or the Podiatry Department for advice on: 03307 260077 if you discover any problems with your feet or if:

  • A cut or abrasion hasn’t healed within a week
  • Or if you notice any signs of infection (swelling, redness or pain) anywhere on your foot or leg.

National Severe Insulin Resistance Service

Is fertility effected?
Yes – they can have problems with periods and can struggle to conceive.

Is the bariatric surgery only for overweight patients?
Access to Bariatric Surgery is via individual funding requests.

Psychological Wellbeing Service

Can patients self-refer to silver cloud?
Patients can register through PWS and they will be able self-refer soon to the silver cloud.

Do you see people as couples?
Partners tend to join the sessions after a while.

Diabetes in Pregnancy

Should Type 2 ladies who are pregnant be prescribed Metformin (if they are not already)?
Sometimes.  If patients are already on Metformin don’t stop it. 

Why do they need a higher dose of folic acid?
There is an increased risk of Spinabifida 

Is it a low threshold to start aspirin?
Yes

26/04/2019