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|01 Jewish. Political. Ealing County School. Evacuated…|
|02 Father tailor. Mother ran Keen`s Cleaners. Interest in medicine at Habonim.|
|03 Didn`t join army. Interviewed at St. Mary`s by Lord Moran. |
|04 Taught by George Pickering – experimental - got me in to diabetes.|
|05 After army, Pickering invited me to research blood pressure. Attempts at MRCP. Sent to Robin Lawrence at Kings to measure younger patients.|
|06 Wilfred Oakley uninterested. Lawrence`s diabetes gave insights. I`d previously seen chronic illness in TB ward.|
|07 Diabetes had been seen as solved - Beginning to see long-term effects. Kimmelstiel-Wilson syndrome. Over next 20 years, hazards anticipated.|
|08 People who trained me didn`t understand complications. Should Type 1 be treated as strictly as by Joslin? |
Risk of vision loss, renal failure, heart attack & stroke. Consultants didn`t warn patients. Importance of control only recognised later.
|09 In 1950s, impressed by Lawrence. Diet. Enormous clinics. Doctors shared room. Lawrence hypo. Eye examinations. |
At St. Mary`s did general medicine & diabetes.
1960, National Institutes of Health Fellowship, USA.
|10 In 1950s, clinic patients mostly insulin-taking. Patients waited patiently, but I was angry. Day Centres followed visit to Berlin, mid-60s. European Diabetes Epidemiology Study Group.|
|11 Saw Dr. Volker Schliack`s house for patients` residential training. Opened Guy`s day centre. Others opened. |
In 1950s, Lawrence uninterested in non-insulin diabetes – considered mild. Years before realised Type 2 complications. Bedford Survey began 1962.
|12 Returned from U.S. to John Butterfield, Guy`s |
(Wonderful year in Bethesda, but wanted to include clinical work.)
Productive decade. More liberty at Guy`s than St. Mary`s. Lecturer, senior lecturer, reader, then after 10 years, personal chair. Bedford Survey to discover rate of undiagnosed diabetes, with Clive Sharp…
|13 1962 - Urine samples collected from 72 or 73% of population. Glucose tolerance test for random sample showed area of uncertainty.|
|14 Diagnostic uncertainty found in U.S. by Kenny West. In Bedford, added ‘borderline` category. Birth of IGT - impaired glucose tolerance. Monitored 10 years. Half given Tolbutamide, half placebo. Little effect on rate of development. Need for early tests. Microalbuminuria. Borderline group had increased risk of heart disease. |
|15 1960s increase in Type 2 - clinics overcrowded. British Diabetic Association. More equal doctor/patient partnership.|
|16 1n 1960s, around 10% on Guy`s wards diabetic. Diabetes Specialist Nurse most important development since insulin. Diabetes Centres. With John Ward at Royal Hallamshire, saw outpatients visit ward.|
|17 BDA helped fund Centres, with nurses, dietitian, chiropodist - now threatened. Not either primary care or hospital – need both.|
|18 Even in 1960s, mini-clinics, with consultant & GPs. Ron Hill in Poole. Joan Walker, in Leicester, after war.|
|19 Joan Walker did 1st UK diabetes survey, mid-1950s. Was founder member of what became BDA Medical & Scientific section. I addressed meeting, 1956. Doctors worried re discussing complications with patients there. Philip Randle formed Med & Scientific section for healthcare pros only, 1960. |
|20 1970s – full impact of complications. Type 2 not mild. Tight control without ruining life. Self-measurement of blood glucose. Lawrence had used multiple doses.|
|21 Lawrence adjusted quick-acting insulin before meals. Flexibility of multiple doses not recognised until end of 1970s. John Ireland, Glasgow, developed pen injector. I didn`t believe self-measurement reliable. Study re reflectance meters. Peter Sanderson, Bob Tattersall, gave meters to patients.|
|22 First continuous subcutaneous infusion. Learnt from George Alberti that John Parsons had pump. With John Pickup, applied to National Institutes of Health for study. NIH planning Diabetes Control & Complications Trial, DCCT. Invited to run it, but decided not to. Joined ethical committee. Patients` cooperation showed Lawrence & Joslin right – tight control reduces complications. |
|23 Illusion that tight control complete solution. Tight control worsened retinopathy at first & more hypos. Then got better. Clear tight control helped Type 1. And Type 2? Early 1970s study made things difficult…|
|26 …Dr. Eishi Miki said not much heart disease with diabetes in Japan - dumbfounded by heart disease & gangrene at Joslin clinic. Japanese who moved to U.S. had increased risk. Changed advice to patients – forget dairy fats & eat high fibre foods…|
|27 …study showed patients had previously only cut out sugar. Now general population given same advice. Twice as important for diabetics to reduce cholesterol. |
In 1970s, worked with dietitians, but gave dietary advice myself.
|28 Mid 1970s, 12 centres started `WHO multinational study of vascular disease in diabetes` at CIBA Foundation. Showed little in Japan – lots elsewhere. |
|29 By 1980s, realised importance of screening for eye & kidney disease, high blood pressure & foot care. Chaired WHO expert committee, 1979. Patient collaboration essential…|
|30 …each region should develop own plan. St. Vincent Declaration, end of 1970s. More patients spoke than healthcare professionals. Diabetes National Service Framework.|
|31 1980s, early screening for Type 2 complications spread. |
Not enough specialists for Type 2 increase…
|32 …Role for primary care. In 1940s & 1950s GPs scared - referred to hospital. Continued until 1980s. As numbers increased, patients moved to GPs without preparation. Need for GPs & specialist to cooperate. GPs can help Type 2. I work in local practice. Diabetes Centre should be hub.|
|33 1980s, human insulin. Some people returned to animal insulin. Human insulin better for most – modified for delayed effect & rapid action.|
|34 Beginning of 1970s, switch from U40 & U80 to U100 organised by BDA & Dept. of Health. Reviewed injections. Local healthcare professional groups formed.|
|35 Changeover taking hold 1980s. Centres helped. |
Patients who feel human insulin loses warnings should revert. Studies show no difference. Feelings intense because lives depend on insulin – shown when British insulin put in Danish vials.
|36 End of 1980s, NHS reforms. At Guy`s, Resource Management Initiative meant healthcare professionals made policies through ‘sub-hospitals`. A plot! Prepared for internal market. Took government to court, backed by BMA.|
|37 Lost. Launch of NHS Federation - public service, not private profit. I retired 1990. Continued to work at hospital & at son`s GP surgery, Watford – many South Asians. (My study with Hugh Mather had shown high incidence.)|
|38 Reviewing all diabetics at surgery. They`re more comfortable at surgery than at hospital. Need for better links between specialist centre & primary care. Nurses` role important. I learnt from nurse at Lawrence`s clinic.|
|39 At son`s surgery, try to make patients anxious enough but not too anxious. |
My research funders included Croc Foundation at San Antonio, where gave results of WHO multinational study.