LETJXRS TO THE EDITOR

Letters on any aspect of diabetes care are welcomed and should be addressed to the Editor

Diphosphonates to treat acute Charcot’s art hropat hy Sir, In his comprehensive review of Charcot’s arthropathy Dr Purewal (Practical Diabetes International, May/June 1996, pages 8-3-91) briefly mentions the Diphosphonates in the treatment of the acute stage of this condition. Since the publication by Selby etaF, we have treated six patients with acute Charcot’s arthropathy with Diphosphonates and I have been impressed with the results. Our protocol has been to give 15 mg of Pamidronate intravenously weekly for 4-6 weeks. Pain has been reduced and both clinical and radiological evidence of inflammation has also improved. The expected degree of deformity also does not seem to have materialised. The problem that we face is uncontrolled use in a small number of patients, and 1 think we urgently need a controlled study. The problem is recruiting a large number of patients which may well require a large multicentre UK study. Can I be reassured that a study is or could take place?

I would endorse the views of Dr Purewal that Charcot’s is not that uncommon a condition which can have serious consequence and if there is a treatment which could significantly alter the progression then I think it is beholden upon us to undertake proper clinical studies as soon as possible.

COLIN JOHNSTON, Comultant Physician and Endocrinologist Heme1 Hempstead General Hospital, UK

Ref ecence 1. SelbyPL,YoungMJ, BodtonqlM. Biphosphonates- a new treatment for didbetic chdrcot neuroarthropathy? DzubetMed 19966; 11: 28-31

Thyroid function preclinic samples make sense? Sir, We were interested to read the report by O’Malley et a1 (PracticalDzabetesInternational May/June 1996, Vol 13 No.3, page 96) and would agree that such a system can reduce the numbers of return patients to clinics by giving advice on for example, insulin adjustment on the telephone. Like many diabetes centres we have used the system for a number of years, but recently we have analysed the phone calls received by the centre and have found a staggering 82% rise in numbers of phone calls over the last two years.

Approximately 55% of these calls are from patients, their relatives or carers for advice about diabetic control, adjusting treatment etc. A certain number of these calls are pre-arranged at specific times, but many come out of the blue and can be quite disruptive during patient education sessions. About 26% of the telephone calls are from GPs or from the practice staff. About 19% of the phone calls are from practice nurses who are running diabetes clinics on behalf of GPs asking for advice on the mailgement of patients. As the majority of these nurses have spent some time training with the staff in the diabetes centre, they know them well and tend to phone the diabetes centre when there is a problem.

With the number of calls now exceeding 250 per month, and many occurring unpredictably, there can be considerable disruption of the working programme. Even when it is possible to defer the telephone call and reply later, there is still a considerable amount of diabetes specialist nurse time involved. A conservative estimate is that a minimum of one hour per day is taken up by telephone calls and there is more disruption of working pattern than if a specific time could be set aside for dealing with pre- arranged phone calls. We are currently looking at this problem to see if there is any way of condensing the phone calls to specific periods of time when a member of staff would be available to deal

with them. While we would agree that a phone-in service is useful and

certainly reduces the number of return visits to clinics, it is a two- edged sword and frequent non-arranged calls can cause significant problems for the diabetes centre staff.

ADR HARROWER, Coitsultant Physician with Sandra Coats, Helen Jack, Patricia McCue, Elizabeth Murphy, Pat Sullivan, Linda Tallon - DIABETES CENTRE TEAM, Monklands Hospital, Lanarkshire, UK

The skill of treating diabetic foot ulcers Sir, I was most interested to read the article Which Dressing for Diabetic Foot Ulcers? by Dr RA Fishen and Moira Digby (Pract DiabetesIntVol13 N o 4, page 106). I have worked for many years as a DSN at Leicester Royal Infirmary, but in February of this year was fortunate to be involved in the setting up of a Diabetic Foot Clinic. Until that time I had not realised the major importance of manual debridement by a skilled chiropodist in the treatment of neuropathic foot ulcers. All of the hydrocolloid and alginate dressings which were favoured in Dr Fisken’s survey make manual debridement difficult and also contribute to blocking the drainage of pocketed pus. The skill of the chiropodist and the relieving of pressure seem paramount to healing neuropathic ulcers.

In our clinic we use a NA dressing and a saline wick should the wound require packing. Dry gauze is then applied. We find these dressings need to be replaced daily because often there is a profuse serous discharge, but as we use a scotchcast boot which is removable, this is not a problem. Long-term antibiotic therapy is also used. It is a simple inexpensive method of treating foot ulcers and patients are kept mobile and free from hospital admission.

management of the diabetic foot.

ANNIE GRAVES, DiabetesSpecialist Nurse, Knighton Street Out-Patients, Leicester, UK

I would be interested to hear other centres’ experiences in the

A call for research fellowships for paramedical staff in diabetes Sir, The importance of multidisciplinary teamwork in diabetes care is now becoming well established, The crucial role of the diabetes nurse, dietitian and chiropodist in the delivery of good-quality care to people with diabetes in both the community and hospital setting is recognised. However, we believe there are at present too few opportunities for paramedical staff to spend time evaluating and researching their contributions to diabetes care.

To remedy this, we would like to see the development of part- time research fellowshipsAectureships attached to University Departments - perhaps of General Practice, Medicine, or Public Health - for paramedical professionals. They then could spend, say, one day a week fr three years on evaluation and research in diabetes care.

Funding for such part-time research posts is never easy to find. We would want to ask our colleagues in the diabetes pharmaceutical industry to consider the possibility of sunding such positions as pilot projects. We feel that this idea would help in developing the academic base of the paramedical professions in diabetes. We are also sure that the research and evaluation carried out would result in better care for people with diabetes.

ROGER GADSBY, GP/SeniorLecturer i?z GP Warwick University, UK

MARY MACKINNON, Diabetes Co-or~iizator/Lecturer-Practitioizer Sheffield University, UK

198 Practical DiubetesInternational November/December 1996 Vol. 13 NO. 6