February

Seville, November 2016

Another successful Gulloebl Film Festival has taken place chez Lola II and Mr M, with the usual high quality films and hospitality. My favourites this time: Grosse Point Blank (which was much more funny than I remember), and Best in Show (which was just as funny as I remember). My contribution was to drive mum and dad over to join in - the first time they have been to the house for quite a long time.

Meanwhile, the LRTP continues with Ilf varnishing stairs and kitchen doors and painting kitchen skirting, walls and ceiling. It all looks beautiful. I have, at last, felt able to just sit and read a book for an hour or two without the nagging feeling that I should be doing something. Of course there are still plenty of things I should be doing, but at least I can relax some of the time.

I have made an investment in buying a ski helmet and ski boots. The procedure for fitting the boots included measurements, a certain amount of trial and error, and experimenting with different manufacturers. Sadly the ones that fitted best were plain black and white rather than the blue and electric pink ones with furry lining. The inners were softened by heating and moulded to the shape of my feet. I've been wearing them around the house with rags tied around the bottom to protect my lovely floors, and the fit seems perfect. I'll be trying them out in the field next week on my second ski trip of the year.

The main thing bothering me at themoment is entirelymyown fault. In a distracted state I looked at my laptop keyboard and wasmildly dismayed at its filthycondition. So Iremoved the space bar and did a fair amount of cleaning witha small paint brush. Canyou see what has happened since then?

What I've been reading

Holes
by Louis Sachar

narrated by Kerry Beyer

"Stanley Yelnats has been unjustly sent to a boys' detention center, Camp Green Lake in Texas, where the Warden makes the boys 'build character' by spending all day, every day, digging holes: five feet wide and five feet deep."

It's a book for young adults but I enjoyed it hugely. I think I've been subjecting myself to works of quality for too long, so an easy read with a great story, good writing and plausible plot is unexpectedly pleasurable. All my reading should be fun; I have let it become too worthy.

The Sleepwalkers: A History of Man's Changing Vision of the Universe
by Arther Koestler

"A thought-provoking account of the scientific achievements and lives of cosmologists from the Babylonians to Newton."

I thought this would be an interesting history of astronomy from the viewpoint of someone writing in 1959, and I also remember finding it interesting when I read it in my teens. It is, however, dense, academic and enormous, covering the lives as well as the work of Copernicus, Tycho Brahe, Kepler and Galileo in immense detail but giving Newton not much more than a couple of paragraphs. I had a marathon journey home from Italy which gave me the chance to do some prolonged reading, otherwise I'm not sure I could have finished it.

The Assassin's Prayer
by Ariana Franklin

"The King of England has ordered his Mistress of the Art of Death - anatomist and doctor Adelia Aguilar - to accompany 10-year-old Princess Joanna on her thousand-mile journey to marry the King of Sicily. They must take with them the legendary sword Excalibur."

The fourth and last book of this series - last because the author died after writing this one. It's pretty good, but not as good as the previous ones, and there's much less of the anatomy and forensics which contributed a lot to the appeal of the first books.


Not much reading in two months, but my current audio book is an epic tome lasting more than 48 hours and I'm only half way through. Spending a week on holiday puts me in arrears with my podcast listening too, so books take second place until I've caught up!

Tuesday

Spain, November 2016

It's getting ridiculous how I spend my Tuesday off running around like a mad thing Getting Stuff Done rather than enjoying some time to myself with a book and a cup of tea. Not that there aren't plentiful cups of tea, but usually accompanying at least one other activity. Unlike Saturdays, when I try to have at least a bit of a break.

Last Tuesday felt particularly hectic:

• Set the alarm to wake up, because...
• Dropped the car off for an oil change and service, highlighting problem with tracking and/or steering
• Bought some milk and posted a letter on the way home
• Cooked mushroom and egg on toast for breakfast (this is a treat for a day off)
• Made four lunches for the rest of the week from interesting buckwheat pasta bought on holiday
• Contacted AEG customer support to enquire about certain operations of new microwave oven - did it over the web but should have phoned because response has not been forthcoming
• Phoned chimney sweeps and then realised this would have to wait because...
• Planning how to buy ski boots and this is more urgent than chimney sweeping
• Arranged to meet friend in Birmingham for lunch (less urgent than ski boots)
• Ordered ski helmet for collection at the weekend
• Lunch consisting of leftover soup and salads
• Garage called to inform me that one tyre was damaged to the point that I was fortunate it hadn't exploded
• Three more phone calls for various enquiries and appointments
• Started writing blog about insulin pump training day
• Cleared utility room ready for disassembly of cupboard in order to enable fitting of stopcock push-button valve
• Changed keysafe combination for kitchen fitters (I have a different combination when I'm expecting tradesmen)
• Scheduled future plans for replacing bathroom radiator
• Shopped for plastic tubs on the way to collect the car
• Came home and organised more kitchen stuff into new plastic tubs
• Drove to B&Q to buy a shelf for the kitchen
• Drove on to work in order to attend meeting for patients on insulin pumps who are not achieving their aims, but the time had been changed so I missed the first two hours
• Drove on to meditation with Buddhists. We are looking at the archetypes who comprise the Mandala of the Five Buddhas, and to be honest the discussion is not doing much for me, but the meditation is good and it's nice to have company for some of the day.

Not every Tuesday is this busy, but most of them are. I used to wonder how I managed to work full time, but I must have done all this stuff at the weekends. Since that Tuesday I've had a whole week followed by another Tuesday. Plumber Ulf came to sort out the stop tap business and while he was here he changed my bathroom taps and pipes so that it now takes less than a day to fill the bath. There's been badminton, I collected the ski helmet, and I've also done a lot of floor waxing and polishing so the living room is lethal when wearing socks. And at the weekend the soul of the television was stolen with a quiet 'pop' and faint smell of burning. It was about 15 years old, so fair enough.

In between all this I've still been going to work, but there's very little new to report on that front. Patients continue to be interesting but impossible to write about, I enjoy delivering the group education as well as the one-to-one consultations, but I'm always happy to go home at the end of the day.

Another insulin pump

Krakow Botanical Gardens, July 2016

There are a number of different insulin pumps available on the UK scene - unfortunately one fewer than there were last week, as one company (Animas) has withdrawn from the pump market. We support three different pumps in our service, although the majority of people use one particular brand (Roche). A training day was offered by Medtronic, one of our less used suppliers, and all three of our nurses, one doctor and I attended to learn more about how the pump is used and about some other associated products.

It's a 'tubed' pump, which means that a tube carries the insulin from the reservoir in the pump down to a cannula inserted subcutaneously. [Tubeless or 'patch' pumps (like the Omnipod) are mounted directly onto the skin with the cannula on the underside of the pump.] A blood glucose monitor communicates with the pump, and an insulin calculator is integrated into the pump rather than the monitor. The main consequence of this is that the pump has to be accessible for anything other than a preset bolus amount - the other brands we use can stay hidden under clothing as all their functions can be operated from the blood glucose monitor alone.

Aside from this one drawback, I like the Medtronic pump. It has potential beyond just being an insulin pump because it can be hooked up with an integrated Continuous Glucose Monitoring (CGM) system. This allows for anticipation of low blood glucose (hypoglycaemia) and the pump can actually suspend insulin delivery for up to 2 hours ('low glucose suspend'). It can do this automatically or with user input, with or without alarms, day or night. This has been shown to prevent hypos without leading to high blood glucose afterwards.

'Low glucose suspend' kicks in when blood glucose is within 3.9 mmol/L of a user-selected 'Low Limit' and predicted to drop to less than 1.1 mmol/L above the low limit within 30 minutes. So if the user selects a low limit of 3.4 mmol/L, insulin can be automatically suspended if 4.5 mmol/L is predicted when blood glucose is 7.3 mmol/L, as measured by the CGM sensor which is monitoring glucose levels through another cannula. Insulin is restarted either when the user intervenes, or when blood glucose is predicted to rise 2.2 mmol/L above the low limit within 30 minutes, or after a maximum of two hours. I started to argue about why the user-specified low limit couldn't be the actual prediction (4.5 mmol/L) rather than 1.1 mmol/L below it (3.4 mmol/L), but our tutor wasn't following my argument so I had to abandon that line.

We looked through the pump's menus, set up two basal patterns, set temporary basal rates, entered blood glucose levels, delivered different types of bolus and generally learned about all the different settings. We were shown different cannulas and inserters and stabbed ourselves with those, and then looked at the reports that can be produced, both with and without the associated CGM trace. They left this bit until the end, and I would have preferred a bit more time to work out what the reports featured, where the most useful and important information could be found, and a bit more practice at interpreting the tables and graphs.

The chap leading the training day was a healthcare professional who works for Medtronic and goes out to patients to start them on pumps, review, or troubleshoot. He also has Type 1 Diabetes himself, and uses a Medtronic pump. Occasionally he would throw in some personal experience about how he would manage a situation himself. Nobody, and I mean nobody that I have met through our diabetes service (or elsewhere) treats their diabetes in the way that he does. "But if I don't do it like this I'll have a higher HbA1c [i.e. worse control], so why wouldn't I?" he said. True, but he is in a bit of a unique position, understanding his diabetes and how the pump works as he does. And he seems more motivated to manage his diabetes than almost anyone I've met.

[For those who know about the numbers, he tested his blood glucose about an hour before lunch, it was 7.1 mmol/L with no active insulin on board and he gave himself a bolus of less than one unit of insulin. "My target is 5.5, I've got the technology, so why not?" he said.]

This company is aiming at development of the technology beyond the 'low glucose suspend' option. They have plans for a 'hybrid' system that will adjust basal insulin all the time according to CGM results, not just when blood glucose is dropping. Bolus insulin for food will still be down to the user, which distinguishes the hybrid from the 'artificial pancreas' level of technology (which does exist but is still too experimental for mainstream use).

At the end of the day we were also reminded of another bit of kit that the company produces, which consists of a cannula that can be worn for up to three days (like a pump or CGM cannula). This one, however, is designed for manual injections, so its function is to enable someone to give all their multiple daily injections for three days through the one device. The obvious benefit of this device is fewer skin-piercing injections; the downside is that by the end of three days the effectiveness of insulin injected in the same spot can fade a little, and the risk of developing lipohypertrophy ('lipos', or fatty lumps) is higher.

The sales pitch suggested that this is a device that would benefit everyone, but would it benefit someone who is doing well and doesn't mind multiple injections? Such a person would be moving their injection site around, wouldn't risk lipos and wouldn't experience the decrease in the effectiveness of their insulin. Balanced against that is the benefit of reducing the unpleasantness of multiple injections. It's difficult to judge the psychological strain of many injections compared with one cannula for three days, but so far I haven't started pushing this device to patients.

Ski Folgarida

It was a great holiday, run by the Ski Club of Great Britain. I discovered that this organisation originated from a time when keen Britons lived in ski resorts, and the Club linked them together so they could visit each others' resorts and ski together with local knowledge. Times have changed, but the focus is still on higher ability and more technical skiing (and snowboarding). I joined one of their holidays in 2014, and this was a similar one that also included three days instruction. On the other three days we were supposed to be guided by a Ski Club Leader, but he turned out to be an instructor too and so we got instructed on all six days, and often more by the Leader than by the official instructor.

The Italian resort Folgarida is a long way from Milan airport with more than three hours on the bus to the hotel, which was right on the piste but well away from the village, which meant they tried hard to put on entertainments in the evenings. One night there was a pianist/singer, another night we had a local cheese and meat tasting, but I missed much of the evening activity because after dinner I'd generally had enough and went to bed.

There were 14 of us including the Leader, and what an interesting group of people they were. A pilot, an economist at the Bank of England, a Forensic Psychologist, a BP executive, a retired owner of a children's nursery who had previously been a ballet dancer, a retired photographer, a BBC website editor, a couple of retired lawyers. Mealtime conversation was a great deal more stimulating than what I'm used to at work. I got on well with most, but not at all with two of them.

The skiing went well - I was initially put in the more advanced group, but I switched for the last two days because the numbers worked better and it got me away from one of the people I didn't get on with, which is when I discovered I didn't get on with the second one. Unlike the previous Ski Club holiday we weren't forced off piste all the time, but did a very little bit of off piste much more successfully than before. One of the highlights was a long quiet gently sloping run through the woods, another was the opportunity to have one's picture taken at the start of a World Cup downhill slope, and a third was an interesting local liqueur called 'Bombardino'.

As always I made a trip to a local supermarket where there was no interesting chocolate, so instead I bought some interesting pasta with a recipe for local dish 'pizzoccheri'. I also bought some of the delicious cheese and salami from the hotel cheese-and-meat tasting. The food in general was good, with a couple of oddities thrown in. We were given menus each evening to choose the following evening's dishes without much explanation, so one of my main meal choices turned out to be three very large (~250g) pieces of cheese, accompanied only by a teaspoon of honey and a teaspoon of mustard. The cheeses were very tasty, but not what I would have chosen for dinner had I known. On another night the 'grilled cheese with caramelised onion' turned out to be just that - a small browned onion on a plate next to two slices of cheese that were slightly melted. Luckily I hadn't chosen that option.

At the end of the week my skiing ability was rated exactly the same as it had been four years ago, which surprised me because I feel a great deal more competent now than I did then. Then another 13-hour journey to get home, where I have been feeling a little sad at the lack of interesting people and their stories, but happy that I have another ski trip planned for six weeks' time.