Noticeboard: Vol 11 No 5

Titrating insulin doses
Q Has anyone devised a protocol for district nurses for tirating insulin doses? We are hoping to incorporate such a protocol into care plans so that people can titrate their insulin on a weekly basis according to blood glucose and hypoglycaemia without the need for a GP to sign for it each time, which would save everyone valuable time. They would, of course, receive adequate training.
Susan Aderman,  Community Diabetes Specialist Nurse, Cambridgeshire PCT

A With district nursing services stretched to the limit, I would have thought they should only be supporting people with insulin who cannot self inject owing to visual impairment/manual dexterity or mental impairment, in which case it may be difficult for them to self adjust anyway.
Jill Hill, Diabetes Nurse Consultant, Birmingham East and North PCT

Toe troubles
Q Why do renal patients suffer spontaneous apical necrosis of the feet?
Anna Evans, Community Podiatrist, Suffolk PCT

A One reason is vascular occlusion of small vessels but there is also a condition called calciphylaxis that can be seen in people with end-stage renal impairment and has a poor prognosis.
Scott Cawley, Lead Specialist Podiatrist, Cardiff

Adrenal glands and cortisol
Q What effect do adrenal glands and cortisol levels have on type 1 diabetes? I am seeing a child whose levels are so erratic that I was wondering if I am missing something else. Could there also be an adrenal problem?
Name and address withheld

Painful neuropathy
Q We are interested in whether any other DSN teams offer a nurse-led service of assessment and treatment of painful neuropathy. We are in the process of designing such a service and would value other colleagues’ experiences. 
Phil Gardner and Julie Wood, DSNs, Bradford

A I have had experience of setting up a neurovascular assessment service in both primary care and the specialist (acute) care settings. The aim of the clinic is to ensure that patients with suspected vascular deficiency and/or painful neuropathic symptoms are referred for high-quality assessment, care and information as well as gaining access to a pathway of care that is systematic and evidence based. 

The painful neuropathy care pathway is about to be launched by Enfield PCT. It has been written in conjunction with local diabetes specialist teams, podiatrists and pharmaceutical advisors for the PCT and has been approved by our Professional executive committee in Enfield PCT (www.enfield.nhs.uk).

One clinic is held per week with eight patient slots. Four slots are for new-patient assessments and four slots for follow up of patients already on the neuropathy care pathway.

Foot assessments are carried out and include the following.

• Foot pulses assessed at posterior tibial and dorsalis pedis sites.
• Doppler studies are undertaken and ankle–brachial pressure index (ABPI) is calculated.
• Testing to diagnose neuropathy with 10g monofilament and Rydel–Seiffer calibrated tuning fork.
• Treatment commenced, as per neuropathy care pathway.
• Basic risk assessment and information on the following:
  – Smoking
  – BP control
  – Aspirin
  – Cholesterol
  – Diabetes control
• Education and information on foot care.

The healthcare team is informed of outcomes and expected follow up. Approximate costs for initial equipment are as follows (all prices are approximate and exclude VAT):

Equipment                                                                             Cost
Diabetic foot kit                                                                     £700.00
(includes hand-held Doppler† and 10 g monofilament)
Extra anaeroid sphygmomanometer with extra large cuff   £65.00
Reidel–Seiffer tuning fork                                                      £66.13
Total‡                                                                                     £831.13

†Extra warranty may be purchased for the hand-held doppler.
‡There will also be ongoing costs for consumables.

Kit McAuley, DSN/Diabetes Facilitator, Enfield PCT