Neil Munro

Practical steps to improving the management of type 1 diabetes: recommendations from the Global Partnership for Effective Diabetes Management

The Diabetes Control and Complications Trial (DCCT) led to considerable improvements in the management of type 1 diabetes, with the wider adoption of intensive insulin therapy to reduce the risk of complications. However, a large gap between evidence and practice remains, as recently shown by the Pittsburgh Epidemiology of Diabetes Complications (EDC) study, in which 30‐year rates of microvascular complications in the ‘real world’ EDC patients were twice that of DCCT patients who received intensive insulin therapy. This gap may be attributed to the many challenges that patients and practitioners face in the day‐to‐day management of the disease. These barriers include reaching glycaemic goals, overcoming the reality and fear of hypoglycaemia, and appropriate insulin therapy and dose adjustment. As practitioners, the question remains: how do we help patients with type 1 diabetes manage glycaemia while overcoming barriers? In this article, the Global Partnership for Effective Diabetes Management provides practical recommendations to help improve the care of patients with type 1 diabetes.

The predictive validity of selection for entry into postgraduate training in general practice: evidence from three longitudinal studies

BACKGROUNDnThe selection methodology for UK general practice is designed to accommodate several thousand applicants per year and targets six core attributes identified in a multi-method job-analysis studynnnAIMnTo evaluate the predictive validity of selection methods for entry into postgraduate training, comprising a clinical problem-solving test, a situational judgement test, and a selection centre.nnnDESIGN AND SETTINGnA three-part longitudinal predictive validity study of selection into training for UK general practice.nnnMETHODnIn sample 1, participants were junior doctors applying for training in general practice (n = 6824). In sample 2, participants were GP registrars 1 year into training (n = 196). In sample 3, participants were GP registrars sitting the licensing examination after 3 years, at the end of training (n = 2292). The outcome measures include: assessor ratings of performance in a selection centre comprising job simulation exercises (sample 1); supervisor ratings of trainee job performance 1 year into training (sample 2); and licensing examination results, including an applied knowledge examination and a 12-station clinical skills objective structured clinical examination (OSCE; sample 3).nnnRESULTSnPerformance ratings at selection predicted subsequent supervisor ratings of job performance 1 year later. Selection results also significantly predicted performance on both the clinical skills OSCE and applied knowledge examination for licensing at the end of training.nnnCONCLUSIONnIn combination, these longitudinal findings provide good evidence of the predictive validity of the selection methods, and are the first reported for entry into postgraduate training. Results show that the best predictor of work performance and training outcomes is a combination of a clinical problem-solving test, a situational judgement test, and a selection centre. Implications for selection methods for all postgraduate specialties are considered.

Is multidisciplinary learning effective among those caring for people with diabetes

The role of multi‐professional learning for those providing clinical services to people with diabetes has yet to be defined. Several assumptions are generally made about education in the context of multi‐professional settings. It is argued that different professions learning together could potentially improve professional relationships, collaborative working practices and ultimately standards of care. Greater respect and honesty may emerge from a team approach to learning with a commensurate reduction in professional antagonism. Personal and professional confidence is reportedly enhanced through close contact with other professionals during team‐based learning exercises. We have examined current evidence to support multidisciplinary learning in the context of medical education generally as well as in diabetes education. Previous investigation of available literature by Cochrane reviewers, aimed at identifying studies of interprofessional education interventions, yielded a total of 1042 articles, none of which met the stated inclusion criteria. Searches involving more recent publications failed to reveal more robust evidence. Despite a large body of literature on the evaluation of interprofessional education, studies generally lacked the methodological rigour needed to understand the impact of interprofessional education on professional practice and/or health care outcomes. Nevertheless, planners continue to advocate, and endorse, joint training between different groups of workers (including nurses, doctors and those in professions allied to medicine) with the objective of producing an integrated workforce of multidisciplinary teams. Whilst the concept of multi‐professional learning has strong appeal, it is necessary for those responsible for educating health care professionals to demonstrate its superiority over separate learning experiences.

Insulin for type 2 diabetes: choosing a second-line insulin regimen

Guidance has been published on the choice of initial insulin regimen for patients with type 2 diabetes [NPH (isophane) insulin or a long‐acting insulin analogue] but not on how to choose a second regimen when glycaemic control becomes unsatisfactory.

Developing a new clinical skills assessment (CSA) for licensing UK general practitioners: the why, the how and the when

To cite this article: Neil Munro, Kamila Hawthorne, Mei Ling Denney, David Sales, Chris Robinson, Amar Rughani, Fiona Patterson, Malcolm Lewis & Val Wass (2006) Developing a new clinical skills assessment (CSA) for licensing UK general practitioners: the why, the how and the when, Education for Primary Care, 17:4, 301-310, DOI: 10.1080/14739879.2006.11864080 To link to this article: http://dx.doi.org/10.1080/14739879.2006.11864080

Current, new, and emerging therapies for managing hyperglycaemia in type 2 diabetes.

The last decade has witnessed the introduction of several new drug classes and drug formulations that effectively reduce hyperglycaemia in type 2 diabetes. Expansion of drug choices is set against a background of increasing awareness of the progressive nature of type 2 diabetes. The next decade will see emergence of new therapies with novel modes of action further broadening the palate of agents available for clinical use. This expansion will enable tailoring of therapy in diabetes based on individual response to a particular drug, as well as any specific side-effects arising from treatment.nnConsensus guidelines have now incorporated metformin as the first choice oral agent, along with appropriate dietetic and lifestyle advice, in the early management of hyperglycaemia in type 2 diabetes.1 It has also a role in preventing people with impaired glucose tolerance (IGT) progressing to type 2 diabetes.2 Metformin acts by reducing gluconeogenesis (elevated in type 2 diabetes) and improving insulin sensitivity. This is the only biguanide in current practice. Patients can experience significant gastrointestinal side effects which may be ameliorated by switching from immediate-release preparations to newer delayed-release formulations.nnRecent NICE guidance promotes the use of sulphonylureas as second-line therapy.3 These agents act by directly stimulating insulin secretion by beta cells in a nonglucose dependent manner and can cause, in some individuals, weight gain and hypoglycaemia.nnThe place of thiazolidindiones — the ‘TZDs’ or ‘glitazones’ — has come into question following the publication of a meta-analysis showing an excess of myocardial infarctions in patients treated with rosiglitazone.4 As insulin sensitisers, whose action is mediated through peroxisome proliferator-activated receptor γ (PPARγ) activation, these drugs showed much promise in terms of durability of effect and, in those who respond well to the agent, useful reductions in HbA1c. Pioglitazone has been shown to have beneficial effects …

General practice (GP) foundation training: the antidote to 'badmouthing' of general practice.

Doctors now undertake a two-year FTP which includes the pre-registration year. The objective is to develop and enhance core or generic clinical skills regarded as essential for all doctors. These include team-working, communication, ability to produce high standards of clinical governance and patient safety, improved patient experience, and expertise in accessing, appraising and using evidence as well as time management skills. During this time doctors also have the opportunity to sample a range of clinical specialties before competing for entry to one of the basic specialist training programmes, including general practice. A very significant number of Foundation Training Programmes, especially during the second year (FY2), include four-month attachments in general practice. Large numbers of newly qualified doctors now have postgraduate experience of general practice irrespective of their long-term career intent. The effects of these new training structures merit close examination. The general impact of the FTP is clearly of interest to a wide range of stakeholders. Medical Education England (MEE) has commissioned a formal evaluation of the two-year FTP. Professor John Collins has been asked to chair this evaluation.

Fixed-dose combinations in diabetes--do they improve medication adherence?

In 2005, The Cochrane Database of Systematic Reviews assessed interventions for improving adherence to treatment recommendations in Type 2 diabetes and concluded that, from the 21 studies assessed, ‘there were neither significant effects nor harms’ (1). The current article by Scherthaner in Diabetic Medicine (2), reviewing some of the more recent evidence, puts a new perspective on the possible role of fixed-dose combinations (FDCs) in improving drug adherence in the management of hyperglycaemia of Type 2 diabetes.

Patient preferences for diabetes care

Patient choice or preference has been promoted as an essential element of a patient-centred health service. In response to a questionnaire, accessed via a specialist hospital diabetes clinic where the majority of patients had longstanding insulin treated diabetes, over 90% of patients expressed a preference for consultation with a specialist doctor and 70% preferred a specialist nurse to be involved in their ongoing care in the specialist diabetes centre setting.

A new cause of neuroglycopenia: "missing the point".

Confirmation of diagnosis of hypoglycaemia with capillary blood glucose measurement is often undertaken by patients when they develop symptoms of a low glucose level. This then leads to appropriate dietary action and resolution of hypoglycaemia. We report a case of severe hypoglycaemia in a previously fit 90-year-old retired army surgeon with Type 2 diabetes who had misread the glucometer sensor display. He was falsely reassured, despite symptoms, by reading ‘17’ mmol/ l when the actual result was 1.7 mmol/ l, and so did not take any immediate action. His medication comprised gliclazide 40 mg od, metformin 850 mg bd, and omperazole 20 mg od. He was subsequently admitted to the emergency department following collapse. On admission he had right-sided hemiparesis and speech difficulty in association with a plasma glucose of 1.4 mmol/ l. Intravenous dextrose (50%) was administered with immediate and complete resolution of his weakness and speech impairment. During the next 24 h and following withdrawal of hypoglycaemic agents, his glucose remained above 5.0 mmol/ l. The importance of the visual clarity of display on glucometer sensors has never been formally assessed to our knowledge. At present, the majority of glucometer sensors display the decimal point at the bottom of the screen, in a variety of sizes, which can easily be ignored, particularly during visual disturbance associated with hypoglycaemia. Improving the position and size of the decimal point display, as well as increasing the awareness of this pitfall in design for patients and their professional educators, will avoid potential cases of neuroglycopenia due to ‘missing the point’.