ATTD 2019: Conference Report

16th May 201916th May 2019 Deborah Glover News ATTD, Diabetes, PWD

Advanced Technologies and Treatments for Diabetes 2019 – Berlin: Conference Report

As ever, the ATTD annual conference was a masterclass of organisation and content. Three days of lively interaction and almost too many sessions to attend, meant that delegates left for home with full brains and many, many bags full of papers, gizmos and chocolates…

While I am not a diabetes nurse specialist, attending the ATTD conferences gives me valuable insights into the amazing research being undertaken to make the life of PWD easier. I must thank Kenes, the organisers, for generously giving me a press delegate badge, which allowed access to all areas (mostly!). Here I present some of my thoughts and take-home messages from this fabulous event.

Take-away messages

Medtronic – 670g launched in Europe; aim to have a personalised closed-loop system that will keep time-in-range >85%, and adapt to behaviour and physiology within next two years. CareLink system promoted
Dexcom – Reporting 670g/SmartGuard suspend-before-low studies, and giving a clear message that continuous glucose monitoring is effective at reducing glycaemic variation. G6 CGM promoted. Latter can be liked to Siri and Apple watch
Sanofi – Gla-300 improves glycaemic control by 30-40% when used with CGM and CSII; 2^nd generation basal insulins are better and will be better with technology
Time in Range – More effective metric for reflecting glycaemic variability than HbA1c
Harvard Closed-Loop System – Working towards and ecosystem; human-centric design, towards wearable devices. Currently trialling use of smartphone-connected AP rather than having separate handset
The Accu-Chek Solo micro-pump – Comprised of an inserter, pump holder, 6mm or 9mm cannula, a durable component, a reservoir and a controller. Reservoir holds up to 200 units of insulin, and the controller allows full pump control, bolus (extended and dual), temporary basal rates and SMBG. It is also removable during use
Tandem – T:slim X2 insulin pump with Basal-IQ predictive low-glucose suspend (PLGS)
Commence CGM immediately post-diagnosis
The portable diabetic retinopathy camera was the star of the exhibition – never have so many eyes been photographed in such a short period of time!

1. Plenary Sessions

Decision Support Systems (DSS)

Do we need DSS? – eGlycemic Management System (eGMS) (Glytec). Such systems can help improve quality of life and achieve better clinical outcomes. The eGMS dosing algorithms for intravenous, subcutaneous, and pediatric insulin are standardised, thereby facilitating a decrease in rates of hypoglycaemia and hyperglycaemia by analyzing the data and providing efficacious real-time dosing recommendations. Can be used in hospital and home settings. 2018 study demonstrated 95% of pts within target (with associated reduction in hypos), a saving of 72 minutes per nurse, and a decrease in length of stay. This amounted to a total saving of $9.7m

ATTD Yearbook

This session outlined the articles contained in the 2018 ATTD yearbook, with comment from the ATTD selection committee.

2. Parallel Sessions

Closed-loop systems: where are we now?

Medtronic 670g hybrid closed-loop in USA – Delivers auto-basal every five minutes in accordance with a number of parameters. It has improved time in range; however, needs to be calibrated 3-4 times per day , carbohydrate intake has to be entered and it does not share information via Bluetooth

Cambridge closed-loop system – In a 12-week RCT comprising children, adolescents and adults, over 12 weeks using either closed-loop or SAP, time to target was improved by 11%, mean glucose reduced by 0.8% to 3.9mmol/dl, HbA1c reduced by 0.4% (baseline 8.3%) and time in range improved. In a three-week RCT (KidsAP), using U100 or U200 aspart insulin in the closed-loop system, the study group achieved 70% time in target. Another study of the system vs standard treatment over 7 days resulted in a 20% increase in time in range for the study group

Harvard closed–loop system – 12-week study, 24h ambulatory AP; 88% of time spent in range, 1% <70mmol/dl. New development – working towards and ecosystem; human-centric design, towards wearable devices. Currently trialling:

- use of smartphone-connected AP rather than having separate handset
- use in pregnancy
- other biomarkers and how they may enhance the AP system

University of Virginia closed-loop – Project NIGHTINGALE; international study using InControl with a variety of CGM and pumps or Tandem, Control-IQ, and Dexcom CGM (includes auto insulin correct, a dedicated hypo safety system and intensified control overnight) to explore time spent <70mmol/dl during early evening/night closed-loop control. Of 60 who have completed study, 33 had the mobile configuration (inControl) and 23 had embedded control (Control-IQ). Results from evening/overnight closed-loop control showed that both systems improved time in range and decreased the number of hypo episodes. Both had good connectivity. There was an overall preference for the use of the system for 24 hours rather than just overnight

Psychological interventions to increase the use of technology in T1D pts

Adherence to insulin pump behaviours in young children – Children often administering insulin without full information (e.g. carb count or blood glucose measurement). Review of information showed that: 42% of parents are not entering child’s BG, but administering insulin; many parents calculate their adolescent’s dose, and that parents adherence to pump advice relate to their child’s glycaemic outcomes. However, feeding back pump and CGM information to parents helps them correct behaviours and identify why they are reacting to BG readings rather than implementing behaviours to prevent. The REDCHIP programme has demonstrated a decrease in fear of hypo, parenting stress, diabetes stress and child HbA1c

Psychosocial aspects and diabetes technology – The burden of treatment can often outweigh the benefit, especially in diabetes. Challenge to ‘onboard’ PWD. A number of educational interventions can help to manage diabetes distress etc, and improve ‘on-boarding’ with regimens, thereby reducing HbA1c. Also have to consider how to deal with the emotions PWD feel when they have ‘adhered’ to regimen, yet targets are not being met. In summary, effective ‘on-boarding’ can be achieved by; an effective assessment of user needs beyond glycaemic control; personalising device settings such as alarms and individual targets; considering the barrier to and benefits of pump use, balancing technology with psychosocial needs

Preventing poor psychosocial and glycaemic outcomes in teens – Teens are emotional decision makers; make technology easier for them to manage, make it wearable and comfortable. May have to consider ‘buy-in’ for only short periods, then review. Manage expectations

3. Industry Symposia and Industry Parallel Sessions

Sanofi: Viewing the diabetes spectrum through a new lens

Drivers of unmet needs. Fear of hypo from both clinicians and patients often prevents starting of insulin (in Type 2) and leads T1D to adjust their own dosage (especially after a hypo).

Dynamic titration, whereby insulin is titrated within the first 8-12 weeks is successful in 70-80% of PWD. An early glycaemic response is predictive of long-term control; a hypo during the first 12 weeks of insulin therapy indicates a six-times greater likelihood of long-term hypo risk. BRIGHT Study: Gla-300 vs Deg in T2 insulin naive pts or those with uncontrolled glucose. Both insulins had similar effect in terms of reducing HbA1c. Majority of changes occurred in first three months, with little change after (predictor of long-term control). Incidence of hypo throughout the day was numerically lower for Gla-300.

Improving outcomes in T1D – Hypos affect quality of life, contribute to lost productivity, increased healthcare costs, and are linked to cardiovascular problems. Minimising glycaemic variability (GV) is therefore critical; however, GV within day and between day makes insulin dose titration difficult, as do individual requirements, variable delivery and variable pharmcokinetics.

Gla-300 improves glycaemic control by 30-40% when used with CGM and CSII; 2^nd generation basal insulins are better and will be better with technology

Time in range and GV – HbA1c metric is easy, cheap and predictive of vascular problems; however, the ‘ideal’ level varies between countries and physicians, it only represents an average and doesn’t reflect GV. Pts understand % time in hypo range, % time in hyper range and % time in target, and GV.

– Time in range can correlate to/be indicative of potential complications such as retinopathy; a 5-10% increase in time in range (commonly 70-180[in some cases 140]mmol/dl) is a benefit

– GV is a determinant for risk of hyper & hypo episodes. It reflects amplitude and time, and glucose excursions. It is measured by the coefficient of variance (above 36% represents and increased risk of hypo) and low blood glucose index. Recent study demonstrated that using Gla-300 vs Gla-100 resulted in fewer nocturnal hypos and a smoother 24h GV profile.

Medtronic: Automating insulin delivery to maximise glycaemic control with SmartGuard Technology

Technology can help reduce sever hypo. Hybrid closed-loop 670g now available in Europe. Has auto-basal function (changes very few minutes at different rates). This counteracts Dawn phenomenon and frequency of hypo vs those who programme basal rate ahead of time.

– Aim that in next 2 years will have a personalised closed-loop system that will keep time-in-range >85%, and will adapt to behaviour and physiology.

SMILE Study – Use of MiniMed 640g with SmartGuard suspend-before-low compared with CSII (MiniMed 640g without CGM) in high-risk (hypo unaware) patients. Six-month study. Results showed 73% reduction in number of hypo events, 79% reduction in time spent in hypo and a significant reduction in patient reported fear of hypo. Concluded that suspend-before-low feature provides additional benefits to CSII users

MiniMed 670g: Increasing time-in-range – Study of 670g with SmartGuard auto mode and 670g manual mode. HbA1c dropped to 6.9% from 7.4% in study group. Reduced glycaemic variation seen, particularly in the early hours. Time-in-range (increased by 10%) was similar to other pivotal studies.

Next steps in closing the loop – CareLink – software that enables you and the healthcare provider to download and see historical data that has been collected in the form of graphs, charts and reports

Dexcom: Fit for the Future – Merging Technology and Digital Solutions for Integrated Diabetes Management

Progress towards closed-loop therapy using Dexcom CGM. The Control-IQ, Dexcom and Tandem Control algorithm gives an auto-correction bolus, has automatic basal-rate modulation and takes into account insulin-on-board and other factors to prevent hypo.

2015-2018 Steady State AP (artificial pancreas) study: Protocols developed for mobile closed-loop control. 125 participants. Time-in-range (<70mmol/dl) improved, particularly overnight

CGM-Based decision support for multiple daily injection pts using Dexcom CGM – Less than 50% of T1D pts reach their glycaemic target. In addition, only a small fraction of data generation by devices is used; however, treatment decisions are multifactorial and their impact changes daily. Breton et al (2018); pilot of patient-facing decision support system, (automated insulin titration, bolus calculation with glycaemic prediction and insulin-on-board, carbohydrate treatment advice and hypo alerts). The DSS significantly reduced glycaemic variation, while maintaining glycaemic control by reducing hypoglycemia exposure.

Technology innovation – Dexcom G6: No finger-pricking or calibration required, urgent ‘low-soon’ alert, custom alert schedules, 10-day wear sensor, indicated for treatment decision/dosing, and MARD 9%. Soon to have improved data share facility (10 people), Dexcom CLARITY (more information on glucose trends), compatibility with Apple watch and Siri (can ask latter for glucose reading), and reminders for sensor expiry. Will be compatible with a number of insulin delivery devices (iCGM)

Roche: Integrated, personalised diabetes management. Connecting the dots

Big data – the future of diabetes management – Healthcare data such as electronic medical records, wearable data and genetic data accounts for 80% 0f internet traffic. Unfortunately, it is complex, presented in various formats, and is unstructured, inconsistent and not commoditised. Such data can determine; triggers of high management costs, preventative measures, admission/readmission reduction and contribute towards decision support tools and therapeutic algorithms.

– Tools include: prevention, diagnostics, treatment and monitoring (e.g ‘patientslikeme’, Glooko, etc) MySugr has demonstrated improved glycaemic management in terms of HbA1c and time in range. BlueStar, a patient coaching app and helped reduce both hospital visits by 58% and HbA1c.

– Challenges to the introduction of such tools include; payer reimbursement, reach (availability), changing physician behaviour (from pills to behavioural management/decision support system advice). However, funding bodies are demanding

better outcomes in care, as are PWD, so adjunctive tools are being adopted where possible

– Predictive analytics: 1. define desired clinical outcome 2. Choose correct technology features (real-time personalised content and features) 3. Understand full-care ecosystem (connectedness to total care ecosystem) 4. Establish new capabilities and ways of working (holistic operating model)

Drugs, data and technology: how to overcome clinical inertia – Despite available guidelines for management, inertia remains an issue; doctors and PWD reluctant to change treatment regimen despite evidence that alternatives may be better in terms of outcomes. Insulin titration is often delayed even if BG indicates a need to change.

– PROValue study – integrated, personalised diabetes management programme (T2D with insulin) which included lifestyle interventions and pharmaceutical adaptation. HbA1c was lowered by 0.5% as a result of earlier, more frequent changes to insulin dosing

Insertable CGM technology – 6-month sensor (Eversense) wear time – 27% of CGM users discontinue during 1^st year due to trouble inserting the sensor, discomfort, dislocation of sensor during activity, privacy, skin reaction, or payer issues. The Eversense is implanted sub-dermally and can be left in-situ for up to 180 days. The PRECISE study demonstrated that % time in target ranged from 53% to 69% across countries studied.

Taking CSII to the next level; new pump solutions – Micro-pumps are the next big thing. Current patch pumps, although proven to reduce HbA1c and hypo frequency, particularly in those at highest risk are thought to be wasteful (environmental impact and waste of insulin), increase the risk of occlusion as the site is not visible, and require an additional device. In addition, data from patch pumps and tethered pumps can vary.

The Accu-Chek Solo micro pump is comprised of; an inserter, pump holder, 6mm or 9mm cannula, a durable component, a reservoir and a controller. The reservoir holds up to 200 units of insulin, and the controller allows full pump control, bolus (extended and dual), temporary basal rates and SMBG. It is also removable during use

Suggest the future is about; connectivity (using mobile phone as controller or data hub); safety (low-glucose suspend, carbohydrate recommendation); flexible design (tube length personalised), and automated insulin delivery.

Novo Nordisk: Towards ideal mealtime insulins

Changing paradigm in mealtime insulins – Increasing concern regarding post-prandial spikes and associated correctional behaviour. Current fast-acting insulin analogues take about 10 minutes to lower glucose, maximum insulin concentrations not reach for 60 minutes, and PWD have to wait 15-20 minutes post-injection before a meal, all of which affect quality of life. Aim of new insulins is to address these issues. Prandial insulins with hyaluronidase accelerated pharmokinetic activity and post-prandial glucose control.

– New insulins: Biochaperone lispo (former affects stability and solubility), Trepostrinil lispo (former is local vasodilator, citrate increases vascular permeability) and Fast-acting insulin aspart (FAIA) (niacinamide is an absorption modifier, arginine increases stability)

– Biochaperone lispo causes faster insulin kinetics compared to lispro

– Fast acting aspart concentration maximised 4.9 minutes earlier than insulin aspart, had a two-fold higher insulin exposure and a 74% greater insulin action within first 30 minutes

Fast-acting insulin aspart; clinical data – Greater early insulin exposure seen in CSII users and FAIA (vs insulin aspart). In pump use, when FAIA was compared to insulin aspart, onset of exposure was 11.8 minutes earlier, insulin exposure within the 1^st 30 minutes was three-fold higher and offset of exposure was 32.4 minutes earlier. When given as subcutaneous injection, results were 9.5 minutes earlier, two-fold higher and 12.2 minutes earlier respectively, suggesting that FAIA is more effective when used in CSII

– Pharmacokinetics: FAIA has an earlier onset, greater earlier and maximum insulin exposure and similar total exposure (to insulin aspart)

– Pharmacodynamics: FAIA has a great early glucose-lowering effect and a similar total maximum early glucose-lowering effect

– Conclusion from ONSET studies: Mealtime and pos-prandial FAIA may be an effective treatment option in children and adults with T1D using pump or MDI therapy, with detemir or degludec as basal insulin;

Technological advances in diabetes care – Self-care is the key to diabetes management, but need to address unmet needs such as fewer complications, better GV control, and improving adherence. 71% of audience stated that CGM had made the biggest difference to the lives of their pts (insulin pumps 22%, smartphone apps 7%) due to better HbA1c control, identification of post-prandial hyperglycaemia, overnight hypoglycaemia and daily glucose trends. However, these have issues, ranging from price per unit, wear time and interstitial glucose reading rather than blood.

– Abbot Libra: Requires no calibration, stays in-situ for 14 days, shows real-time glucose result with an eight-hour historical trend, a glucose trend arrow, and allows data-sharing with HCPs

– Freestyle Libra 2: Bluetooth technology allows dangerously high/low glucose alerts and has MARD of 9.5%

– Upcoming ventures: Tandem/Dexcom/TypeZero collaboration, Diabeloop, Boston insulin alone trial, Senseonics/Roche/TypeZero collaboration soon

T:slim X2 insulin pump with Basal-IQ predictive low-glucose suspend (PLGS) technology – reducing hypoglycaemia without finger-pricks

User experience research – Technology has to work and be easy to use – 80% of medical device errors are due to pt error. User-centric design was important in developing T:slim. Software is updatable (charges may apply). PLGS algorithm predicts glucose trend in near future and suspends insulin delivery if hypoglycaemia is suspected (based on previous 4 glucose sensor readings), as opposed to threshold suspend where hypoglycaemia is required to suspend.

– PROLOG trial: At-home randomised RCT of PLGS – T:slim pump and Dexcom G5 sensor (no alerts sounded when insulin suspended [80mmol/dl]). Delivery resumes when sensor glucose is rising, or glucose is no longer predicted to fall below 80mmol/dl, or absence of CGM data for 10 minutes, or suspension exceeds 120 minutes in any 150 minute period. Results – sensor time spent <70mmol/dl decreased by 30% overall, increased time-in-range and scored highly in system usability ratings. Compared with real-world data (RWD); time <70mmol/dl was 2.6% (study) vs 1.2% (RWD)

– Patient survey compared with Medtronic 670G revealed that the T:slim rated better in terms of satisfaction, trust, feelings of diabetes control, better sleep and ease of use

Education for pump users – CARES paradigm very useful; Calculate (how does closed-loop system calculate insulin delivery and which parts are automated?), Adjustment (how can user adjust insulin delivery? What parameters can be adjusted in CL mode? What is fixed in the system?), Revert (when should user revert to open-loop? When will the system default to OL? How does the user optimise time in CL?), Education (where can users and clinicians find additional education? What are the key education points for CL device?, Sensor (what are the pertinent sensor characteristics?)

4. Conclusion

Conferences come and go, but rarely do they sessions leave a lasting impression. However, from a non-specialist viewpoint, ATTD is different; each session is packed with information (sometimes a little too much for the brain to assimilate!) and the chance to network with peers is second to none. Visiting the exhibition is both educational and social, and rarely does one feel that the visit is a ‘selling’ transaction. Most interesting for me is the number of health care professionals and company employees who themselves have Type 1 or Type 2 diabetes; this gives them both a unique insight into the needs of PWD and an extra incentive to work on ways to make it all a bit easier.

I look forward to Madrid for the 2020 event!

Advanced Technologies and Treatments for Diabetes 2018 – Conference Report

18th April 201818th April 2018 Deborah Glover News

The 11^th Annual Advanced Technology and Treatments for Diabetes (ATTD) was held at the Austria Centre, Vienna from the 14-17^th February 2017. This report presents some general observations about the conference

Scientific Programme – Key Points

Wednesday 14^th February: Opening Ceremony

Continuous glucose monitoring (CGM), whether in real time or intermittently viewed, reflects the daily variability of glycaemic control, whereas measurement of HbA1C doesn’t reflect intra and inter day variability of glycaemic excursions (International consensus on use of CGM” Diabetes Care 2017;40:1631–1640 https://doi.org/10.2337/dc17-1600)

Thursday 15^th February

Plenary Session: Coping with Glucose variability

Reversibility of Brain Changes in Diabetes – Impaired awareness of hypoglycaemia (IAH) carries a high risk of hypoglycaemia; pump technology and CGM can improve awareness. HARPdoc study of hypoglycaemia awareness restoration programme for problematic hypoglycaemia despite optimised self-care ongoing
Nasal glucagons – Launch in 2018 (Lilly). 3mg dose safe and effective across the entire age spectrum for T1D in pivotal studies

Friday 16^th February

Industry Symposium (Cellnovo)

Over 300 conference delegates attended the symposium chaired by Boris Kovatchev, University of Virginia. Dr Julian Shapley began the symposium by outlining the history of the Cellnovo Diabetes Management System (DMS), particularly its unique real-time data capture. Dr Olivia Hautier-Suply then presented the clinical characteristics and glycaemic outcomes of the recent analysis of real-time, real-world System user data from the Cellnovo Online Platform (Hautier-Suply O, Friedmann Y, Shapley J. A retrospective review of the clinical characteristics and blood glucose data from Cellnovo System users using data collected from the Cellnovo Online Platform. European Endocrinol. 2018;14(1)). This showed some significant glycaemic improvements. The benefits of accessing users’ real-time data were reflected in the presentation ‘Real-life experience of the Cellnovo System: The clinician and user perspective’ from Peter Kelly, a diabetes nurse specialist, and Sally Read, diabetes nurse specialist and Cellnovo System user.
The symposium finished with a round-table discussion based on the topic: ‘The Cellnovo System: a platform for Future Innovation’. Moderated by Dr Shapley, the panel members included Dr. Daniel Cherñavvsky, Assistant Professor of Research, University of Virginia, Chief medical Officer, TypeZero Technologies, Charlottesville, Virginia, Dr. Pau Herrero, Faculty of Engineering, Imperial College, London, Member of PEPPER Project, Dr. Beatriz Lopez, University of Girona, Spain, Member of PEPPER project, and Mr. Chad Rogers, CEO, TypeZero Technologies, Charlottesville, Virginia.

Parallel Session: Closing the Loop

The International Diabetes Closed-loop (iDCL) trial – Four iDCL study protocols:

Feasibility study n=126 Roche combo spirit + Dexcom G5 + TypeZero algorithm, ongoing
EU pivotal trial of the Roche-Senseonics-TypeZero 180-day closed loop system expected to begin soon
Tandem t:slim X2/Dexcom G6/TypeZero Control IQ embedded system study (May 2018)
Harvard’s “Enhanced Control-to-Range (eMPC)” algorithm on a mobile device controlling either Tandem’s t:slim X2 or Insulet’s Omnipod (TBD), with input from Dexcom CGM (end 2018)

Dan05 study of closed loop (modified Medtronic 640G, Enlite 3 CGM, and Cambridge control algorithm on Android phone) in children and adolescents – to determine whether 24/7 automated closed-loop glucose control combined with low glucose feature will improve glucose control
Beta Bionics pancreas studies – automated insulin and glucagon delivery in the same device; pivotal study finishes end of 2019

Roche Plenary Session: Fit for the Future – Merging Technology and Digital Solutions for Integrated Diabetes Management

AP provides better overnight control; need daytime closed-loop system. Values beyond HbA1c should be used. Appropriate patient populations should be defined and used in studies
Integrated solutions to overcome ‘clinical inertia’ (Only 6% of PWD in Europe achieve their time-in-range target). Working in partnership with MySugr using app to log data automatically , improve outcomes and support patients
Eversense CGM can be left in situ for up to 6 months – works by fluorescent sensing. Has smart transmitter, on-body alerts and sends readings to the app every 5 minutes – shows trends and alerts and can be viewed remotely. Sensor outer cover has to be changed daily. Data from studies have informed algorithm and shown good results. Second trial in US underway.

Sanofi Plenary Session: Casting New Light on Basal Insulin

Outlined evolution of GM and CGM, the latter proving to better than SMBG in all glycaemic parameters and is recommended as a tool to reduce HbA1c in adults. However, which metric is best indicator of glucose management – need standard metrics for analysing CGM
Administration of GLA-300 vs GLA-100 with CGM decreased nocturnal hypoglycaemic events and less glucose variability in T1D
Next generation of insulin (Deg-100) gives flatter glycaemic profiles which are more stable in T1 pts

Parallel Session: Ispad Session Challenges with Diabetes Technology in Paediatrics

Diabetes Technology in Adolescents and Young Adults – improving adherence to treatment, self-care through Apps/software, simplified CGM, pump data uploading, reminders and easy access to treatment and transition by telemedicine
Future projects (apps, software, telemedicine): advanced dose decision making systems, virtual diabetes clinics, advanced diabetes coaching, multi-device interface (CGM, activity tracker, insulin pump), analysing meal, activity patterns and nutrition. But need user friendly systems, smaller devices, single site; better informed systems, activity trackers, physiologic inputs. Customised treatments for adolescents

Saturday 17^th February

Parallel Session: Diabetes Technology for T2DM

OPT2MISE study – continuous subcutaneous insulin infusion (CSII) with monitoring and lifestyle modification for T2. QoL improved, mean glucose lowered and no significant weight gain. Better control seen in those who had not responded to MDI
Retrospective CGM results can promote lifestyle changes, particularly increasing activity. Real-time CGM (rtCGM) with lifestyle counselling can increase exercise, time-in-range vs SMBG.
rtCGM supports initiation of insulin compared to SMBG. Cost-effective. Can help detect glucose variability. In France suggestion that it should replace SMBG.

Parallel Session: Pumps, Sensors and FGM – Where do we Go?

Comparing outcomes between pumps and MDI difficult as too many variables for each. High baseline HbA1c creates barrier to improved control on CSII. Pts using CSII need on-going education/support as some deteriorate clinically after 2-3 years
Administration of bolus 10-20 mins before meal should be standard practice
Work more with ‘non-responders’ to identify reasons why – what is their ‘Locus of Control’ – external or internal? Once determined HCP can personalise education/support etc
Flash Glucose Monitoring (FGM) has been proven to achieve better glycaemic control than SMBG in a number of studies (inc IMPACT trial, IHART trial), with greater user satisfaction and more engagement
FGM should be used for intensive insulin treatment to replace SMBG, whereas CGM is best suited to pump therapy

The Apprentice

8th May 201713th August 2018 Deborah Glover News

Much bruhaha about nursing and nurses is flying around in the Twittersphere at the moment.

What’s happening?

Some believe that a degree in nursing is the only safe way forward because ‘ordinary’ nurses may not know “how to access/interpret/implement research”. I didn’t make that bit up – someone actually put that in a Tweet to me. Perhaps they haven’t realised it yet, but nurses managed to nurse – and quite well actually – before the concept of a degree in nursing was even born
Organisations are exploring ways to fill nurse vacancies, and unfortunately it seems to be with the ‘cheaper alternatives’ such as nurse associates
The sensible folk are exploring alternative (to the degree) routes into a nursing career

I suspect that when it all comes out in the wash, what we will have is a raft of clinicians who have a variety of knowledge, skills and education, all of whom will be happily delivering care at a level they are content with. Perhaps more importanly, they will be delivering the care and compassion that our patients want.

All our yesterdays

Given that nursing is changing, some may say into a role that is not actually nursing, it is perhaps timely to remind ourselves why being a student of the ‘apprentice’ style training (circa 1930-1983), wasn’t so bad. According to tales from those that have gone before us, it was damned hard work, the hours were long, the days off were few, the ward Sisters/Charge Nurses, but mostly Matrons, were tartars whose sole job it was to make your life a misery, you couldn’t get married if you were still training and if as a staff nurse you married, you were immediately put on a 3-month stint of nights, equipment breakages were paid for out of your meagre salary and.. well, the list goes on. But there were good times too:

Working split shifts for 6 and a half days in a row, trying to attend lectures in between shifts/sleep, and having only one full day off a month never did me any harm.
Being part of the rostered workforce while on placement made you feel part of a team (despite as a first year student, being so low down the pecking order that you had to clean the sluice all day, every day for the first 6 weeks, after which you were promoted to bottle/bedpan rounds, and it was only half-way through your second year you actually realised that those people in beds who stared at you whilst you walked down the ward were patients).
You trained at one hospital – ‘your’ hospital. Over your three years of training, you came to know its hospital’s culture, staff and foibles. You were fiercely proud of it. And you probably still are, even it is now a block of flats for people with Shoreditch Beards and trendy shoes….
…which K-Skips weren’t
When you passed your SRN (State Registered Nurse) exam you recieved a length of Petersham and a silver buckle (the former from the hospital, the latter from your proud parents/grandparents/dog) to signify that you were indeed a staff nurse and thus capable of running a ward. It also meant that it was compulsory for you to take your coffee/tea break in the ward office with Sister and the other staff nurses. All at the same time. Whether you wanted to or not. No more stuffing doughnuts in the staff canteen.
After 6-12 months, were given a hospital badge and in some cases, promoted to Senior Staff Nurse. By this time, Sister will have grudgingly admited that “You may make a half-way decent nurse after all”
Such trifles (3-6) always broke the ice at conferences – ‘I trained there too, what set were you in, do you remember Sister Snapdragon?’, and allowed parents/grandparents the opportunity to boast about you to whoever stood still enough to listen.
The fact that it was compulsory to live in the nurses home ensured that our moral welfare was never in danger, that the home sister would come marching into our rooms each morning [or evening in the night nurses wing] to make sure we weren’t late for work, and that being allowed an 11pm ‘late-pass’ was a privilege often rescinded because of some minor misdemeanour such as breaking a thermometer)
The uniforms were fabulous despite having to spend 2 hours trying to change your half-moon shaped piece of linen into something resembling the Taj Mahal.
…K-Skips.
You learnt about the process of turning raw sewerage into fresh water (the visit to the treatment plant being the highlight of year 1) and the journey of a cheese sandwich from teeth to… well, the other end, and can still recite the physiological processes involved.
You learnt to make a bed; importantly, the type of ‘hospital corner’ used took on a Masonic significance as often they indicated the hospital you trained in. And you still make you own bed using those corners (unless you use fitted sheets of course – clearly not designed by a nurse)
You learnt how to cook bland meals for those with ‘gastric ulcers’ and how to boil 40 eggs for the breakfasts at 4.30am because after that you had to start getting patients up, and do the drugs round, and clean the sluice before Sister came on duty. Some learnt the art of buttering mounds of bread and covering with sheets of damp kitchen paper in an attempt to keep them fresh. These lucky few have gone on to have second careers in cricket teas after retirement from nursing.
You learnt that while it appeared that Sister was fulfilling every wish of the consultants, actually what she was doing was skilfully managing them while letting them think they were in charge. And when she discussed clinical matters, she held her own because she knew her patients and their conditions inside out, and so was respected, whether she had a degree or not.

However, what is shiningly obvious is that on the whole, we loved it. And perhaps we don’t want it to change because it was fun. You got to know your patients well. You were part of a caring team and when it all went well, it was great, but when it went a bit wrong, you had the support required. And really, so what if you were shouted out by the night sister because your cap had fallen off during a resuscitation and ‘you don’t look very professional’? You just moaned about her over a snatched coffee and swapped the Cadbury’s for some Elax… (not really)

+Actually, the sewerage plant I visited has been converted into trendy flats…

Flogging a Dead Horse

25th January 201713th August 2018 Deborah Glover News

The NHS is going through what some say is a most diffficult time

That may be putting it mildly!

We may have to learn a lesson or two from the Dakota Indians…

As many variations of these pearls of wisdom are available, I cannot credit this particular version to anyone. But I am eternally grateful for the laughs it produced!

The tribal wisdom of the Dakota Indians, passed down from generation to generation, says that when you discover that you are riding a dead horse, the best strategy is to dismount.

In the NHS, however, a whole range of far more advanced strategies is often employed, such as:

Change riders
Buy a stronger whip
Do nothing: “This is the way we have always ridden dead horses”
Visit other countries to see how they ride dead horses
Perform a productivity study to see if lighter riders improve the dead horse’s performance
Hire a contractor to ride the dead horse
Harness several dead horses together in an attempt to increase the speed
Provide additional funding and/or training to increase the dead horse’s performance
Appoint a committee to study the horse and assess how dead it actually is
Re-classify the dead horse as “living-impaired”
Develop a Strategic Plan for the management of dead horses
Rewrite the expected performance requirements for all horses
Modify existing standards to include dead horses
Declare that, as the dead horse does not have to be fed, it is less costly, carries lower overheads, and therefore contributes substantially more to the bottom line than many other horses
Promote the dead horse to a supervisory position

Is there anybody there…?

23rd January 201713th August 2018 Deborah Glover News

On the 9th January, Theresa May gave a lecture at the Charity Commission

During this speech, she announced a package of measures to transform mental health support in our schools, workplaces and communities. The gist of the content can be found here: https://www.gov.uk/government/news/prime-minister-unveils-plans-to-transform-mental-health-support

One in 4 people has a common mental disorder at any one time; the economic and social cost is £105 billion. But how it affects family, friends and carers is incalculable, as Ms May suggests:

“For too long mental illness has been something of a hidden injustice in our country, shrouded in a completely unacceptable stigma and dangerously disregarded as a secondary issue to physical health. Yet left unaddressed, it destroys lives, it separates people from each other and deepens the divisions within our society. Changing this goes right to the heart of our humanity; to the heart of the kind of country we are, the values we share, the attitudes we hold and our determination to come together and support each other.”

I admit that while I was nursing, mental health was never my thing. I absolutely believe that those who work in mental health are born not made – I have witnessed some fantastic nurses care for those with MH problems in a way that defies any kind of template.

As a student nurse, I spent most of my psychy secondment locked in a cupboard – not because I was scared of the patients, just because the staff on that particular ward were either burnt-out or bored and therefore required entertaining. They didn’t interact with the patients, but neither did they help the General student nurses on secondment; after all, we were only going to be there for 8 weeks, so were only good for dealing with ‘nursing’ things such as wounds and personal hygiene.

Consequently, I have to be honest and say that I know almost as little about management of MH now as I did then, and largely put it to the back of my mind.

But that changed last Sunday. A friend and I had been for our usual Sunday morning constitutional and were looking forward to coffee and breakfast (and more coffee) in a local cafe. It was about 10.00, there were about 10-12 other people in cafe. On the table next to us was a half-finished coffee, glass of orange juice, pair of sunglasses, and a coat was spread across the benchseat.

We had been there about 10 minutes, when one of the people on the table next to that with the detritus, said out loud ‘Do you think she is OK?’ ‘Who?’ we asked, ‘That lady lying there’ came the reply. What we had taken for a coat casually tossed aside, did in fact contain a very, very thin woman. Apparently, said table of people had watched her lie down on the seat about 5 minutes before we arrived.

So there we were, a nurse who hasn’t nursed in quite some time, and ex-physiotherapist (now a CCG Accountable Officer); victims of muscle memory, we were moving even before we had time to think. Pulse taken, resps observed, attempts to rouse made. As I had seen a container of sweetners on the table, my first thought was hypoglycaemia; but she was rousable enough to say she wasn’t diabetic. Then a glance into her open handbag and onto a almost empty bottle of vodka bought me back to the orange juice. And there was answer. A short time later the paramedic arrived (breaking any response time targets) and managed to fully rouse her, but left after doing what he needed to do clinically.

After offering to buy her some breakfast, to which she replied “there’s not point, I’m bulimic”, we listened to her story. She was middle-aged (interestingly, a news story about the rise in anorexia in middle-aged women broke later that week (http://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-016-0766-4), had children, but difficult relationships with her ex and her parents. She had experienced MH issues for several years, and for a myriad of reasons, found accessing emergency care, or indeed any care suitable for her, impossible despite being known to the local MH service. Presumably the alcohol made it all go away for a while…Eventually we had to go. She reassured us that she would be OK. What was so sad was that she thanked us for listening to her. But what had we done? Nothing really except make sure she was clinically OK and chatted for a while. We were walking back to our loved ones, our ‘normal’ lives, our homes, our support mechanisms.

We both have been left wondering what has happened to her after we left? Did she get home OK? Will the paramedics report be sent to someone in a MH service? Where does she go for help when she believes that all avenues have been closed to her? Should we have done more?

We probably will never know. But I hope that the proposals for MH care in the future stop people such as her falling through the system.

Picture Credit: Mandy Ansell

Don’t Panic!

1st December 201613th August 2018 Deborah Glover News

Towel and well-thumbed copy of The Hitchhikers Guide to the Galaxy packed…

I haven’t always been baffled by technology; in my nursing days, I could strip down and reassemble a ventilator, assemble and set infusion pumps, and occasionally fix the bed-pan washer. But as time has marched by, I find myself becoming less and less able to get my brain around it. Although I can assemble Ikea furniture without resorting to violence. So when my business partner Oliver, suggested that rather than us using an ‘off-the-peg site’ to build the Primary Care Nursing Review, we use a company named Don’t Panic! instead, I was immediately reassured. Partly because I knew that any attempt by me to design and build a site (even with templates) had disaster written all over it, but mostly because Douglas Adams was a genius, as the opening line of Dirk Gently’s Holistic Detective Agency -‘High on a rocky promontory sat an Electric Monk on a bored horse’ – proves. So, obviously they had a sense of humour, which was fortunate, as they were going to need it.

Oliver also mentioned that they had something called avatars on their website. I was immediately less reasssured, having previously lost 182 minutes of my life to a film with that name while on Godson-minding duty. Much guffawing later, O explained that an avatar is what we (sorry, just me) middle-aged people call a cartoon. Here are the avatars of the current team, Stuart Lawrence (technical chief high pixie) and James Hackney (Prince of Dorne).

To cut a long story short, they were rather brilliant and not just technically. Douglas Adams summed up their challenge perfectly:

A common mistake that people make when trying to design something completely foolproof is to underestimate the ingenuity of complete fools.

And I have to admit, I was pretty much that fool! But they were patient, explained technical stuff in plain English (mostly!), and did not tut loudly when I asked them about something they had explained to me in the previous 10 minutes. They would make perfect nurses.

Thus, it made perfect sense to me to ask them to create this site despite the fact that their core work is with organisations rather than individuals (especially technophobes such as myself). Stuart, to his eternal credit, almost managed to muffle his scream while James was on the phone agreeing to help. And after a couple of twists in the space-time continuum, again they have delivered in spades, cleverly managing to translate my technical instructions (“please move that squiggly bit from there to behind that other bit”) into exactly what I wanted.

So a big ‘thank you’ to Stuart and James.

The Don’t Panic! team can be contacted via:

telephone: 07725 209 820

website: http://dontpanicdesign.co.uk/

P.S.

Before our first face to face meeting, I wondered whether or not I would be able to recognise the boys from their avatars. When I met them I took a picture. What do you think?

A Luddite is broken…

6th October 201613th August 2018 Deborah Glover News

The Elderly SoMe-er

I came late to Twitter, so could be described as an ‘eldery prima-tweetera’. Being at least a generation older than the usual Twitter/SoMe demographic, it was something I considered to be out of my age-range. And indeed, something I thought nurses on the whole wouldn’t take to – how wrong I was!

However, shortly after I had agreed with Oliver’s (bonkers) idea to set up a multi-platform, digital-only journal (a.k.a. PCNR), I was given the password to our newly opened twitter account, sent to look at the We Communities site (http://www.wecommunities.org/about), developed by the fabulous Teresa Chinn MBE, and told to get on with it.

And I have to be honest I’ve loved it from day one. Of course I read tweets that make me itch to respond with a WTF? (yes, the odd cuss escapes us at times!), or a ‘you have to be joking’. Those I try to leave well alone; after all, it’s really difficult to have an argument in 140 characters (or if you are fat apparently; once, while staying in a hotel, I heard several young people having a heated discussion along the corridor – suddenly, a woman shouted “You’d better lose some weight before you argue with me…”). But I have also responded to some fabulous tweets. Those about work, home, what is happening in the world, etc. And these have led to some great material for PCNR as well as opening up a whole network.

So if social media can work for us as health professionals, why can’t it work for our patients? Well of course, it does. Frank Booth has written about his experiences of sending his ‘heart messages’ to the clinic (https://pcnr.co.uk/articles/119/my-heart-your-care), and as he won’t mind me saying, he isn’t in his first flush of youth! Most of us get appointment reminders by text for dental and physio services. The potential is endless.

It is here to stay, let’s embrace it.

..she is only the instrument by whom the doctor gets his instructions carried out…

2nd September 201613th August 2018 Deborah Glover News

Some people firmly believe that progress is a Good Thing and everything from the past is a Bad Thing…

Recently, I was watching a news report about how boys read more when using a tablet or other electronic gizmo; some ‘commentators’ thought it was great (which it is!) others started batting on about the feel of books etc. I then wondered if anyone said the same thing when schoolchildren started writing on paper… “Oh, it’s not the same as using a slate and chalk…”, or when the inside lavatory was introduced…”Oh, it’s not the same as popping down the garden in the freezing rain…”

So, is the Nurse Associate (NA) role a forward or retrograde step? Well, I would have gone the whole hog and bought back the State Enrolled Nurse (and would also reinstate the State in Registered Nurse, but that will have to wait until I rule the world…). I am rather unconvinced that that a one year ‘training’ is the best way to address the issue of recruitment and attracting those who do not have the qualifications to do a ‘uni’ course immediately. And while organisations can determine the numbers required at a local level, I would very, very strongly suggest that the actual course is heterogenous across the country – you know just like SRN and SEN training used to be – in order that everyone knows what the NA can and can’t do at the end of it.

A couple of years ago, I came across a series of textbooks written by the magnificently monnikered J McGregor Robertson MB, CM, FRFPSG*. These were penned in 1907, and the sections of the duties and qualifications of a sick-nurse would make a perfect template for the NA role. Here is an example or two:

Qualifications of a sick-nurse

Intelligent, painstaking, careful, exact and methodical
Scrupulously clean & tidy in her ways and appearance
Her breath must not be foul-smelling (several recipies for tooth powder and mouthwash are given)
All her work must be done without fuss/noise and without drawing attention to what she is doing
She must not be a gossip or a chatterer
Her own symptoms and ailments are not to be referred to at all

The nurse’s dress & behaviour

Dress must be of soft material that will not rustle, and of a quiet colour
A white apron, with a pair of close fitting linen cuffs, and a white cap (quite right too!)
She should go about the sick-room…with a decided step…not shaking the floor with her movements…
Have warm hands – a cold hand or a clammy hand is an abomination

Duties of a sick-nurse

She must begin with the idea firmly planted in her mind that she is only the instrument by whom the doctor gets his instructions carried out – she occupies no independent position in the treatment of the sick person (so no need for a degree after all…)
She has no opinions or thoughts
Patient observation
Recording food/drink intake/output, temperature, (but only bare facts – she will not colour the report with her own explanation)
Preparation of food

There we are then. The NA role sorted.

Any applicants?

* Dr McGregor-Robertson, according to his obituary (BMJ March 28th 1925), was a great advocate of the ‘Scottish Nurses’ Association’, and worked tirelessly on behalf of Scottish Nurses, so don’t judge his thoughts too harshly!