Touch site, sound?

I’m a great believer in recycling: “Touch site, sound?” was the title I gave to a presentation I first made in 2009.

The audience was healthcare professionals, mostly GPs and practice nurses.   Cheeky of me to re-use my materials in this way? Perhaps, but hey, why not!

Since fatty lumps at injection sites (lipos or lipohypertrophy) are experienced by the majority of people with diabetes who use injections, I truly believe this message will have much greater value when it is in the hands of people with diabetes.   Let’s find out if I’m correct…

lipohypertrophy

I’m a lucky doc, I get to work with some excellent people.  One of these, diabetes specialist nurse Sister Jagjit Kaur, I credit with making me think much more about the injection sites and problems than I ever had before.  Here’s our rose between two thorns at DUK 2009, presenting our first informatics work (we’d achieved a change from 0% to 75% for pre-pregnancy advice to women with D of child-bearing age in a large local GP surgery 🙂 ).

My first Informatics project c2008, at DUK 2009

My first Informatics project c2008, at DUK 2009

 

A big thank you to Jagjit- she showed me just how important these factors are to people with diabetes trying to get stability of their glucose levels and reliable effect of insulin.

Indeed, to me, in theory the “boss”, the importance of these was a total blind spot. It had simply not featured in my training to become a diabetes consultant.  I would spend far more time considering differences between various types of insulin product.

So began a journey that saw us

  • Survey our patients concerning just how common lipos are (over half) & whether patients do get examined regularly (…er, no).
  • Become involved with the work of the Forum for Injection Technique, here are their latest recommendations (I’d so love to be more involved, if you are reading this FIT peeps…)
  • Make conference visits to the Becton Dickenson (BD) stand & visits from their reps. essential to get hold of the best educational resources for our patients

We were really knocked out by a European survey revealing that

  • 75% PWD who do not ‘rotate’ injection sites have lipos
  • 25% PWD who do ‘rotate’ injection sites still have lipos

Why does this happen? What makes a difference? Will lipos always go away. Hard to say.  We simply do not know enough about injection site issues.  It is reckoned you minimise your chances by

  • always moving 1-2 finger-breaths from one shot to the next and not going back to that spot for a while
  • never reusing the same needle (PWD were historically very frugal, a hard habit to break)
  • Using an appropriately short needle (4, 5, 6, 8 and 12.7 mm are available…)

At the last DUK conference, BD had one of their Reps, Kinsey Jones, great guy who has T1 himself, allowing delegates to examine his tummy lipos.  BD are recommending a ‘formal’ examination, on the couch, with healthcare professional applying K-Y Jelly and gently but firmly exploring with gloved-hands.  I’m not sure how that would go down with PWD.  I wonder about the scope for self-examination.  Do you think that may work?  Maybe backed up by show-and-tell.

image002

A seminal moment for me was listening to a conference seminar from a BD expert Dr Ken Strauss at an European Association for Study of Diabetes. Some of his early work is here In 25 mins I learned the following

  • Epidermis and dermis is only 2mm thick, but as the latter is ‘scalloped’ it is a max. of 2.8mm thick. Any needle longer than 3mm will reach the subcutaneous space
  • 50% adults have lipos… but in kids the figure is 70%
  • Whether you are old/young, male/female, fatter/thinner, any race, 4mm needles will be plenty
  • Teach PWD to rotate early, they do; try to do this later, they don’t…

Does this REALLY make that much difference to insulin absorption and action? You tell me what you think.  It certainly did in the cases in my talk and seems to for many of the PWD I meet each week.  My own opinion is that this effect is as least as big as related issues of injection technique, e.g. resuspension of mixtures, differences between body areas, ambient temperature etc.  Whatever PWD can do to make the effects of insulin injections more predicable is certainly money in the bank.

I’m a pragmatist when it comes to clinical research- it really ought to be for the direct benefit of the people I see, if it is to be worth doing.  I’m still hopeful that one day soon my team and I can engage in some injection-site research, I think this will become a much more important issue as awareness grows.

In the meantime the lovely people at OurDiabetes #ourD have asked me to host a Twitter chat on Lipohypertrophy & insulin injection technique one Tuesday night soon.  The format is to choose 5 key questions which PWD answer between 8-9pm. Please leave a comment & maybe suggest what questions you would like to hear answers to.

I was going to ask PWD if they would wish to share lipo-selfies during that Twitter-chat. Would that stray over the boundary of good-taste, or could it help break down a D-taboo?  Thanks for reading.

More background materials here.

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4 thoughts on “Touch site, sound?

  1. Great to see this blog, sharing some knowledge and asking for questions.

    To help me and no doubt others, could you explain some of the shorthand used in the slidedeck please?

    page 3 MDT = Multi Disciplinary Team
    page 4 YAC = Young Adult Clinic
    page 6 2e hypos = ?
    page 7 O/E = ?
    page 10 PJ = Personal Journey?
    page 12 s/c=subcut
    page 14 PMH=Previous Medical History
    page 14 WS=Working solution?

    • Thanks David, I left the presentation as it was originally constructed, five years back for a professional audience. So apologies that it’s not always easy to understand. Here’s what you need –
      page 6 2e hypos = his wife believed that his aggressive behaviour only occurred secondary to hypoglycaemia, so ‘2e hypos’ should be ‘2e to hypos’
      page 7 O/E = on examination
      page 10 PJ = these are the patient’s initials,
      page 12 s/c=subcut
      page 14 PMH=Previous Medical History; same difference, past medical history
      page 14 WS= more patients initials

      If I was designing it all over again, I would do so rather differently 😉 looking back a few years, I always find it interesting. My use of abbreviations has plummeted too. Cheers!

      • That’s great, thank you! I’m pretty sure if I shared a slidedeck from work you’d be scratching your head with all the shorthand, so I think yours wasn’t too bad on that front 🙂

        As for lipo selfies: I would show you the ones I have on my legs, but as they can’t be seen with a visual check it might look a bit odd… I can certainly feel the little lumps though. When the areas of rest start to run out I move around to my bum. I might have strayed into the too much information zone 😀

        I have a few ideas for questions, but let’s see what others come up with first.

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