PCDS JUBILEE IN BIRMINGHAM

Primary Care Diabetes Society (PCDS) celebrated its jubilee and organized its10th National Conference in Birmingham (UK), on 20-21 November, 2014.

The conference was held in The National Convention Centre.

Being a jubilee, PCDS invited sister organization Primary Care Diabetes Europe (PCDE) and hosted representatives of PCDE who, in this report, reflect on these two days in Birmingham.

In general, the conference was well organized, plenaries gave the framework of the scientific program, connected with 8 parallel tracks.

During the first plenary symposium Dr.Martin Hadley Brown (GP in Thetford, GP trainer and a Specialist Clinical Tutor in the University of Cambridge Clinical School, former chair of PCDS and also a member of the General Assembly of PCDE) gave us an overview of the available oral blood glucose lowering agents, including the golden oldies and the newer drugs. There is not an easy schedule for the proper oral glucose lowering agents. He concludes with the quote that the motor of the diabetes treatment is the people, not the agent itself. Basal insulin: start the right way and intensify when required for clear reasons.

This talk was followed by the official opening: PCDS Chair Dr.David Millar-Jones (full-time GP in Cwmbran, Specialist in Diabetes and Lecturer of Cardiff Medical School) welcomed the audience warmly, with specific humour and often with jokes.

“Your hidden champion” came to the stage, who is a well know TV journalist Ken Reid (Political Editor, Belfast) presenting his neglected symptoms and therefore late diagnosed diabetes with serious diabetic foot ulcer. His views, beliefs were explored and commented by Dr. Nigel Campbell (GP, Lisburn). Both agreed that proper patients education is one of the most important tools in diabetes care.

Thereafter the almost 700 participants split into the breakout sessions and rotated between them.

In different workshops, besides medical experts, specialized nurses provided excellent advice. The role of specialized nurses in the UK is unfortunately unique for doctors coming from the Continent where they play the most important role and opportunities involving specially trained nurses are underused.

Julie Widdowson and Jane Diggle (resp. diabetes educators in Norfolk and Practice nurses, Wakefield District CCG) gave their advice on intensifying insulin regimens and the pros and cons. The advice on self-monitoring and even self-titrating doses can be given safely and effectively, taking into account the factors that should be explored before considering intensification. Beneath the physiological impact of diabetes we have to know about the psychological aspects of having diabetes.

Mark Davies (consultant clinical psychologist from Belfast HSC Trust) currently a principal investigator on a Diabetes UK-funded project why people choose not to attend structured diabetes education programme’s. Diabetes distress as it has become known, by definition considers distress in the context of the patient’s illness narrative. Diabetes distress is more prevalent than depression and it is a better predictor of glycaemic control.

The impact of diabetes on sexual functioning in men and women was introduced by Lesley Mills (senior diabetes specialist nurse from Warrington). She reflected on the psychological and organic reasons, which are many, more than diabetes mellitus, the identified questions that should be asked and the tests which can add benefit. Diabetes can deteriorate both sexual functions and desire in men and women and sexual issues are very rarely addressed during routine medical visits. She gave examples of some practical issues how to involve patients in this discussion.

Professor of behavioural Medicine and Fellow of Wolfson College in Oxford, Prof.Paul Aveyard gave the effectiveness of free available weight reducing programmes and commercial weight loss interventions, focusing on those that are available to primary health care teams. The two main forms of these are the referral to practice nurse support or a commercial weight loss provider. Although weight-loss trajectories are often followed by a weight regain, the effectiveness of commercial programmes is far better than the programmes delivered in primary care. He advised to refer people with overweight to a commercial programme.

The proper cardiometabolic risk assessment was outlined by Dr. Paul Downie (SpR in Chemical pathology, University Hospital, Bristol). He demonstrated the role of ‘non-HDL cholesterol’ in the pathology of atherosclerosis. The appropriate measurement of lipids considers the different daily peaks of cholesterol fractions, where the level of triglycerides is closely related to fasting. He recommended daily 20 mg atorvastatin as primary and 80 mg as secondary prevention for diabetic patients.

‘Leg pain” in type 2 diabetes is important to consider as it is an important driver of medical disability and costs related to diabetes. The two main causes are ischemia and neuropathy. During this session, Prof. Mike Edmonds (Professor of Diabetic Foot Medicine at King’s College Hospital, London), focused his presentation on clinical symptoms that are relevant to make differential diagnosis between these two conditions. Regarding ischemia, classical presentations are intermittent claudication and also rest pain in severe chronic ischemia. In neuropathy, patients will have classical rest pain, therefore, rest pain may be a challenge for diagnosis. Three questions will help in differentiating between vascular or neuropathic causes; Where is the pain? Nature of the pain? When is the pain worse? In neuropathy, pain is usually bilateral, in feet; it is burning and pain is worse in bed at night, increased by feet contact with bedclothes. In ischemia, pain is unilateral and includes numbness, paraesthesia; pulses are absent and there are signs of ischemia; and lastly rest pain is relieved by blood supply in 2 to 3 weeks.

Dr.Tom Yates (Senior Researcher, University of Leicester) emphasized the importance and the therapeutic role of daily exercises and all physical activities for everybody and mainly for diabetics.

Dr. Alex Miras (Clinical Lecturer in Metabolic Medicine, Imperial College London) wishes for the obese patients a better understanding for their need for bariatric surgery, to prevent the development of T2DM. Physical activity is better achievable for them, after having had this surgery. The effects of this weight loss are cost-effective, evident for the effect on their glycaemia and microvascular diabetes complications. On the other hand, the treatment should be individualised and identified to avoid medical, surgical and nutritional complications.

The first day was crowned with an excellent gala dinner followed by dance. The old fashioned but relatively young musicians played original Beatles songs and other popular music’s from the 60ties and 70ties.

On the morning of the 2nd day Diabetes Chronic Kidney Disease management was a clinical area that was discussed in 2 different sessions (Drs. Asad Rahim, Prof. Jiten Vora, Dr.Richard Brice) and in the track rotation by Dr. Stephen Lawrence. In both sessions the new NICE recomendation was presented. In Diabetes CKD where both eGFR and Albumin/creatinine ratio are now recommended to stratify which is the risk and also how to monitor those patients. The eGFR assesment by MDRD clinical practice was also discussed. Both sessions concluded with an interactive, clinical cases discussion whereby the audience were to identify what must be their clinical attitude , considering an holostic approach of this high risk individuals with established CKD.

Dr. Colin Kenny (GP, Dromore, Editor-in-Chief, Diabetes & Primary Care) was the speaker on the second session of the day “Emerging stories that will impact your everyday diabetes care”. A great review of the best papers published the former year. He was followed by Prof.Jonathan Valabhji (Clinical Director for Obesity and Diabetes, NHS England) who was involved in Diabetes Distilled, an online tool, monthly highlighting important key evidences relevant to primary diabetes care. This might impact the daily practice in a positive, time effective way.

Dr. Rob Sabsford ( Consultant cardiologist, Leeds) provided recommendations for the ‘Best practice CVD management in people with diabetes’ emphasizing the complexity of care and therapeutic requirements.

In other parallel workshops the specialized nurse taught us how to start basal insulin in a correct way, and how to act when basal insulin is not enough. Su Down (nurse consultant diabetes and clinical leader for the Intermediate Diabetes Service in Summerset) pleas for a continuing and structured education in the start of basal insulin. The importance of a correct injecting technique might make the difference between bad regulation and stable regulation. Although structured education is always difficult to organize but at least concrete control of the places of injection can declare why blood glucose varies a lot from time to time and what might cause unexpected hypo’s.

The meeting was closed by two pharma symposiums by Dr. Iain Cranston (Hospital Porsthmouth) and by Prof. Azhar Farooqi (University of Leicester) followed by Dr. Adie Viljoen (Cambridge University).

The observers, and surely the participants as well, had good impressions and new, updated knowledge can help all of us in the daily clinical practice