Welcome to our first digital issue of Diabetes & Primary Care. I hope that you received our e-journal and that it made it easy for you to link directly to the resources you want to read. You will notice that DiabetesontheNet.com, where the journal is hosted, has been completely redeveloped to make browsing faster and simpler, and to display content in a way that is easier to view. We would welcome your feedback on what works and what needs further tweaks to improve your experience. Please encourage colleagues and friends to view articles that you find useful, particularly if they may not have read the journal previously. The fully responsive digital format resizes for phone, tablet or desktop use. Navigation has been improved with the creation of a range of clinical hubs, each one aggregating all the articles, e-learning and events relating to a particular area of interest. Searching is easier and your personal area for recording your learning and event attendance has been enhanced.
For those of us who still prefer to read journals on paper, a PDF file of each article can be downloaded and printed before you return to the digital journal to enjoy the interactive resources, such as the Welsh Government-funded module on Pre-conception, Pregnancy and Postnatal Advice for Women with Diabetes. For this and future featured modules, the journal will give you the opportunity to test your knowledge of the topics covered so you can individualise your learning and hone in on the most personally useful parts to study. Over the next few issues, we will be featuring modules on diabetes diagnosis, diabetes prevention, blood glucose monitoring and a primary care-orientated module to support our care of children and young people with diabetes.
In this issue
We begin our new series of Tools to Support Practice by showcasing Diabetes UK’s Information Prescriptions. Many of us already use these to agree self-management plans and help motivate people with diabetes to set and achieve goals. An expanded range of information prescriptions is now available on SystmOne, EMIS and Vision for downloading and activating.
Kevin Fernando previously shared his perspective on the new SIGN 154 guideline and, in this issue, he provides a useful summary of the glucose-lowering drugs, including the summary algorithm from the guideline.
Clare Bailey helps us understand The 8-week Blood Sugar Diet in our series What People with Diabetes are Reading. Linked to this, Associate Editor-in-Chief Jane Diggle shares her very positive practice experience of helping people implement this way of eating.
Matt Capehorn encourages us to make more effort to diagnose obstructive sleep apnoea (OSA) and will return in the next issue to update us on when to refer and how to manage OSA to help reduce the significant morbidity and mortality associated with this condition.
It gives me great pleasure to highlight Gwen Hall’s PCDS Lifetime Achievement Award in Part 2 of our PCDS conference report. The award recognises Gwen’s contribution to the PCDS, her role as Associate Editor-in-Chief of Diabetes & Primary Care, supporting my two predecessors, Eugene Hughes and Colin Kenny, and her enthusiasm and skill in improving patient education and delivering quality diabetes care throughout her (continuing) career – all this while also being a wonderful wife, mother and friend.
Following positive feedback on Part 1, we share the second tranche of presentations from the November 2017 PCDS conference in the same bullet-point format, ensuring that it is easy for us to read and retain our speakers’ key messages. In future issues, we will share highlights from our regional PCDS conferences and the ADA and EASD, so if you are attending these conferences and want to contribute summaries of one or two presentations, please contact our in-house editor, Richard, at email@example.com.
Diabetes and surgery: a bad combination?
A prospective randomised observational study of 7565 inpatients published in this month’s Diabetes Care (Yong et al, 2018) identified that almost one third of surgical inpatients aged 54 years or older had diabetes. Having diabetes or higher HbA1c were associated with poorer surgical outcomes. Those with diabetes had increased mortality at 6 months post-surgery. For each percentage increase in HbA1c, there was a significant increase in major complications, ICU admission and hospital length of stay. In contrast, there was no significant association found between prediabetes and poorer postoperative outcomes.
In response, Ketan Dhatariya’s How to prepare people with diabetes for surgery provides guidance on information to include in our referral letters and how to optimise glycaemic control and other aspects of care at this important time. Of course, sometimes people with diabetes will need emergency surgery and then we don’t have time to optimise blood pressure (BP), glycaemia and smoking cessation but, if we can help tighten glycaemic control prior to surgery, it can be associated with improved postoperative outcomes.
Unsung heroes: our in-house diabetes team
Over recent weeks, I have become aware of significant contributions to the care we are offering to people with diabetes by new additions to our diabetes team – our reception and administrative staff. Previously, our diabetes specialist practice nurse and I undertook much of the administrative work, including our call and recall system, ourselves. Now we are overjoyed to be able to share many tasks with our highly skilled admin team.
Although the changes are just getting started, already people with diabetes are commenting on the beneficial changes. We have updated our systems for coding hospital diabetes review letters and automated our responses to diabetic retinopathy screening DNAs to ensure that we help people understand the importance of this aspect of care and that they have another early invitation to attend. Whenever possible, we have delegated tasks and generally smartened up our systems, leaving our clinical team to focus on what we do best – hands-on care for people with diabetes.
This is, of course, completely in line with the Welsh Government’s early recommendations on prudent healthcare, which remind us that we should each “do only what only you can do”. The time saved from administrative tasks will allow additional reviews of our most needy people with diabetes, including those in nursing and care homes, and reviews of those who are truly housebound are ongoing. By offering more flexible surgery diabetes annual review appointments for our frail elderly, we anticipate that many “almost housebound” people will be able to attend surgery with the support of family or friends. Those who have already attended tell me they thoroughly enjoyed being out and about again, and that they are determined to make the effort to get out more in future, when support allows.
Revisiting BP targets
The concept of “how low should we go” with blood pressure targets in people with diabetes has been fiercely debated over the years. The June 2018 issue of Diabetes Care refuels the debate with editorials (Lamprea-Montealegre and de Boer, 2018) and comment pieces accompanying clinical papers. Reviewing the divergent findings of the ACCORD-BP study (which included people with diabetes) and the SPRINT study (which did not), several authors reopen the debate of potential benefits from BP control <140/90 mmHg in those with diabetes without underlying renal or eye disease. Attempts to apply the SPRINT study findings to subsets of participants in the ACCORD-BP study demonstrate conflicting findings (Buckley et al, 2017; Mi and Mukamal 2018).
Building on this information, in our next issue, Papers That Changed Practice returns in a new format with hypertension – leading us through diabetes history, and reminding us how blood pressure management moved on from UKPDS-BP to ACCORD-BP and beyond. We’ll learn how our current BP targets evolved to their current levels, have the chance to try out Rutter and Sattar’s (2018) tool to help us individualise BP targets, understand whether drug choice or BP achieved is more important, and why we no longer combine ACE inhibitors with ARBs.
Thank you to you, our readers, for making our first digital issue of Diabetes & Primary Care successful. Please tweet and share the resources that you find useful with colleagues, and look out for alerts when we add new content to the site between issues.
Until we meet again, have a good summer and I hope you all have the chance to enjoy some “down time”, whether you choose to stay at home or to travel.