The following blog post is an assignment which has been completed for Module 6 of the Diabetes Diploma course by Group: 032011 of the class of 2011-2012, September intake. This input is from the students and does not reflect the views of Diploma-MSc. It is the responsibility of the students to establish copyright of the images used in the postings and not Diploma-MSc.

Group Members: S Broderick, P Gillard, L Grobbelaar, L Haniff-Ismail, SB Magee, B Mankal, K Miah, J Mthembu, B Murtaz Khalid, A Olivier, C Osman Ali, E Rehman, and N Taylor

Word Count: 956 (excluding title page, pictures, tables and references.)

How does my blood sugar level affect me?

Diabetes is the fifth leading cause of death in the developed world and fatalities are mainly caused by blood vessel disease¹⁰. Diabetes causes hyperglycaemia, an abnormally high blood sugar or glucose level. This may contribute towards blood vessel disease over time, if your blood glucose levels are not well controlled.

Both large and small blood vessels can be affected, the following information relates to large vessel disease, also known as cardiovascular disease.

What is cardiovascular disease and what is my risk of developing this?

Cardiovascular disease includes:

• Heart attacks and angina
• Stroke
• Impaired blood flow to the legs and feet⁷

People with diabetes are up to 5 times more at risk of heart disease, stroke and circulation problems, compared with people that do not have diabetes⁹. Additionally leg amputations are far more common in people with Type 2 Diabetes⁶. Scary statistics, but YOU can help prevent these problems.

Figure 1 – Examples of complications due to large blood vessel disease

Is there any evidence linking glucose level with risk of cardiovascular disease?

Research has shown that diabetes and high glucose levels increase risk of cardiovascular disease⁸. High blood glucose levels over time can lead to increased deposits of fatty material inside the blood vessel walls. This can affect blood flow and increase the risk of clogging and stiffening of the blood vessels (medically termed: atherosclerosis).

Figure 2 – Fatty deposits inside a blood vessel: Atherosclerosis

It has also been proven that these risks are present even in individuals who don’t have diabetes but who have glucose levels at the high end of normal limits⁴.

For example, a study called DECODE showed that, as glucose levels increased, so did the risk of heart disease⁵. This risk was increased with increased glucose levels both before and after a meal was eaten.

Another study the UKPDS, proved an important link between improving glucose control and preventing cardiovascular disease in people with type 2 diabetes. Ten years after this trial was completed, the risk of a heart attack and death from any cause was greatly reduced in people who had better control of their glucose levels compared to those who had higher levels. This is called the “legacy effect”, meaning that good glucose control early after diagnosis of Type 2 Diabetes has a long term benefit¹¹.

What is a “healthy” blood glucose level?

Multiple important medical trials have searched for an ideal long term glucose target, measured by the HbA1C blood test (which measures your average blood glucose over the previous 3 months), but it appears that not one size fits all!

One large trial, ACCORD² was stopped prematurely as undesirable outcomes were observed when glucose levels were treated aggressively.

Other trials namely ADVANCE³ and VADT showed no benefit in reducing the risk of large blood vessel disease by lowering HbA1C too far. Intensive treatment is also associated with other risks such as weight gain and hypoglycaemia (abnormally low blood sugar levels).

Figure 3 Symptoms of hypoglycaemia

The important message is that you need to discuss and agree an appropriate glucose level with a health professional trained in diabetes management, usually a GP or diabetes nurse educator. Your target level will depend on the length of time since diagnosis of diabetes, your age and whether you have a history of cardiovascular disease or not. For most people an HbA1C level of less than 7% will be ideal. In younger people with no history of heart and blood vessel disease less than 6.5% might be targeted, but in the sick or elderly a level of less than 7.5% might be more appropriate and safer¹⁴.

Figure 4 HbA1c blood test and average blood glucose level

What medications may I be prescribed to lower my blood glucose and reduce my risk?

It is not only the lowering of blood glucose that is important, but also the method of lowering. Certain anti-diabetic medication provides additional protective mechanisms that reduce the risk for heart and blood vessel disease. One example of this is metformin, a commonly prescribed oral anti-diabetic drug. In addition to metformin’s glucose lowering effects, the UKPDS trial demonstrated a 39% reduction in risk of heart attack when using metformin compared to other anti-diabetic tablets and insulin 15. Another study showed the medication pioglitazone was effective in lowering glucose levels and also had a beneficial effect on cholesterol and blood pressure and in reducing the number of heart attacks⁹,¹³. Newer treatment options on the market known as incretins have also shown to have a positive effect on the heart¹².

It is important for everyone with Type 2 Diabetes to discuss available treatment options with your physician, as with glucose targets an individualised approach is needed. There are many factors that need to be considered before selecting the right drug for each patient.

What else can I do to reduce my risk?

Lifestyle interventions including weight loss and exercise can aid in reducing risk of cardiovascular disease (see Table 1).

Table 1 – How can I help prevent large blood vessel disease?

Figure 5 Smoking and heart disease

Figure 6 Exercise pyramid

Figure 7 Healthy plate model

Control of cholesterol is also important. Cholesterol is made by the body and is also present in some foods. If your body makes too much cholesterol due to an inherited genetic problem or if you have a larger proportion of saturated (animal) fat in your diet your cholesterol level may rise. This is a silent disease and is only detected by a blood test. Another portion of cholesterol, known as triglycerides, is the most common form of fat in the body. Excess calories are stored as triglycerides and many foods contain this¹. Steps you can take to lower your cholesterol are shown in Table 2. If your level remains above target despite these steps you may need medication. You should discuss this with your doctor.

Table 2 – How can I lower my cholesterol

Irish Heart Foundation http://www.irishheart.ie/iopen24/cholesterol-t-87.html

In summary:

Type 2 Diabetes is a high risk condition but with the help of your diabetes team, and appropriate lifestyle changes, you can reduce your blood glucose to a safe level and minimise your risk of complications.

References:

1. Abbott (2011) ‘High Triglycerides and Type 2 Diabetes’. [Online] Available at: http://www.omacor.co.uk/patient/leaflets-and-reminder-service.html (Accessed on 19 July 2012)
2. ACCORD Study Group (2008). ‘Effects of intensive blood glucose monitoring in Type 2 Diabetes’. New England Journal of Medicine, 358, pp. 2545-2559.
3. Advance Collaborative Group (2008) ‘Intensive blood glucose control and vascular outcomes in patients with Type 2 Diabetes’. New England Journal of Medicine 358, (24), pp. 2560-2572.
4. Coutinho, M., et al (1999). ‘The relationship between glucose and incident cardiovascular events: a meta-regression analysis of published data from 20 studies of 95 783 individuals followed for 12.4 years’. Diabetes Care 22 (2), pp. 233-402.
5. DECODE study group (2003). ‘Is the current definition for diabetes relevant to mortality risk from all causes and cardiovascular and nonvascular diseases?’ Diabetes Care, 26, pp. 688-696.
6. Diabetes Statistics (2011). Data from National Diabetes fact sheet. [Online] Available at: www.diabetes.org/diabetes-basics/diabetes-statistics (Accessed on: 28 June 2012)
7. Diabetes UK (2011). ‘Diabetes for beginners: Your complete guide to living with diabetes’. Diabetes UK
8. Laakso, M. (1999) ‘Hyperglycaemia and cardiovascular disease in type 2 diabetes’. Diabetes. 48, pp. 937-942.
9. Lincoff AM., Wolski K., Nicholls SJ., Nissen SE. (2007) Pioglitazone and risk of cardiovascular events in patients with type 2 diabetes mellitus: a meta analysis of randomized trials, Journal of the American Medical Association, 298, pp, 1180-1188.
10. Lockman, KA., et al (2011) ‘Fundamentals in Diabetes: an introduction to vascular complications’ Journal of Diabetes Nursing 15(7), pp. 256-264.
11. Macissac, RJ., et al (2011). ‘Intensive glucose control and cardiovascular outcomes in type 2 diabetes’. Heart Lung Circulation 20(10), pp. 647-654
12. Nikolaides, LA., et al (2004) ‘Effects of glucagon-like peptide-1 in patients with acute myocardial infarction and left ventricular dysfunction after successful reperfusion’. Circulation, 109, pp. 962-965.
13. Nissen SE., Nicholls SJ., Wolski K., Nesto R., Kupfer S., Perez A., Jure H., De Larochelliere R., Staniloae CS., Mavromatis K., Saw J., Hu B., Lincoff AM., Tuzcu EM., PERISCOPE investigators (2008). ‘Comparison of pioglitazone vs glimepiride on progression of coronary atherosclerosis in patients with type 2 diabetes: the PERISCOPE randomized controlled trial’. Journal of the American Medical Association, 299, pp, 1561-1573
14. SEMDSA Guideline committee (2012). The SEMDSA Guideline for the management of Type 2 Diabetes. JEMDSA 17, (1), pp. S1-S94.
15. UKPDS Study Group (1998). ‘Effect of intensive blood-glucose control with metformin on complications in overweight patients with Type 2 Diabetes (UKPDS 34)’. Lancet, 352, pp. 854-865

• Figure 1 – Plague build-up in arteries. [Online] Available at: http://www.healthcentral.com/cholesterol/h/what-causes-plaque-buildup-in-arteries.html (Accessed on: July 2012)
• Figure 2 – Atherosclerosis. [Online] Available at: http://www.therapyportal.co.uk/articles/why-are-vitamins-d3-k2-so-important/ (Accessed on 8 July 2012)
• Figure 3 – Symptoms and signs of hypoglycaemia. [Online] Available at: http://hypoglycemiasymptoms.blogspot.com/2011/04/hypoglycemia-symptoms.html (Accessed on: 8 July 2012)
• Figure 4 – HbA1C Chart. [Online] Available at: http://seamist.hubpages.com/hub/hba1c-test (Accessed on: 8 July 2012)
• Figure 5 – Smoking and heart disease [Online] Available at: http://curepages.com/coronary-heart-disease-and-your-cigarette-smoking-status/ (Accessed on: 11 July)
• Figure 6 – Exercise pyramid Available at: dms-dev.com (Accessed on 10 July 2012)
• Figure 7 – Healthy plate model. [Online] Available at: www.myplate.gov (Accessed on 10 July 2012 2012)

The following blog post is an assignment which has been completed for Module 6 of the Diabetes Diploma course by Group: 042011 of the class of 2011-2012, September intake. This input is from the students and does not reflect the views of Diploma-MSc. It is the responsibility of the students to establish copyright of the images used in the postings and not Diploma-MSc.

Group Members:  Ahmed F, Balchin I, Balu S, Darbyshire M, Gopakumar N, Griffiths J, Sarkar D, Schlenther C, Snyman S, Van der Westhuizen L, Van Zyl T and Wiese L

Word Count: 1071

Do you have diabetes?

If so, do you know that your chances of having heart disease or stroke are higher than someone without diabetes?

Do not despair!

Read on for some hints and tips on how to prevent this.

A group of diabetes specialists from around the world (The International Diabetes Federation) issued a warning that we risk having as many as 438 million people with diabetes by 202514. The World Health Organisation highlights that illness and deaths of patients with diabetes result from blood circulation complications¹⁵.

What is Type 2 Diabetes?

Type 2 diabetes develops when the body fails to make enough insulin, or when the insulin produced does not work properly⁴. The number of people with type 2 diabetes is increasing, affecting 2.8 million people in the UK. It is thought that a further one million people have the condition but are not aware of it ¹⁴.

What is Macrovascular Disease?

Atherosclerosis occurs when plaques made out of fat deposits and blood clots, build up in the wall of blood vessels. This causes damage, hardening and narrowing of the blood vessels. When blood vessels to the heart, brain and limbs are affected, we call this macrovascular disease. Factors that can contribute to macrovascular complications are:

• High blood sugar
• Insulin resistance
• High cholesterol
• High blood pressure
• Smoking
• Abnormalities in blood clotting
• Age
• Race
• Obesity

Macrovascular diabetes complications include heart disease, stroke and peripheral arterial disease.

Heart Disease

People with diabetes have a higher chance of developing heart disease than non-diabetic people. In people with diabetic neuropathy (where blood supply to the nerves are affected by diabetes), the usual symptoms of heart disease may not be noticed. Therefore, if you have diabetes, it is important to seek care early, even if the symptoms are not serious.

Stroke

People with diabetes have a higher chance of getting a stroke than non-diabetic people. Ischaemic stroke occurs when oxygen supply to the brain is reduced due to the narrowing of the blood vessels leading to the brain. In addition, people with diabetes often have high blood pressure, causing abnormalities in the small blood vessels of the brain. Haemorrhagic stroke occurs when high blood pressure causes rupture of the small vessels in the brain.

Peripheral arterial disease

Peripheral arterial disease occurs when blood vessels to the limbs are affected. People with diabetes have a higher chance of developing peripheral arterial disease than non-diabetic people. The resulting poor circulation impairs healing of any injury. Peripheral diabetic neuropathy increases the risk of injury to the feet and legs. A serious infection could travel up the leg, leading to the possible need of surgery.

What is a glycaemic target?

When a blood glucose test is performed it gives a reading for the level of glucose (sugar) in the blood. This test can indicate if the glucose level is too high, too low or within target (recommended) range.

Why is it important to maintain the recommended glycaemic targets?

The Diabetes Control and Complications Trial (DCCT) and United Kingdom Prospective Diabetes Study (UKPDS) have demonstrated the importance of intensive glycaemic control in preventing the progression of diabetic complications. By maintaining a healthy glycaemic range this can reduce the chance of developing macrovascular disease.

What are the current targets and recommendations?

The above diagram shows targets set from some of the largest organisations that have completed studies to provide for the best recommendations. It is important to discuss your individual glycaemic target with the GP.

How can I achieve my glycaemic targets?

Lifestyle Changes play an important role in weight management and help control blood glucose levels1. Some of the following could help:

1. Maintain an ideal body weight

Being overweight increases the risk of heart disease. A well-balanced diet combined with regular exercise can help achieve weight loss. Even moderate weight loss (5-10%) can have major health benefits⁶.

2. Stop smoking

Studies have shown that stopping smoking reduced death caused by heart disease. Within 2 years of smoking cessation, your risk will be the same as a non-smoker. Lungs will improve and money will be saved⁴. Seek advice from the GP on smoking cessation programs¹.

3. Eat healthy foods

Several studies showed that dietary factors can effect blood lipids and therefore increase the risk of heart disease, stroke and peripheral artery disease. A balanced diet consisting of carbohydrates, protein, fruits and vegetables as well as good types of fat are recommended¹.

4. Get active

In order to control blood sugar levels, reduce the risk of heart disease and assist with weight loss, regular moderate physical activity is recommended for at least 30 minutes five times a week¹,¹².

5. Reducing blood pressure

A high salt intake can contribute to high blood pressure. By following a healthy diet including low salt and low saturated fat diet, with plenty of fruit, vegetables, low-fat dairy products and regular exercise, this can lower blood pressure.

6. Reducing cholesterol

Unhealthy cholesterol or too much total cholesterol can increase the chance of developing heart disease. A diet that is high in fibre and low in saturated fats and cholesterol can help reduce unhealthy cholesterol levels.

7. Monitor your own blood glucose regularly

Testing provides valuable information for the health care provider and identifies high and low blood glucose levels before serious problems develop. Good glucose control can lower the risk of complications.

8. Go for regular check-ups to monitor your HbA1c levels

HbA1c is a test that determines average blood glucose levels over the past three months, and is an indication of how well a person is managing their diabetes. It will be the measurement used to monitor the progress and change in medication, if necessary.

9. Use your medication as prescribed by your health care provider

Keeping a reliable supply of medication is essential. There is evidence that patients with type 2 diabetes collect less than 80% of their prescriptions. Non-adherence is a much overlooked cause of why almost half of patients fail to reach their glycaemic target, with two thirds of such patients dying prematurely of heart disease².. It is important to contact the GP if unsure of medication. Information on diabetes can also be obtained through using information technology⁷.

10. Look after your mental health

Depression is common in people with diabetes. Mental health problems should be discussed with the GP, because this is linked to poor control¹⁶. This need not mean more medication; relatively simple counselling therapies lead by nurses or other staff can be helpful.

Be in control of your diabetes, don’t be controlled by it!

Website you can visit for more information

• www.diabetes.org.uk/Guide-to-diabetes/
• www.diabetes.org/
• www.bbc.co.uk/health/physical_health/conditions/in_depth/diabetes/
• www.nhs.uk/conditions/Diabetes-type2/Pages/Introduction.aspx
• www.patient.co.uk

References

1. American Diabetes Association and American Heart Association (2007) ‘Primary prevention of cardiovascular disease in people with diabetes mellitus’, Diabetes Care, 30, pp. 162-172.
2. Bailey, C.J and Kodack, M. (2011) ‘Patient adherence to medication requirements for therapy of type 2 diabetes’, International Journal of Clinical Practice, 65(3), pp. 314-322.
3. Brunnhuber, K. and Cummings,K. M. (2007) ‘Putting Evidence Into Practice Smoking Cessation’, British Medical Journal, pp. 1-40.
4. Diabetes UK (2012) ‘What is type 2 diabetes?’ [Online] Available at: www.diabetes.org.uk/Guide-to-diabetes/Introduction-to-diabetes/What_is_diabetes/What-is-Type-2-diabetes/ (Accessed: 29/06/2012).
5. Fisher, M. (2006) ‘Macrovascular disease in diabetes’, Medicine, 34 (3), pp 101-103.
6. Kannel, W.B, D’Agostino, R.B and Cobb, J.L. (1996) ‘Effect of weight on cardiovascular disease’, The American Society for Clinical Nutrition, 63 (3), pp 419S-422S.
7. Kaufman, N.(2010) ‘Internet and information technology use in treatment of diabetes’, International Journal of Clinical Practice,166, pp. 41-46.
8. Krummel, D.A. (2004) ‘Medical nutrition therapy in cardiovascular disease’, in Mahan, L.K. and Escott-Stump,S.(ed.) Krause’s Food, Nutrition, & Diet Therapy. 11th ed .Philadelphia: Saunders, pp. 860-896.
9. Mann, D.M. Ponieman, D. Leventhal, H. and Halm, E.A. (2009) ‘Predictors of adherence to diabetes medications: the role of disease and medication beliefs’, Journal of Behavioural Medicine, 32(3), pp. 278-84.
10. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) ,NIH Publication No. 06-5094, December 2005, last updated: December 6, 2011 ‘Diabetes, Heart Disease and Stroke’ Available at: http://diabetes.niddk.nih.gov/dm/pubs/stroke/ (Accessed July 2012).
11. NHS Choices (2010) ‘Diabetes, Type 2’ [Online] Available at: http://www.nhs.uk/Conditions/Diabetes-type2/Pages/Introduction.aspx (Accessed on 29/06/2012).
12. O’Donovan, G, Owen, A, Bird, S.R et al (2005) ‘Changes in cardiorespiratory fitness and coronary heart disease risk factors following 24 wk of moderate or high-intensity exercise of equal energy cost’, Journal of Applied Physiology, 98 (5), pp. 1619-1625.
13. Patient UK (2012) ‘Type 2 Diabetes’ [Online] Available at: http://www.patient.co.uk/health/Diabetes-Type-2.htm (Accessed on 29/06/2012).
14. Sicree R, Shaw J, Zimmet P (2006) ‘Diabetes and impaired glucose tolerance’ In: Diabetes Atlas. International Diabetes Federation. 3rd ed. Belgium: International Diabetes Federation, pp. 15-103.
15. Skyler, J.S. (1996) ‘Diabetic complications: The Importance of Glucose Control’, Endocrinol Metab Clin North Am, 25, pp. 243-254.
16. Van Bastelaar, K.M, Pouwer, F, Geelhoed-Duijvestijn PH et al (2010) ‘Diabetes-specific emotional distress mediates the association between depressive symptoms and glycaemic control in Type 1 and Type 2 diabetes’ Diabetic Medicine, 27, (7) pp. 798-803.
17. Yusuf, S., Hawken, S., Ounpuu, S. et al (2004) ‘Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study: case-control study)’, Lancet, 364(9438), pp. 937-952.

The following blog post contains the lecture programmes for the Diploma and MSc courses in September 2012. The lectures will take place at Glyntaf Campus, University of Glamorgan, Cardiff on Friday 7^th & Saturday 8^th September 2012

If you would like to download a .PDF of the programme(s) then you can do so by clicking on the following links:

» Diploma Lecture programme (.PDF)

» MSc Lecture programme (.PDF)

University of Glamorgan (Glyntaf Campus)

Diploma Lecture Programme

Day 1 – Friday 7^th September 2012

Day 2 – Friday 8^th September 2012

MSc Lecture Programme

Friday 7^th September 2012

If you would like to download a .PDF of the programme(s) then you can do so by clicking on the following links:

» Diploma Lecture programme (.PDF)

» MSc Lecture programme (.PDF)

Now that the marks are out and I have completed my course, I would like to thank you and all my tutors for having given me the opportunity to be a part of a wonderful experience – undergoing a course at the University. Going through my marks actually brought tears to my eyes. I could have passed with distinction if it was not for the intervention of so many extraneous factors over which I had absolutely no control. I knew my performance was actually going down especially during the last module. But I really could not do anything about it. My sincere apologies.

This learning experience has been wonderful, and it is impossible to believe that the course is over. I wish I could go through it all over again – it was that good. Even though I was not from the UK or SA, the material that was discussed was absolutely relevant to our own practice and something that I could make use of here. Actually when I had started out, I was so nervous and apprehensive about whether I would be able to manage the course. But as the days went by, I found it was such a great experience and the tutors were absolutely fantastic and extremely supportive. I should congratulate you on having such a great team with you!!!

To give your course its due credit, I am staring my own practice from Monday onwards. I have set up an individual clinic and will be having my own practice, supported by community screening programmes. If it were not for the course, I would never have had the confidence to do this. I am truly grateful to you, all the tutors as well as my batch mates for bringing me this far. I think I now have the confidence to go in for the MSc next year. I was honestly a bit fearful about taking it up. Now I feel better.

A big thanks to Jen, who patiently put up with my numerous mails regarding my eligibility since I did not have any English language certificate. Thank you Jen for all your support.

With warm regards,

Annabel

Primary hyperparathyroidism is biochemically identified by hypercalcaemia without the expected appropriate suppression of parathyroid hormone. In cases of persistent, non-progressive mild to moderate hypercalcaemia it is important to exclude familial hypocalciuria hypercalcaemia (FHH) as a cause. FHH is due to a mutation in the calcium sensing receptor gene but is asymptomatic. Parathyroidectomy does not result in a normal serum calcium and no active treatment is required. It should be considered if there is a family history of hypercalcaemia, particularly if parathyroidectomy has failed to normalise their calcium.

Biochemical Investigation

Most (99%) FHH patients have a PTH of <9.1 with mild to moderate hypercalcaemia. To screen for FHH relative hypocalciuria should be demonstrated by either a 24 hour urine calcium, calcium:creatinine clearance ratio or fractional calcium excretion. The local laboratory may have a recommended urine screening test and so liason with the laboratory is important to ensure the correct samples are taken. It is also important to note that vitamin D deficiency can cloud interpretation of results so patients should be vitamin D replete before further investigation is undertaken.

From October 2011 HbA1c results reporting has changed. This followed the recommendations of the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) call to adopt the same measurement to make it easier to compare HbA1c results between studies and laboratories worldwide. Hence this change is due to the development of a standardised reference method for measuring HbA1c and also a move to using the Standard International (SI) unit of millimoles of HbA1c per mole of Hb (mmol/mol) [1].

This was first adopted in June 2009. During the first two years until May 2011, results were being reported in both units as %age and mmol/mol, so as to enable health professionals and patients to get used to the new units. This was then further postponed for 6 months.

When HbA1c results are expressed as %age haemoglobin, the equation describing the relationship is:

IFCC/HbA1c (mmol/mol) = [DCCT/HbA1c %age – 2.15] × 10.929

In a busy diabetes clinic converting these units can be a challenge.
An easy way to get an idea of the HbA1c values is to follow the rule of 2s. For eg. 7% would be 7-2 =5 and 5-2=3: 53 mmol/mol or 9% would be 9-2=7 and 7-2=5: 75 mmol/mol.

Another useful way to remember these conversions is that 7.0% is equivalent to 53 mmol/mol. Every %age increase or decrease thereafter is equivalent to 11 mmol/mol. For eg. 8% is 64 mmol/mol and 9% is 75 mmol/mol. These methods work well for HbA1c from 4% up to 13% which is the case for the majority of patients with diabetes presenting to our clinics.

A number of international societies are moving to use HbA1c to diagnose diabetes. An HbA1c of 48 mmol/mol (6.5%) is recommended as the cut point for diagnosing diabetes. However, a value of less than 48 mmol/mol (6.5%) does not exclude diabetes diagnosed using glucose tests.

References

1. Barth JH et al. Consensus meeting on reporting glycated haemoglobin and estimated average glucose in the UK: report to the National Director for Diabetes, Department of Health. Ann Clin Biochem 2008; 45: 343-4

Short synacthen tests (250mcg IV or IM Synthetic ACTH) have been used to assess patients for both primary and secondary hypoadrenalism. The caveat in the latter is that hypoadrenalism needs to have existed for at least 6 weeks if an accurate result is to be obtained (1). The short synacthen test is a simple procedure to perform and is usually undertaken around 9am. Blood is drawn and cortisol measured at baseline and then 30 mins after the injection of 250mcg of synthetic ACTH.

The gold standard for assessing hypoadrenalism is the insulin tolerance test, yet this is a complex procedure to perform, is often unpleasant for the patient and is contra-indicated in patients with epilepsy, arrhythmias and ischaemic heart disease. The short synacthen test has the advantages of being simple to perform, generally safe and reliable.

Interpretation of the synacthen test is quite straightforward. A morning cortisol of <100 nmol/l is highly suspicious of adrenal insufficiency (2). Previously, a cortisol response above 550nmol/l has been regarded as a normal response yet, our data in Cardiff examining a large population of normal subjects, revealed a 30 minute peak cortisol in excess of 450 nmol/l following synacthen can be regarded as a normal result.

1. Klose M. Adrenocortical insufficiency after pituitary surgery: an audit of the reliability of the conventional short synacthen test. Clin Endocrinol 2005;63(5): 499-505
   http://www.ncbi.nlm.nih.gov/pubmed/16268800
2. Le Roux CW. Is a 9am serum cortisol useful prior to a short synacthen test in outpatient assessment. Ann Clin Biochem 2002;39:148-150. http://www.ncbi.nlm.nih.gov/pubmed/11930947
3. El Frahan etc al. Determination of method specific normal cortisol response to the short synacthen test. Endocrine Abstracts 2011;C5: OC3.2 http://www.endocrine-abstracts.org/ea/0025/ea0025oc3.2.htm

The following blog post contains a list of our Diploma MSc students who graduated from the class of 2011-2012. Congratulations to all of you!

Diabetes Diploma Students

Diabetes MSc Students

The following blog post is a preview of a poster which we have created. This poster will be on display at the DUK (Diabetes UK) Conference between Wednesday 13^th – Friday 15^th. We would like to thank all Students who contributed.

Please Click Here To View DUK Social Media Poster

There is growing use of social media such as Facebook, YouTube and Twitter within healthcare. It is a very effective mode of communication and healthcare professionals, hospitals and institutions are increasingly using it for various purposes. With the expanding use of social media in healthcare comes increasing responsibility upon the healthcare professional to use it responsibly. This blog provides a brief overview of what needs to be considered when using social media:

1. Remember that what you post is not private but can be seen by the entire world. Use this acid test – read what you are going to post and if you are not happy for this message to be posted to be posted to a wider audience beyond close friends then don’t post it. Similarly, if you have photos of yourself which maybe compromising do not post them somewhere where they will be widely viewed.
2. Decide on what you are going to use social media for and generally adhere to it. If you are going to use social media for professional reasons then adhere to that rather than posting photos of yourself sun bathing for example. Then, if it’s a professional approach that you are adopting, endeavour to make what you post interesting. Avoid repetitively re-tweeting other people’s points, people want to hear your view about a subject or a paper.
3. Be professional – you are not allowed to use any patient identifiable data. This includes what you might consider as anonymised data – do not say, I just saw an interesting patient with achondroplasia and a goitre as that patient or friends/relatives could easily note that it is them to whom you refer. It is better to state references to achrondoplasia and hyperthyroidism for instance. Any mention of patients should be avoided unless specific consent is obtained. It’s exactly the same for using clinical photos in publications.
4. Make your aim clear on the description of yourself on your account. State that these are your views and do not represent the views of your employer or organisation. Avoid any clinical advice to patients through social media. Try to avoid ‘friending’ patients through Facebook or posting directly to patients. For instance if patients ask you directly for advice, be human about things and just simply state that advice over the internet is impossible so suggest they consult their own HCP. Again, it’s worth stating in your account that clinical advice cannot be given.

Importantly have fun whilst using social media and certainly try out different things. Remember you are an expert in your field and what you say is important in terms of improving patient care.

This is some useful advice to get people started and this guidance from the RCGP may also assist
http://www.rcgp.org.uk/policy/rcgp-policy-areas/~/media/Files/Policy/A-Z%20policy/RCGP-Social-Media-Highway-Code.ashx

Historically, type 2 diabetes is well known as an adult-onset disease; however, lately, the incidence of the disease is reported to be increasing in children and adolescents dramatically worldwide with the highest prevalence in those of American-Indian, Hispanic, African-American and Asian descent.⁽¹⁾ An increased prevalence of T2DM has also been reported in Japanese, Canadian, Australian and Libyan children.⁽²⁾ The SEARCH study currently provides the best prevalence data of paediatric T2DM in the US. According to these data the prevalence amongst children and young adults below 20 years of age in 2001 was about 20.000 or cases per 10,000 US youth. ⁽³⁾

Despite the increased prevalence of T2DM in the paediatric population, there is limited information about the relative effectiveness of treatment approaches. Furthermore, the treatment options are much more limited in adolescents than adults with T2DM.⁽⁴⁾

The ideal goal of treatment is normalization of blood glucose values and HbA1c. The ultimate goal of treatment is to decrease the risk of the acute and chronic complications associated with diabetes. Pharmacological therapy is recommended for children who are unable to achieve satisfactory glycaemic control through physical activity and diet.⁽⁵⁾

Metformin is the initial pharmacological treatment of choice if metabolically stable. The Global IDF/ISPAD Guideline for Diabetes in Childhood and Adolescence, published in 2011 and the recent Clinical Practice Guideline from the American Academy of Paediatrics, published in 2013 stated that initial care of T2DM will depend on the severity of symptoms at presentation.

Insulin may be required for initial metabolic stabilisation if significant hyperglycaemia (HbA1c > 9 % or plasma BG concentrations > 250mg/dl and ketosis is present, even in the absence of ketoacidosis.⁽⁶⁾ Otherwise, there is little evidence that insulin is superior to oral agents for initial treatment of T2D in children.

Currently, there are six types of glucose lowering oral agents for the treatment of T2DM: biguanides; sulfonylureas; meglitinides; alpha glucosidase inhibitors; thiazolidinediones; DPP-4inhibitors. Because the pathophysiology of T2DM in children and adolescents appears to be similar to that of T2DM in adults with only few differences (faster decline in beta cell function, different response to treatment in terms of durability of the efficacy and potential differences in the safety profile related to developmental aspects – pubertal, bone and neurocognitive development, faster progression from Impaired Glucose Tolerance to T2DM) it is reasonable to assume that oral agents will be effective in children. ⁽⁷⁾ Yet, the efficacy and safety data are not available for children nor are any of the oral drugs FDA approved for use in children. In European Union, the only approved drugs in paediatrics T2DM are metformin and insulin.

Most medications used for T2DM have been tested for safety and efficacy only in people older than 18 years, and there is scant scientific evidence for optimal management of children with T2DM. Similarly, the diabetes education materials designed for paediatric patients are directed primarily to families of children with type 1 diabetes mellitus and emphasize insulin treatment and glucose monitoring, which may or may not be appropriate for children with T2DM.

Once again, paediatric diabetes practitioners are left with just metformin and insulin for adolescents with T2DM. Early treatment is essential for paediatric patients in order to slow or delay progression of the disease and its complications. Further research is needed to determine the natural progression of T2DM and treatment approaches in paediatric patients. ⁽⁸⁾

Clinicians should remain alert to new developments with regard to treatment of T2DM.

References:

1. Dabelea D, Hanson RL, Bennett PH, et al. Increasing prevalence of type II diabetes in American Indian children. West J Med 1998; 168: 11-16
2. Kitagawa T, Owada M, Urakami T, et al. Increased incidence of non-insulin dependent diabetes mellitus among Japanese school children correlates with an increased intake of animal protein and fat. Clinical Pediatrics 1998; 37: 111-16
3. SEARCH for Diabetes in Youth Study Group, Liese AD, D’Agostino RB, Hamman RF, Kilgo PD, Lawrence JM, et al. The burden of diabetes mellitus among US youth: prevalence estimates from the SEARCH for Diabetes in Youth Study. Pediatrics. 2006 Oct; 118(4):1510-8.
4. TODAY Study Group, Zeitler P, Epstein L, Grey M, Hirst K, Kaufman F, Tamborlane W, Wilfley D. Treatment options for type 2 diabetes in adolescents and youth: a study of the comparative efficacy of metformin alone or in combination with rosiglitazone or lifestyle intervention in adolescents with type 2 diabetes. Pediatric Diabetes. 2007 Apr; 8 (2): 74-87
5. Eva M. Vivian. Type 2 Diabetes in Children and Adolescents- The Next Epidemic? Current Medical Research and Opinion. 2006; 22(2):297-306
6. Global IDF/ISPAD Guideline for Diabetes in childhood and adolescence, 2011, p 22
7. DeFronzo RA. Pharmacologic therapy for type 2 diabetes mellitus. Ann Intern Med 131:281-303, 1999
8. Kenneth C. Copeland, Janet Silverstein, Kelly R. Moore, Greg E. Prazar, Terry Raymer, Richard N. Shiffman, Shelley C. Springer, Vidhu V. Thaker, Meaghan Anderson, Stephen J. Spann and Susan K. Flinn. Management of Newly Diagnosed Type 2 Diabetes Mellitus (T2DM) in Children and Adolescents. Pediatrics 2013;131;364; originally published online January 28, 2013; DOI: 10.1542/peds.2012-3494

At Diploma MSc, we offer experience of the use of social media alongside our courses. Indeed, we believe that understanding today’s means of communication is essential to communicate with both your patients and peers.

We would like to share with you what our director Dr Steve Davies sent to some students at the start of module 6, when they were initially anxious about the new social media activity.

This is truly motivating and we hope it will inspire you as well!

Ladies and Gentlemen,

The course is breaking new ground. Deliberately we introduced this activity (social media) in the last module as you would have by now become familiar with literature reviews and patient posters, info sheets etc. But, we want to extend you. I appreciate everyone’s concern on the individual and group activity. This is GREAT. I’m glad it has created such a stir!

I have been witness to the development of individuals on this course which has been fantastic. We are about creating leaders and opinion leaders through this course and the online nature lends to a radicalness that you will not see anywhere else. How are people communicating these days? Facebook now has more daily usage than Google! In the future, Web2 technology and social media is evolving to be a tool through which we communicate with our colleagues and patients.

Now that you have evolved your investigative and research skills through the last 5 modules it is now your opportunity to shine on the world stage! This is the only course in medicine that has done anything like this.

I think you are doing a fantastic job, don’t underestimate yourselves. You should be influencing and shaping delivery of service both locally and more widely. This type of technology is to be embraced by leaders like yourselves rather than feared.

Go to it!

Steve Davies

Please see the attached poster which was accepted at Diabetes UK 2013 The use of social media amongst Healthcare Professionals (HCPs) within and on-line postgraduate (PG) diabetes diploma course.

The first students to take part in this course will have the opportunity to participate in the 5th and 6th September 2013 introductory lectures at the Glyntaff Campus, University of South Wales, before starting the online courses on 9th September 2013.

The online course, based on the Royal College of Physicians curriculum, is composed of 6 modules.

The students will be guided by our expert tutors through our online platform all throughout the course.

To see the programme of each module click here.

If you want to be part of it, you only have until the 15th August 2013 to apply; hurry and apply here!

Follow all the news about the course on Twitter @DiplomaSEM.

We would like to share with you the poster presented by our student Dr Samreen Safdar at the 2nd World Congress on thyroid cancer in Toronto.

Dr Samreen Safdar graduated with distinction from Rawalpindi Medical College, Pakistan. She then completed a postgraduate diploma in MRCP internal medicine and in MRCP subspecialty certification in Endocrinology and Diabetes with the Royal College of Physicians of the United Kingdom.

Dr Samreen Safdar is part of the cohort of students that will graduate in December 2013 from the Postgraduate Diploma in Endocrinology course with the University of South Wales and has applied for the MSc in Endocrinology with University of South Wales also.

Dr Safdar is currently working as an assistant consultant internist and endocrinologist at the King Faisal Specialist Hospital and Research Centre in Riyadh, Saudi Arabia.

In July 2013 she presented at the 2nd World Congress on thyroid cancer in Toronto on “Follicular variant of Primary Papillary thyroid carcinoma in Thyroglossal duct cyst: a case report and literature review” that you can view here.

Dr Samreen Safdar also published a case report as primary author about “Fatal hemophagocytic syndrome as a manifestation of immune reconstitution syndrome (IRIS) in a patient with AIDS” in the Saudi Medical Journal and has also worked on “Prevalence of vitamin D deficiency in Type 2 diabetes Mellitus and its correlation with HbA1c in Saudi population”, an extract of which will be presented in the IDF World Diabetes Congress of 2013 in Melbourne.

Click here to view Dr Samreen Safdar’s poster on Follicular variant of Primary Papillary thyroid carcinoma in Thyroglossal duct cyst: a case report and literature review.

The University of South Wales is currently offering competitive bursaries to UK based endocrine nurses for the September 2013 intake of its Postgraduate Diploma in Endocrinology:

• The Ipsen Bursary
• The Novo Nordisk Bursary

The course is accredited by the University of South Wales and was launched in 2012. It is currently the only online course for endocrinology in the UK which can be completed in one year.

Key features of the course:

• Online

• Part-time

• One year

How to apply for the bursary:

To compete for the bursary, please write a 500 word paper entitled:

“How this postgraduate qualification will support the delivery of care to my endocrine patients”, and send it to info@diploma-msc.com before 21st August 2013.

Places will be awarded by a panel of judges to the best two applicants.

To be eligible to apply for the bursary, you must have received an unconditional offer for the course (closing date 15th August 2013).

Visit our website for further details.

Entry Requirements for the PG Diploma:

Health professionals with an Undergraduate degree or equivalent qualification. In the case of RGN qualification or equivalent, healthcare professionals can be accepted on the course via accreditation of prior experiential learning (APEL).

If you think this opportunity is for you, grab it!

Contact:

For more information, don’t hesitate to contact us at:

info@diploma-msc.com.

More bursaries:

To view other bursaries available, visit our grant information section.

The following blog post contains the lecture programmes for the South African Diploma and MSc lectures in August 2013. The lectures will take place at the CDE on Monday 26^th & Tuesday 27^th August 2013.

Postgraduate Diploma in Diabetes

University of South Wales (CDE)

Lecture Programme

Day 1 – Monday 26^th August 2013

Day 2 – Tuesday 27^th August 2013

MSc Lecture Programme

Monday 26^th August 2013

The Diploma MSc team had the pleasure of attending the 15^th CDE Postgraduate Forum in Diabetes Management on the 23^rd-25^th August 2013 in South Africa.

The Forum, efficiently organised by Michael Brown, is the biggest annual diabetes-specific meeting in Sub-Saharan Africa. It hosted 450 delegates — mostly GPs, primary and secondary care physicians — who represent a considerable portion of the diabetes healthcare community.

The numerous lectures, given by internationally renowned experts in diabetes, had a lasting impression on the attendees.

You can have a look at the 15^th CDE Postgraduate Forum in Diabetes Management Programme here.

Diploma MSc had the chance to exhibit along with the other corporate partners at the Forum Exhibition.

Over 20% of our students are from South Africa, and this event enabled us to broaden the visibility of our online courses in Sub-Saharan Africa and to meet potential future students.

By meeting many experts in the field of diabetes through our stand, we also hope to welcome new passionate tutors from South Africa for our future courses.

Supporting staff

Two major players in the pharmaceutical industry, Eli Lilly and Company and Pharmexx, have taken the unique step of supporting a member of their sales team in studying for Diploma MSc postgraduate diploma in diabetes.

Pharmexx is backing sales representative Jayne Irwin on this pioneering course, which is the only postgraduate diploma to welcome pharmaceutical representatives to study with other health professionals, including doctors and nurses.

See the article about Jayne’s story in Pharmaceutical Field.

Thirst for knowledge

Jayne, a Diabetes Community Specialist, has more than 20 years’ experience working in the pharmaceutical industry yet feels the diploma will give her credibility in her work with nurses and doctors.

“After 20 years in the pharmaceutical industry, I have developed a real thirst for knowledge about diabetes,” explained Jayne. “This course will enable me to build my knowledge to a professional level where interaction with clinicians becomes more meaningful, leading to patient management plans being personally tailored as a result.”

“Pharmexx have been fantastic in supporting me. In expanding my knowledge of diabetes I am able to better understand the quandaries doctors and nurses face, particularly in the diagnosis and treatment of diabetes. This gives me more credibility in my work with them which has numerous professional benefits. The beauty of the online course is that it fits into my busy job as it allows me to study whenever I can and at any time of the day without the need to travel to lectures.”

What the experts say

The course, delivered by the University of South Wales through diploma-msc.com, is in its fourth year, and annually attracts more than 100 healthcare professionals from across the globe. The diploma course is entirely online making it ideal for the busy health professional. The postgraduate diploma is unique in that it can be completed in one year and students can progress on to a MSc which also can incorporate independent prescribing. Other specialty diplomas and MScs are offered in Endocrinology and Sports and Exercise Medicine.

For Dr. Steve Davies, Consultant Endocrinologist and head of Diploma-MSc.com, it is clear that the role of the pharmaceutical representative is “evolving towards an important member of the multidisciplinary team. That a representative takes the initiative and studies alongside doctors and nurses and begins to understand the clinical issues that they face is a very welcome development. We, within the NHS, need more people with such commitment.”

Lynn Doogan, Project Director of Pharmexx, says the company is delighted to be supporting Jayne as she expands her skill set through this innovative diploma: “We understand the benefits to our business of Jayne developing her knowledge and understanding of diabetes. In doing so she will be able to develop stronger working relationships with health professionals and this holds the potential to have a direct benefit to us.”

For James Carlisle, Lilly Diabetes UK Head of Sales, “Lilly regards the professional development of its employees and partner company representatives as one of its highest priorities. We invest significant time and resources in working with our sales representatives, helping improve their skills to better match Lilly’s medicines and services with the needs of Healthcare Professionals and their patients with Diabetes. It’s great to see Lilly’s commitment matched by Jayne’s personal commitment in pursuing a better understanding of the world in which the Healthcare Professionals she regularly meets with operate and the issues their patients face”.

If, like Jayne, you wish to gain confidence and improve the care of people with diabetes, APPLY now for our online courses. We have intakes in March and September each year.

Visit the list of our online courses here

We were very happy to receive this lovely email from a student this morning. Let us share it with you:

Hi Diploma MSc

I have thoroughly enjoyed the course so far and found navigating the site really easy, it doesn’t take long to get the hang of it, honestly!  You soon learn once you have accidentally submitted your portfolio at the end of the first entry!

There is great support from everyone from the administration staff to the tutors right from the beginning of the application process. Everyone seems to know you by name if you have to ring, and the staff go out of their way to help you and not make you feel stupid.

I was concerned initially by the fact that as the course was delivered online I wouldn’t feel supported by the tutors or other course members.  Let me assure everyone that this is not the case, as long as you log on regularly, there is an abundance of support. There is a comprehensive reading list with good access to a lot of references you will need to complete each module.

Personally I have found it a little addictive and can log on 2 or 3 times a day as life allows!  It is so convenient and totally flexible.  You can study anywhere at anytime!  Although it is quite “full on” during the module, there are 2 week breaks in between modules leaving you time to go on holiday, if not just take your laptop with you!

As  I am not a fan of social networking, don’t have a Facebook or Twitter account, I was worried I wouldn’t manage the concept of communicating via message blogs/forums.  Again this worry soon disappeared and I am really enjoying meeting and chatting colleagues from all over the world.  The connections with overseas students certainly adds another dimension to your learning also.  It makes you think about diabetes more “globally” than just how it is in your own area.

I have found the tutors value and respect your experiences and positively encourage you with plenty of good humour.

The weekly quizzes prompt discussion which all lead towards you writing your individual/group assignment.

My only negative comments would be that I didn’t like the end of module exam. I think it was just the fact that it is against the clock, oh that and the fact you have to pass it!

Best wishes

Abby

——————–

Abigail Maisey’s own words – no edits!

Visit our website to get more information about our courses
or call us at: +44 (0) 29 2068 2050. We would be happy to have a chat with you!