Maintain a practice register of people with diabetes with annual recall andclinical review.
Ensure all patients receive an adequate explanation of their condition, itsrisks and their management.
Provide health education on diet, physical activity, weight, blood pressure,foot care and blood glucose control.
Offer smoking cessation support and nicotine replacement to all smokers.
Aim to reduce raised blood pressure to below 140/80mmHg.
Aim to control HbA1c to 7.5% or below.
Offer statin treatment to people whose coronary heart disease risk is 15%
Audit performance towards these objectives.
literature of overall good qualityand consistency addressing thespecific recommendation.
conducted clinical studies but norandomised clinical trials on thetopic of recommendation.Orsystematic review of case-controlor cohort studies.
descriptive studies (e.g. correlation or case controlstudies).
committee reports or opinionsand/or clinical experiences ofrespected authorities. Indicates anabsence of directly applicableclinical studies of good quality.
The guidelines are designed for use in ambulatory care in primary, secondary and community settings to improve the
management of people with type 2 diabetes.The guidelines aim to improve identification, organisation and quality of diabetes
services including provision of information for patients and carers. These are set out as the primary objectives listed on the
This work complements the National Service Framework (NSF) for diabetes. By April 2003 Primary Care Trusts should ensure
that local priorities are identified and all practices have a protocol describing the systematic management and audit of type 2
These guidelines do not cover type 1 diabetes, gestational diabetes, diabetes in pregnancy or diabetes associated with
endocrine disease.These guidelines have been agreed locally (see appendix 2 for details). They are based on the National
Institute for Clinical Excellence (NICE) guidelines on management of type 2 diabetes (www.nice.org.uk), the National Service
Framework for diabetes (www.doh.gov.uk/nsf/diabetes) and the Scottish SIGN guidelines.(www.sign.ac.uk). Additional sources
To improve readability not all recommendations are graded by strength of evidence. However the major therapeutic
The organisation of care : initial diagnosis, the diabetic register and annual review
Appendix 2 How these guidelines were developed
Appendix 4 Patient information services and benefits
All laboratories in east London are Diabetes Control and
Complications Trial (DCCT) aligned. This is the preferred
methods and the laboratory standards are based on those
Symptoms: tiredness, polyuria, polydipsia, skin infections,
used in the DCCT and the UK Prospective Diabetes Study
Risk factors for diabetes: age >65years, Asian/African
Caribbean, BMI >30, family history, previous gestational
The International Federation of Clinical Chemistry (IFCC)
has recently developed a new reference method, which
measures true HbA1c and all laboratories will be required to
The following indicative levels of HbA1c are based upon the
North Thames and Eastern Region Survey and Audit for
Diagnosis and Management of Diabetes Mellitus. HbA1c: Indicative levels of control Blood Pressure treatment thresholds
Treatment is recommend at all ages including over 75,
whatever the initial cholesterol level.
Type 2 diabetes is often present several years before
There is as yet no consensus on a population screening
diagnosis and up to 50% of people already have
programme. Such programmes have not been shown to be
complications such as retinopathy, neuropathy or
cost-effective or beneficial to outcome in people with type 2
cardiovascular disease at diagnosis.
diabetes. Population sub-groups at high risk have been
identified for screening, though evidence of benefit is not
Type 2 diabetes may present with polyuria, thirst, recurrent
candida or skin infections or with dehydration often
precipitated by infection. A significant number of people with
1. People who have pre-existing cardiovascular disease i.e.
diabetes are first identified on routine testing.
raised blood pressure, coronary heart disease, peripheral
vascular disease and stroke, should have random blood
Type 2 diabetes is now affecting an increasing number of
glucose measured as part of their annual clinical review.
children/adolescents who should be managed in conjunction
with paediatric and adolescent services.
2. Women with a history of gestational diabetes and people
with impaired glucose tolerance or impaired fasting glucose
are at high risk of developing diabetes. The diabetes NSF
recommends sustained and regular follow up. However there
is no consensus on how or whether this can be achieved and
Blood glucose levels are continuously distributed and the
no evidence of benefit to support it.
definition of diabetes is an arbitrary one, based on the risk
associated with a particular level of blood glucose. The World
3. People with a family history of type 2 diabetes especially
Health Organisation (WHO) has recently revised these
at younger ages, or who are obese or from South Asian and
African Caribbean population are all at increased risk of
This classification also defines two intermediate groups,
impaired fasting glucose and impaired glucose tolerance, both
For groups 2 and 3, opportunistic case finding prompted by
of which are at high risk of developing diabetes and
symptoms or risk factors is a matter for clinical judgement
and no formal screening programme is advocated. This may
lead to identification of some individuals with previously
Patient with a fasting glucose between 6.1 - 6.9mmol/l
(impaired fasting glucose) should have an oral glucose
1. Diabetic symptoms: polyuria, thirst or weight loss plus
A fasting blood glucose concentration of ≥7.0 mmol/l
Two hour blood glucose concentration of ≥11.1 mmol/l after an oralglucose tolerance test with the equivalent of 75g of anhydrous glucose or
Blood glucose refers to a plasma venous sample
2. No symptoms of diabetes
The result in asymptomatic people requires at least two measurements
One test in the diagnostic range should be followed by at least one
additional glucose test result on another day.This may be either a
random sample, a fasting sample or from the two hour post glucose load.
If the random or fasting values do not confirm the diagnosis the two hour
glucose tolerance test value should be used.
The organisation of care : initialdiagnosis, the diabetic registerand annual review
Practices and local diabetes services should have an agreed
protocol and arrangements for the education of newly
diagnosed diabetic patients or their carers, including:
Education on diabetes and its risks.
Hazards and self management (NSF standard 7).
Availability of local services - chiropody, retinal
screening, practice nurses or diabetes nurse specialists,
diabetes dietitians, other dietitians where appropriate.
Benefits advice and where appropriate, mobility or
Annual review (NSF standard 4)
Plan for follow-up including arrangements for the
Review of blood glucose control/hypoglycaemia
A disease register should be maintained with a
mechanism for annual (or more frequent) follow-up.
Risk factors, advice and drug treatment should be
GP or hospital responsibility for annual review should
Liver Function Tests (if recently started on statin)
Attendance at retinal screening should be recorded
Responsibility for follow-up of non-attenders should be with
the responsible physician. In practice, attendance often
lapses and opportunistic vigilance by primary care and
Foot examination including peripheral pulses
10 year coronary heart disease risk assessment
At least one reminder should be sent to people who do not
attend annual reviews. It is possible this may alter in the light
(A template is available for EMIS computer systems -
A variety of interventions to improve self-management,
involved to provide structured education,
metabolic and psychological outcomes have been used.
Education supplemented by continuing support for changes
It should be recorded whether a patient has received:
in behaviour. These should be based on valid theories that
recognise the nature of behavioural change. Health
Initial education on diabetes and its management
professionals should receive training in patient centred
including self-monitoring and diabetic emergencies.
A personal care plan, in an appropriate format and
Education programmes, computer aided packages and
telephone prompting may be of benefit as part of a
multidisciplinary lifestyle intervention programme.
When appropriate, a patient held record to record
Staff training will be required to provide these services.
Smokers should be offered support to quit as part of a
programme that includes nicotine replacement and intensive
Patients with diabetes and their families provide 95% of their
Smoking status should be recorded annually and smokers
care themselves. In type 2 diabetes there is little evidence of
should be offered support to quit at each review. For more
benefit from self-monitoring of blood glucose but its use is
widespread. If self-monitoring is used, it should be viewed
as part of lifestyle change and concordance with medication
and not as a stand-alone intervention.
The principles of healthy eating should be emphasised: a
For self monitoring of glucose in type 2 diabetes there is no
diet low in sugar, saturated fat and salt and high in starchy
national consensus on the type (urine or blood) or method
(visual or electronic reading of sticks) or frequency of self-
monitoring. Local practice usually favours electronic meters
See Appendix 1 on Healthy Eating for further details of an
in those capable of using them, though patient preference
Referral to a dietitian on a least one occasion, should be
Patients require formal instruction in self-monitoring, the
considered for all patients with diabetes. Overweight and
recording of results in a patient held record and their
obese people should be encouraged to modify their diet and
reduce their calorie intake. Local resources for continuing
support i.e. Weight Watchers or similar should be
Patients should be taught about hypoglycaemia and its
management and diabetic emergencies (see page 8).
All people should be encouraged to engage in moderate
The objectives of treatment - target weight, blood pressure,
levels of physical activity (e.g. daily walking for at least 20
smoking cessation where appropriate, blood glucose,
minutes, 3 or more times a week) as part of their routine
HbA1c, and serum cholesterol should be identified and
activities (A). Local schemes - exercise on prescription,
mechanisms for achieving these through exercise, diet and
supported walks - should be considered. For more
medication explained. Foot care should be discussed (for
further details see page 14). Ideally each patient should have
Patients with complications or associated disease should
seek medical review before embarking on exercise
programmes. However, graded increases in activity are
Adherence to therapy should be discussed, together with the
In people who have failed to achieve blood glucose control
after lifestyle counselling and support, drug therapy should
change and adherence with treatment(see lifestyle section).
NICE recommends 6 monthly HbA1c measurement (and no
Metformin improves peripheral glucose uptake and
more frequently than 2 monthly) depending on levels of
control or changes in therapy. In east London it is more
realistic to aim for a minimum of 12 monthly HbA1c
Metformin has been shown to both improve glucose control
and reduce mortality and morbidity (A) and is the first-line
drug in people who are overweight (BMI 25 kg /m2 or more)
A target HbA1c of between 6.5% and 7.5% is optimal (B).
(A). Metformin may also be first-line therapy in people who
However, this target level is based on average levels
are not overweight (A), including South Asian who have a
achieved by patients taking part in trials - half of these failed
30% increased cardiovascular risk at BMI as low as 23.
to achieve these targets even on intensively supervised
(Yusuf S 2000 J Hypertension 18 Supplement 35-65).
treatment. In UK diabetic clinics the level averages 7.5-8%.
Start metformin 500mg (to be taken after meals) and build up
In practice, individual targets may be more appropriate
gradually over several weeks - see BNF for details.
depending upon initial HbA1c levels, response and
Metformin is contraindicated in heart failure, alcohol
adherence to treatment and in the elderly, risk of
dependence and renal impairment (creatinine > 130mmol/l).
Lactic acidosis is a rare complication often associated with
An HbA1c audit threshold of 7.5% is only a proxy measure of
adequacy of control and below 6.5% is optimal.
Where glucose control remains unsatisfactory a
sulphonylurea may be added (A). Although blood glucose
Local laboratories are moving towards a common standard of
control may improve, there is a lack of evidence that
HbA1c measurement. See Major Thresholds for Diabetes on
morbidity or mortality are improved by this combination.
page 3. The table below gives indicative thresholds for
HbA1c. There is no general agreement about these
thresholds, but they fit in with the NICE and Diabetes NSF
Insulin secretagogues include the sulphonylureas (eg.
gliclazide, glibenclamide) and the rapid acting insulin
secretagogues (nateglinide and repaglinide). These drugs
augment insulin secretion and effectively lower blood glucose
(A) though there is a lack of evidence of their effect on
Sulphonylureas may also be used in people who are not
overweight (A), and may be added to metformin where
If haemoglobingopathy or abnormal red cell turnover prevents
HbA1c estimation, blood glucose profiles or corrected serum
Sulphonylureas may be used when metformin is not
fructosamine should be used. Local diabetes specialists
should be consulted for target level and predictors of control
Hypoglycaemia is a risk with sulphonylureas, and clinicians
and patients should be alert for symptoms and their
Nateglinide or repaglinide may be useful in attaining tight
When, despite metformin and a sulphonylurea, glucose
control remains poor, a glitazone may be added either to
Patients and professionals should be aware of the symptoms
metformin or to a sulphonylurea. Weight gain and fluid
and initial management of diabetic emergencies.
retention may be a problem. If there is no improvement in
blood glucose control within 4 months, consider stopping
them and re-consider other treatment options (D).
Glitazones should always be used in combination with other
This may be the first manifestation of diabetes. It is
oral agents, preferably with metformin or alternatively with a
characterised by very high blood glucose and dehydration
sulphonylurea. Diabetes specialists may use triple therapy -
and is associated with high mortality.
glitazones in addition to both metformin and sulphonylureas -
though this combination is not currently licensed.
Glitazones reduce peripheral insulin resistance. Though they
improve control of blood glucose (A) there is no current
Hypoglycaemia is associated with the use of insulin or
evidence that these drugs improve mortality or morbidity.
sulphonylureas. Sweating, disturbed behaviour or confusion
There is also no evidence that they confer any advantage
may precede fits or life-threatening coma.
over insulin and there is less evidence about their long term
safety. Their place in management remains controversial.
Patients on sulphonylureas or insulin should be encouraged
(Gale EAM Lessons from the glitazones. Lancet 2001 357:
to carry glucose at all times eg dextrosol tablets. Most
hypoglycaemia can be managed by the patient and their
carers, using the simple resources below, repeated after 10-
Glitazones should not be used in combination with insulin.
Liver function tests should be measured at initiation, two
monthly for the first year and thereafter annually.
Sugar 2-4 teaspoons, 3-6 lumps, solid or in water.
50ml of Lucozade, Coca Cola or similar sugary drink
In type 2 diabetes, insulin therapy should be considered in
(not ’diet’ type) which is approximately a quarter cup.
people whose blood glucose is inadequately controlled on
Hypostop gel, 10g glucose per ampoule. (1-2 ampoules).
oral glucose lowering drugs. Bedtime insulin is sometimes
combined with oral treatment to improve control.
Three dextrosol tablets (available commercially).
Once recovered, a long acting carbohydrate such as a
Appropriateness of insulin should be discussed with the
sandwich needs to be eaten to prevent recurrence.
patient and their carer. Choice of insulin and regimen should
be determined by local preference and patient choice.
Severe hypoglycaemia causing coma or lack ofco-operation
Formal education in the use of insulin, the management of
raised blood glucose, infection and hypoglycaemia should be
Glucagon 1mg intramuscularly (subcutaneously or IV) as
first line treatment followed by oral glucose when patient
rouses. Glucagon may not work in a fasted patient ie
Acarbose may occasionally be considered as an alternative
in people unable to use other oral drugs. Flatulence may be
If no response to glucagon after 10 minutes, IV glucose
may be given 50ml of 20% glucose or 25ml of 50%
glucose (flushed with saline to reduce venous irritation).
More than 50ml of 50% glucose may cause cerebral
There is no evidence that drug treatment of obesity with
oedema in the very old or adolescents.
either orlistat or sibutramine reduces morbidity or mortality
from diabetes, nor have studies specifically targeted people
with diabetes for inclusion. There is evidence from studies in
Hypoglycaemia from oral hypoglycaemic drugs may recur
people without diabetes that their use is associated with a
after treatment and if so continued monitoring would be
small reduction in average weight. Their use in diabetes
necessary, possibly under hospital supervision.
remains uncertain and advice from NICE guidelines should
be followed (NICE technology appraisal no 22,31.
Continuing treatment should be reassessed if hypoglycaemia
Care for people with increased urine albuminexcretion
ACE inhibitors in people withmicroalbuminuria or proteinuria reduce
People who have microalbuminuria or proteinuria are at
increased risk of renal and arterial disease and require
more intensive investigation and treatment.
Full history, examination, urinalysis for culture and
sensitivity, renal ultrasound if clinically indicated. Definition
Optimal management of other cardiovascular risk
factors and blood glucose control (A). Microalbuminuria - albumin:creatinine ratio greater than
Start ACE inhibitor - see below (A). or equal to 2.5 mg/mmol (men) or 3.5 mg/mmol
Maintain blood pressure below 125/75 mmHg (British
(women), or albumin concentration greater than or
Hypertension Society 1999 guidelines) or 135/75 (NICE
equal to 20 mg/l
2002 guidelines) Most will require more than one drug
Proteinuria - albumin:creatinine ratio greater than or equal to 30 mg/mmol or albumin concentration greater
Aspirin and a statin will be appropriate in most cases. than or equal to 200 mg/l.
Microalbuminuria (MCA) is the earliest sign of diabetic renal
Starting ACE inhibitor therapy in people with
disease (nephropathy). It is associated with increased
mortality and cardiovascular disease or more rarely renal
ACE inhibitors reduce blood pressure and progression of
failure. Microalbuminuria describes a level of albumin in urine
which while low, is above normal. Proteinuria describes a
greater amount of albumin in the urine which can be
ACE inhibitor therapy should be used with caution in those
detected by standard urine dipstick.
with peripheral vascular disease, renovascular disease or
There is a major resource issue in screening for MCA. In the
absence of firm evidence of benefit, no firm recommendation
Measure serum creatinine and electrolytes one to two
weeks after initiating ACE inhibitor therapy and at each
increase in dose. Some ACE inhibitors are not licensed for
use at the blood pressure levels recommended in this
Urinary protein and serum creatinine should be measured as
See the BNF for starting dosages and titration to optimal
part of the annual review (NICE recommends each visit).
dosages. Angiotensin II receptor blockers (A) are an
alternative where cough limits the use of ACE inhibitors.
First morning urine specimens are preferable. If not
Urine dipstick for proteinuria. If positive, send for culture
Positive results should be confirmed on at least two more
Testing sticks for microalbuminuria are not available
To obtain a quantitative estimation of proteinuria, a 24
If serum creatinine is 150 umol/l or more, discuss with
specialist as to whether referral is appropriate. This will
People with previous myocardial infarction, angina, stroke or
peripheral vascular disease should either take simvastatin
(A) or pravasatin, fluvastatin or atorvastatin. The aim of
treatment is to reduce cholesterol below 5mmol/l or by 25%
cardiovascular disease, as well as tothose without it but whose coronary
The Heart Protection Study shows clear benefit below
heart disease risk is 15% or more over10 years. It also applies to people over
5mmol/l and a statin should be started in this group of
people. It is no longer necessary to restrict statins to people
whose cholesterol is above 5mmol/l. The patient s risk, not
(Heart Protection Study. Lancet 2002;360:7-21)
their serum cholesterol,should determine who receives
Monitoring of serum cholesterol and HDL cholesterol does
not require a fasting sample and may be performed on a
random sample. (Serum triglycerides and LDL cholesterol
1. In people without pre-existing cardiovascular disease,
need fasting samples). Serum cholesterol and HDL
estimate 10 year coronary heart disease risk using Coronary
cholesterol should be measured annually as part of the
Heart Disease Risk tables or Framingham calculator
(template for EMIS is available from the CEG, or see back of
2. If 10 year coronary heart disease risk is 15% or more give
The Heart Protection Study (Lancet 2002; 360: 7-21)
intensive advice on weight loss, diet, physical activity and
reported after national guidelines were finalised. The trial is
optimise blood glucose and blood pressure control and
large and of high quality and three main findings are
repeat total cholesterol:HDL ratio and risk estimation after 3
incorporated into these guidelines, which therefore differ
slightly from the current national recommendation. The
3. If 10 year CHD risk remains 15% or more, start treatment
with simvastatin (A) or pravastatin, fluvastatin or atorvastatin
1. The recommendation to treat with a statin applies to all
people at high risk, including those over 75 years of age
(and not simply to people under 75 years).
See Major Thresholds for Diabetes on page 3
2. Treatment in high risk groups should be started whatever
the level of serum cholesterol even if it is below 5 mmol/l.
(People with serum cholesterol < 5mmol/l were previously
Before starting treatment, consider other risk factors (for
3. Simvastatin (A) or another statin with trial evidence of
Optimise smoking cessation (B), blood pressure (A) and
Support dietary change, with a diet high in fruit,
It is not clear whether a fixed statin dose (irrespective of final
vegetables and oily fish, a low saturated to
serum cholesterol) - the fire and forget strategy - or titration
polyunsatuated fat ratio and low in salt and alcohol (B).
of statin dose, to maintain serum cholesterol below 5mmol/l,
is more cost effective. There is evidence for both.
Particular emphasis should be laid on physical activity -
regular walking is effective in reducing risk. Exercise on
prescription may encourage more physical activity (A).
At least one lipid sample should be fasting and include
triglycerides and LDL cholesterol before starting treatment.
Examine cardiovascular system and peripheral pulses.
Check for renal disease (serum creatinine, urinary
Liver function tests should be measured within 1-3 months of
starting and do not need repeating unless there is a two-fold
rise in ALT (alanine aminotransferase) (HPS study). If there
is a persistent 4-fold rise consider referral. Rises in enzymes
less than 2-fold are common and not clinically important.
Patients should be warned to report muscle pain or
weakness because of the rare risk of rhabdomyolysis. This is
more common at high dosage or in combination with a
Evidence from the Heart Protection Study now makes
simvastatin 40mg one drug of first choice. Alternatively other
drugs with trials including diabetic subgroups - pravastatin,
fluvastatin and atorvastatin at comparable dosage or lower
doses of simvastatin might also be considered. Statins
should be taken at night (except atorvastatin).
National guidelines recommend that people with coronary
heart disease are offered a fibrate in addition to a statin, if
triglycerides remain higher than 2.3mmol/l, despite treatment
with a statin (D). This is because raised triglycerides
independently increase the risk of coronary events. We
await the reporting of current trials in progress to determine
the role of fibrates in diabetes. The combination of fibrates
with statins may cause side effects such as muscle and/or
abdominal pain and has been associated with
In the rare event that fasting triglycerides are extremely
raised (>10mmol/l) refer to lipid clinic. NICE (2002) recommend treatment of blood pressure if: First line 140/80 mmHg or more AND 10 year coronary heart
Low dose thiazide diuretics, ACE inhibitors and beta-
disease risk is 15% or more
blockers are all considered effective as first line therapy in
people with diabetes. Combination therapy with two or more
160/100mmHg or more irrespective of 10 year coronary heart disease risk
ACE inhibitors should be offered as first line therapy in
140/80 mmHg or more AND previous stroke, myocardial
people with increased urine albumin excretion
infarct or angina 135/75 mmHg AND proteinuria >1g per 24 hours These recommendations differ from the 1999 British Second line Hypertension Society recommendations. See below.
In the event that blood pressure is not controlled on a
combination of first line drugs, once daily long acting calcium
Treatment should be based on the average of at least three
channel blockers may reduce blood pressure but there is
readings within three months, and if either the mean systolic
conflicting evidence of benefit in people with diabetes (B).
or the mean diastolic is above treatment thresholds,
Twice daily calcium channel blockers should not be used.
Peripherally acting alpha blockers (such as doxazosin) have
shown an absence of benefit and possible adverse actions
when used as first line agents. They can be used as fourth
line agents where the risk of continued hypertension
outweighs any possible harm from doxazosin.
If on treatment, aim to maintain blood pressure below
140/80mmHg (B) The NICE (2002) recommendations differ
from the 1999 British Hypertension Society (BHS) Guidelines
(see page 3) which are still used by some local physcians.
People with pre-existing cardiovascular disease should take
For people with renal disease, the BHS target is
aspirin 75mg daily (A). For true aspirin intolerance,
125/75mmHg or less. However NICE recommend that in
people with proteinuria >1g per 24 hours or renal disease this
People with a 10 year coronary heart disease risk of 15% or
more should take 75mg of aspirin providing their systolic
People who have a blood pressure above 140/80 but below
blood pressure is controlled below 145mmHg (B).
160/100mmHg who do not have renal disease, or
cardiovascular disease and where 10 year CHD risk is below
15%, do not require blood pressure treatment but should be
People with diabetes who additionally have raised blood
*Only half of those intensively treated in the UKPDS study
pressure should be supported to stop smoking and improve
their diet, physical activity and reduce obesity. Salt restriction
(A) and a diet high in fruit and vegetables have both been
See Major Thresholds for Diabetes on page 3
shown to reduce the likelihood of stroke (B).
Blood pressure and risk factor assessment should be part of
the annual assessment with more frequent review where
Referral and review criteria for retinopathy
Annual review (routine care)
If there is no retinopathy or there is only minimal or mild
background retinopathy or low risk background
Refer for or perform an appropriate and acceptable
retinopathy screening test for all people with type 2
diabetes (D) (locally provided by either retinal
Early review (three to six months)
photography delivery by trained opticians or as part of a
If there is a new occurrence, or worsening of the lesions
locally agreed and validated screening programme or by
since last examination. ( A worsening of lesions since last
indirect opthalmoscopy using a slit-lamp).
examination will occur to a modest degree in many
Check visual acuity, corrected with glasses or pinhole
patients due to time. This only needs earlier eye review
if the worsening of lesions is unexpectedly marked).
Patient is at high risk of progression (where there is rapid
change in blood glucose control, severe hypertension or
Use methods of retinal examination that have been
NICE also recommends early referral of patients with
demonstrated to achieve a sensitivity of 80% or higher, a
scattered exudates more than 1 disc diameter from the
specificity of 95% or higher and a technical failure rate of
fovea but most local clinicians feel that this is
unnecessary and would involve so many patients as to
Use tropicamide to achieve midriasis, unless
contraindicated (glaucoma, etc) (C).
Document attendance for retinopathy screening. Referral (within 4 weeks)
If there is unexplained drop in visual acuity. If macular oedema is suspected. Hard exudates within 1 disc diameter of the fovea. There are unexplained retinal findings. Pre-proliferative or more advanced (severe) retinopathy. Cataracts are interfering with the patient’s vision. Retina is obscured on examination. Urgent Referral (within one week)
If new vessels are present. Pre-retinal and/or vitreous haemorrhage. Rubeosis iridis is present. Emergency (immediate)
If there is sudden loss of vision. Retinal detachment. Foot at low current risk Normal sensation and palpable pulses
Agree a management plan, including foot care education,
with each person and maintain on annual review (B).
of annual review to detect riskfactors for ulceration (A)
Foot at risk
Recall annually and review for complications and risk factors
Evidence of neuropathy or absent foot pulses or other
by trained personnel (trained personnel will usually be the
risk factors present
podiatrist or member of the diabetes team, but may also be
Risk factors include plantar callus, poor footwear, social
deprivation or isolation, cigarette smoking, old age, footdeformities, long duration diabetes and poor vision.
Test foot sensation using a 10g monofilament and
Ensure that foot care education is reviewed and
vibration sense using a tuning fork or biothesiometer.
Refer to Foot Health for inspection of the person’s feet 3
Inspection of foot shape, skin condition and footwear.
Advise on appropriate footwear (B). Review the need for vascular assessment and referral. Special care arrangements may be required for older
Foot at high risk The foot at risk and a history of ulceration or peripheral vascular disease or amputation or Charcot disease
The addition of these factors significantly increases the risk of
episodes of complications beyond that of the foot at risk.
Arrange frequent review as necessary, with a maximum
of 3 monthly intervals from specialist podiatry/foot care
Ensure special care arrangements for those people with
At each review, evaluate the provision of intensified foot
Provide specialist footwear and insoles. Skin and nail care, according to the individual’s needs. Ulcerated Foot Current ulceration, infection, cellulitis or discoloration
Arrange urgently foot ulcer care with a specialist podiatry
/multidisciplinary foot care team. They should ensure as a
Investigation and referral for treatment of vascular
Local wound management, appropriate dressings and
Systemic antibiotic therapy for cellulitis or bone infection
Effective means of distributing foot pressures, for
instance using specialised footwear or casts or bed rest.
Monitoring of blood glucose control.
Dietary fat should be limited to 35% total energy (saturated fat
no more than 10%; polyunsaturated fat not exceeding 10%;
monounsaturated fat making up the balance). Patients who are
The principles of healthy eating should be emphasised. The diet
overweight or obese should pay particular attention to reducing
dietary fat by: avoiding fried foods; decreasing use of spreading
fat and oil in cooking; using lower fat diary products (semi-
skimmed milk, reduced fat cheese, low fat yoghurt); choosing
lean meats, (including lean cuts of beef and pork, as well as
High in fibre (especially soluble fibre)
chicken and fish), while avoiding/limiting processed meats
(sausages, burgers, salami); limiting or avoiding high fat snacks
(crisps, nuts, cake, chocolate) and other high fat foods (pastry,
Overweight or obese patients should be encouraged to lose
weight by a combination of changes in diet and physical activity.
Referral to a dietitian should be considered as well as
appropriate use of reputable local slimming groups and Exercise
The Balance of Good Health leaflet is available in several
languages from Health Information East London (HIEL)
Patients should: use an artifical (intense) sweetener in place of
sugar in drinks, foods and on cereals; choose sugar free drinks
Reduce dietary salt intake (particularly if they are
( diet fizzy drinks and sugar free squashes/cordials), avoiding
large volumes of pure unsweetened fruit juice; limit or avoid
Avoid special diabetic food products (they confer no benefit
sweets, confectionery and high sugar foods.
If they drink alcohol, take in moderation (with no need to
The diet overall need not be sugar-free to achieve good blood
change beer to special pils lager, since this confers no
glucose control. Patients may take up to 10% total energy
benefit, and may be harmful with its higher alcohol content).
(calories) as sugar by choosing foods such as cereals (All Bran,
Fruit n Fibre), baked beans, plain biscuits and bakery items
(Rich Tea, Garibaldi biscuits, teacakes, crumpets).
Starchy carbohydrate foods should form the base of each meal
and contribute up to 50% of the total energy in the diet. Patients
should be encouraged to choose carbohydrate foods which are
slowly absorbed (those with a low Glycaemic Index), such as
pasta, long grain rice (e.g. Basmati rice), wholegrain/granary
bread, porridge oats, pulses (lentils, beans, dahl) and fruit.
Patients should be encouraged to include 5 portions per day of
fruit and vegetables, since the soluble fibre in these - as well as
that found in oats (porridge), rye, barley and pulses - will help to
smooth out peaks in post-prandial blood glucose levels.
1. They were based on evidence based guidelines developed with clear criteria for evidence and consensus: the National
Institute for Clinical Excellence guidelines on management of type 2 diabetes (www.nice.org.uk) and the Scottish SIGN
guidelines (www.sign.ac.uk). These guidelines are also in line with the National Service Framework for diabetes
2. Some more recent evidence has been added where indicated.
3. They were sent to all major stakeholders in east London who were asked to comment on three drafts. Full list of
The final draft was agreed by an editorial group (those marked with an asterix below)
The work was coordinated by Jo Law, Sarah Mott, Dr John Robson, Dr Ricardo Cabot, Dr Jean-Michel Wendorff and typeset by
Gladys Fordjour, Clinical Effectiveness Group. It is intended that this work should complement any existing protocols,
guidelines and services already in use in both the primary and secondary sectors.
Any correspondence should be to Dr John Robson at
Clinical Effectiveness Group, Department of General Practice and Primary Care, Barts and the London Queen Mary s School of
Medicine and Dentistry, Mile End Road, London, E1 4NS or email firstname.lastname@example.org
Dr John Anderson, Consultant Diabetologist*
Dr Peter Freedman, Consultant Diabetologist
Prof Gene Feder, Professor of Primary Care
Dr Tahseen Chowdhury, Consultant Physician
Ms Helen Noakes, Diabetes Nurse Specialist*
Ms Esther Beasley, Chair, City & Hackney PN
Dr David Sloan, Director of Health Improvement
Ms Theresa Berry, Director of Nursing and Quality
Ms Valerie Escudier, Diabetes Nurse Specialist
Ms Janet Reid, Diabetes Nurse SpecialistDr Sam Everington, Clinical Governance Lead
Dr Susan Gelding, Consultant Diabetologist*
Ms Sara Davenport, Director of Commissioning
Dr Gopinathan, GPMr Steve Dean, Head PodiatristMs Jayne Brotherdale, Diabetic Podiatrist
Ms Susan McKay, District DietitianMs Yvonne Canel, Lead Primary Care Dietitian
Prof Magdi Yaqoob, Consultant Nephrologist
Ms Lisa Brown, Acting Head of Primary Care
Ms Anne MacDonald, Diabetes Nurse Specialist
Prof Jo Martin, Clinical Director of Pathology *
Ms Teresa O’Shea, Diabetes Nurse Specialist
Ms Jothi Christian, Joint Chair - Newham PN
Mr Jonathon O’Sullivan, Public Health Strategist
Ms Lesley Pavitt, Patient Representative*
Ms Alice Ford, Joint Chair - Newham PN Forum
Dr Sheila Adam, Director of Public Health
Dr Prasanta Bhowmik, Clinical Governance Lead
Dr Jeremy Allgrove, Consultant Paediatrician
Dr Barry Strickland Hodge, Prescribing Advisor*Ms Jan Tomes, Chief Pharmacist Newham H T
City and Hackney For more information about diabetes services please consult “Diabetes Service Directory 2002” available from the Hackney Diabetes Centre 020 8510 5000, www.the-Homerton.demon.co.uk Hackney Diabetes Centre Diabetologist Diabetes Nurse Specialist Team
Sarah Ambrose Willson (Diabetes Team Leader)
Helen Noakes (Diabetes Nurse Facilitator)
Bridgit Parkinson (Diabetes Nurse Facilitator)
Dietitians Diabetes Foot Service Retinal screening Profile of services - City and Hackney Diabetes Clinics New patient Clinic (recently diagnosed type 2 diabetes) Assessment by diabetes nurse and dietitian Medical assessment by physician (including eye examination), feet examined by podiatrist 2 x 2 hours group education sessions Diabetes Clinic Annual review, starting insulin, assessment of treatment, complications, review of medication Problem Clinic Specific issues: nephropathy, erectile dysfunction, neuropathies Antenatal Clinic For new or existing diabetes in pregnant women: urgent referral by fax/letter to ante natal dept, Homerton Hospital, Tel 020 8510 7175, Fax 020 8510 7682 Nurse and Dietitian Reviews One-to-one patient review by diabetes nurse specialist and or diabetes dietitian Eye Screening Clinic Ophthalmology done and photographs taken of the retina, assessed by optometrist and diabetologist Standard referral form for Diabetes Eye Screening is located in “Diabetes Service Directory 2002” Three levels of support depending on GP’s skills or request 1. GP skilled: referral for a one off opinion from Eye Screening Clinic 2. GP reasonably skilled, but wishing regular crosscheck: referral for alternate year appointment at Eye Screening Clinic (with GP screening intervening year) 3. GP can opt for patient screened yearly at Eye Screening Clinic Sight threatening eye disease: Fax Urgent Referral to 020 8510 5015 or page Dr Anderson/Registrar through Homerton Switchboard or refer to Moorfields Eye Hospital St Bartholomew’s Hospital Clinics Young Adult Clinic (type 1 diabetes) at Diabetes Clinic Evening clinic at St Bartholomew’s Hospital Annual review, insulin starts, assessment and treatment of complications Children and Adolescents Contact Consultant Paediatrician Dr Jeremy Allgrove (Royal London Hospital on 020 7377 7000, ext 3455 or Diabetic Nurse Specialist Clarie Wyatt (RLH), ext 3938) or Dietitian Maddy Leriti (RLH, bleep 1079). Joint Adolescent clinic held monthly with Dr Jeremy Allgrove and Professor Hitman at Whitechapel Hospital. Diabetes Nurse Facilitator Supporting GP practice in diabetes care: please call 020 8510 5005 for help with: Organising diabetes care: appointments, diabetes register, recall system, equipment Setting up and running a diabetes clinic Assisting with diabetes audit, annual reviews, case discussions, educational support Supporting Practice Nurses and GPs starting patients on insulin Promoting quality control of blood glucose meters Participate in community events to raise awareness about diabetes Promoting appropriate referral of patients to specialised services Diabetes Eye Screening In C&H PCT Eye screening should be carried out through one or more of the three follow routes: 1. Fundoscopy by GP 2. Retinal photography at Eye Screening Clinic at Hackney Diabetes Centre following above protocol 3. Secondary care ophthalmology, Moorfields Eye Hospital, Royal London Hospital Diabetes Foot Service (based at St Leonard’s Hospital) Daily emergency clinic (020 7301 3347); registration only between 9.00am - 9.30am Urgent referrals sent to emergency clinic at St Leonard’s Hospital Non-urgent referrals sent to St Leonard’s Hospital for routine appointment Substantive foot surgery referrals sent to Trevor Prior, Homerton Hospital Outpatients Advice on Glucose Monitoring Meters Contact Hackney Diabetes Centre Education Hackney Diabetes Centre 1. For patients Group education sessions for recently diagnosed type 2 diabetes Group education sessions for people with type 2 diabetes starting insulin 2. For health professionals 3 x half days “Insulin Management Course” 5 x half days “Diabetes in Primary Care Course” Other resources Local Diabetes Service Advisory Group (LDSAG)/Diabetes National Service Framework Implementation Group Clinical priorities in diabetes care in City and Hackney PCT Chair: Dr Clare Highton, contact through Hackney Diabetes Centre 020 8510 5000 Please see Patient Information Services and Benefits on P24 for further information about local resources. Diabetes Centre Diabetologist
Dr Niyi Sonibare (Community Diabetic Consultant)
Diabetes Specialist Nurse (DSN)Team
(Newham General Hospital DSN Team Leader)
Dietitians Podiatrist Retinal screening Scheme Barry Blackman Optician Profile of services - Newham Diabetes Clinics Shrewsbury Road Diabetes Centre All routine diabetes referrals via unified Diabetes Referral Form to Shrewsbury Road Diabetes Centre Stable, uncomplicated type 2 (according to Incentive Scheme): Level 1/non participating - may refer all patients - may refer all type 2 diabetics, who are insulin requiring, need to commence insulin or <40 yrs - may refer type 2 diabetics, who need to commence insulin or <40 years old Type 2 diabetes, uncontrolled or with complications /complex needs All levels may: Refer to diabetologist, Shrewsbury Road DSN referrals Please contact Shrewsbury Road Diabetes Centre on 0202 8586 5240 for complete referral criteria for level 1, 2 & 3 practices Newly diagnosed type 1 Bleep Medical Registrar on call at Newham General Hospital Diabetes in Pregnancy Contact Newham General Hospital, Theresa Joseph 020 7476 4000 bleep 909 Dr Carol Gayle and Miss Jamna Saravanamuthu hold a weekly joint obstetric diabetes clinic at Newham General Hospital Children and Adolescents Children under 16yrs of age In case of emergency, bleep Paediatric SHO at Newham General Hospital Or refer to Consultant Paediatrician Dr Jeremy Allgrove at the Newham General Hospital on 020 7363 8462,or fax 020 7363 8081, contact Diabetic Nurse Specialist Teresa O’Shea 020 8586 5240 or Dietitian Helen Fermor 020 7363 8788 A joint adolescent diabetes clinic is held monthly with Dr Allgrove and Dr Vijayaraghavan Diabetes Eye Screening Eye examination at annual reviews Routine eyes: refer to Optometrist on the retinal screening scheme for visual acuity, dilated fundoscopy and retinal photographs Non-routine eyes (failing vision, retinopathy, macular abnormality, loss of vision): refer to ophthalmology at Newham General Hospital eye clinic or Moorfield’s Eye Hospital Diabetes Foot Service Routine foot, foot at risk and at high risk: refer to the Foot Health Service Ulcerated foot: contact diabetes specialist podiatrist on 020 8586 6271/6270 or 07903 271263 Education 1. For patients New diabetic patients and any patient with genuine need: refer to Shrewsbury Road for formal education. Available in several languages. See Patient Information Services and Benefits on page 24 Group education sessions for people with type 2 diabetes starting insulin 2. For health professionals Regular seminars and workshops for all GPs and Primary Care staff contact Naru Majevadia on 020 8586 5200 Updates for trained nurses contact Jackie O’Gara (DSN) 020 8586 5240 Updates for residential homes staff contact Rebecca Smeed (DSN) 020 8586 5240 Newham University of Warwick Diabetes Care Course for level 2 & 3 practices contact Jacqui Chapman 020 8586 5240 Community Liaison Please contact Niru Majevadia at Shrewsbury Road Diabetes Centre for advice regarding the following: Level 1 practices help with setting up and running a structured diabetes care clinics Level 2 practices support and advice to progress to level 3 Training and support to become a GP with Specialist Interest in diabetes Visits by the specialist team to GP practices or by primary care staff to the Shrewsbury Road Diabetes Centre Access to locality clinics, GPs with Specialist Interest in diabetes and the community specialist diabetes team Other resources Local Diabetes Service Advisory Group (LDSAG)/Diabetes National Service Framework Implementation Group Clinical priorities in Diabetes Care in Newham Chair: Dr Niyi Sonibare, 020 8586 5255 Health Improvement (HIMP) Diabetes Working Group Chair: Clare Davison (PCT Clinical lead for Diabetes Care), 020 8548 2200 Diabetes National Service Framework (NSF) Implementation Manager Contact Felicia Robinson at West Beckton Health Centre, 020 7445 7046 Diabetes IT/Diamond Manager Mahmoud Nassir-Deen, 020 8586 5244 Diabetes patients representatives Represents patients at (LDSAG)/Diabetes National Service Framework Implementation Group, talk to patients at GP practices, talks to community groups/press - Mr Solanki or Clare Mehamet: email@example.com Please see Patient Information Services and Benefits on P24 for further information about local resources.
Tower Hamlets For more information about diabetes services and referral pathways please consult “Tower Hamlets Diabetes Service Directory ” available from the Mile End Diabetes Centre 020 7377 7836, www.thpct.nhs.uk Mile End Diabetes Centre Diabetologist
Dr Tahseen A Chowdhury (Advice/Community liaison)
Diabetes Nurse Team Dietitian Podiatrist Retinal screening
Alison Powling (Retinal Screening Co-ordinator)
Profile of services - Tower Hamlets Diabetes Clinics Mile End Diabetes Centre Clinics Please write to the diabetes centre at the above address. For standard referral letter please see the Diabetes Service Directory Consultant led Diabetes Clinics Patients with poor control on insulin Poor diabetic control on maximum oral hypolglycaemics (HbA1c>8.0%), in patients who agree to go on to insulin and who have other problems Patients with proteinuria (not necessary to refer patients with microalbuminuria) Patients with active foot ulceration Patients with painful neuropathy Diabetic patients who are pregnant Diabetes Nurse Clinics Education Commencement of insulin therapy for patients with poor diabetic control on maximum oral hypoglycaemics HbA1c>8.0%) who agree to go on to insulin and have no other problems Stabilisation of insulin therapy Diabetes Dietetic Clinic One to one dietetic advice Meter Sessions Distribution of blood glucose meters to patients Diabetes Foot Clinic Ulceration/blister/infection Non Urgent Patient requires education on foot care (e.g. has neuropathy) Nail care if has high-risk feet (neuropathy or vascular disease) Retinal Screening Clinic Run by Moorfields Eye Hospital Digital fundal photography at Mile End Hospital, reading by ophthalmologists at Moorfields Hospital If significant diabetic retinopathy is present, the patient is automatically referred to Moorfields Hospital Diabetes Antenatal Clinic Held in the antenatal outpatients department, Royal London Hospital, Whitechapel Newly discovered pregnant women with diabetes should be referred urgently by letter or fax. (Miss Anita Sanghi, Consultant Obstetrician, Department of Obstetrics, Royal London Hospital, Whitechapel, London E1 1BB, Tel: 020 7377 7395; Fax: 020 7377 7055) Community Diabetes Liaison Community Diabetologist - Dr Tahseen Chowdhury A weekly session in primary care helping GPs and nurses to provide diabetes care in the community 1. Joint (with GP or nurse) problem patient clinics 2. Problem/case discussion sessions 3. Helping to set up and run a diabetes clinic 4. Sitting in diabetes clinic to support the practice nurse and GP 5. Interactive group discussion sessions with patients invited to the practice 6. Organising Educational Sessions for Tower Hamlets GPs/nurses on diabetes Community Diabetes Nurse Shortly to be appointed senior DSN, facilitating diabetes care in the community 1. Helping to organise diabetes care - appointments, diabetes register, recall, equipment and assisting with diabetes audit 2. Helping to set up and run a diabetes clinic 3. Sitting in diabetes clinic to support the practice nurse and GP and case discussion with the practice team 4. Promoting quality control of blood glucose meters 5. Interactive group discussion sessions with patients invited to the practice 6. Educational sessions with the practice team and provision of educational material 7. Promoting appropriate referral of patients to specialised services 8. Support practice nurses and GPs starting patients on insulin 9. Participate in community events to raise awareness about diabetes Contact Dr Chowdhury or Diabetes Specialist Nurse, Mile End Diabetes Centre, 020 7377 7000 ext 4384; Fax: 020 7377 7806; E-mail: Tahseen.Chowdhury@bartsandthelondon.nhs.uk Children and Adolescents Contact Consultant Paediatrician Dr Jeremy Allgrove (Royal London Hospital on 020 7377 7000, ext 3455 or Diabetic Nurse Specialist Clarie Wyatt (RLH), ext 3938 or Dietitian Maddy Leriti (RLH, bleep 1079). Joint adolescent clinic held monthly with Dr Jeremy Allgrove and Professor Hitman at Whitechapel Hospital. Diabetes Eye Screening in Tower Hamlets PCT 1. Screening of all diabetic patients in Tower Hamlets, who are not attending hospital diabetic or ophthalmology clinics, at the Digital Retinal Screening Service, Mile End Diabetes Centre; referral to retinal screening co-ordinator via Retinal Screening Referral form 2 If significant diabetic retinopathy or other problems direct referral to ophthalmologist at Moorfields Eye Hospital, Tel: 020 7253 3411; Fax 020 7566 2052 or Royal London Hospital, Ophthalmology Clinic, Tel: 020 7377 7426; Fax:020 7377 7112 Advice on Glucose Monitoring Meters Contact Mile End Diabetes Centre Education Mile End Diabetes Centre 1. For patients Group education sessions in English or Bengali “Diabetes and Ramadan” session Bengali diabetes leaflets and Bengali diabetes video 2. For health professionals 5 x half days “Diabetes in Primary Care Course”, Hackney Diabetes Centre, Homerton Hospital Regular study afternoons on diabetes - commencing March 2003, Mile End Diabetes Centre Visits to practices for advice and education input by Community DSN and Dr Chowdhury Other resources Local Diabetes Service Advisory Group (LDSAG)/Diabetes National Service Framework Implementation Group Clinical priorities in Diabetes Care in Tower Hamlets PCT Chair: Dr Isabel Hodkinson, fax: 020 8983 7131 or Isabel.Hodkinson@gp-F84696.nhs.uk For information, contact Darren Summers, Tel: 020 7377 7929 or Darren.Summers@thpct.nhs.uk Please see Patient Information Services and Benefits on P24 for further information about local resources.
Patient information services and benefits
Diabetes UK is the leading charity working for people with diabetes.
They carry out research and help people to live with the condition by producing factually accurate information, supported by
They can provide information about the following:
Reducing the risk of serious health problems.
Help yourself to stay fit and healthy.
To access information and support on any aspect of managing diabetes via the Diabetes UK Careline either:
Telephone 020 7472 1030 (voice) or 020 7424 1888 (text)
Or you can visit their website on www.diabetes.org.uk
Diabetes UK Local Groups For more information contact: Tower Hamlets
Social and community services for patients and carers
Urgent medical advice for your GP or out of hours Tower Hamlets Urgent medical advice out of hours Benefits Tower Hamlets
Social services One stop shop Citizens advice
Forms from social security/social services
Diabetes Education Groups Tower Hamlets
type 2 diabetes (in English, type 2 diabetes
Exercise Tower Hamlets Dietary Services Tower Hamlets
If you would like to see a dietitian to discuss your diet you will need a referral from either your GP, practice nurse other
Eye Screening Tower Hamlets
If you are being seen by the hospital out patient department they will carry out the eye examination
Foot Health Tower Hamlets Tower Hamlets
If you would like information about or help with giving up smoking you can contact one of the following:
the National Smoking Helpline on 0800 169 0169 or the local Smoking Clinic on 0800 169 1943
Advocacy and other Local Resources
If English is not your first language and you need help in the following languages the diabetes specialist health advocates
speak Gujarati, Urdu, Hindi, Tamil and Bengali. The specialist health advocates are available only for diabetic appointments
at Shrewsbury Road Centre or for a diabetes specialist nurse. Telephone:
either 020 8586 5240 Shrewsbury Diabetes Centre
(Other languages are available with general health advocates)
If English is not your first language and you need help please telephone:
020 7337 7934 for appointments at your GP surgery
020 7337 7280 for appointments at the Homerton or St Leonard s Hospital
If English is not your first language and you need help please telephone:
020 7337 7934 for appointments at your GP surgery
020 7337 7280 for appointments at the London or Mile End Hospital
This is a programme for all people with a long-term medical condition, not just diabetes. It provides a chance to help people
to gain confidence, knowledge and skills so they can manage their condition better.
For information telephone Amita Shakya on 020 7377 7919.
A facilitated, self-sustaining patient group of older Bangladeshi women with diabetes, from the central Stepney area, with a
Bengali facilitator. For more information contact: Anna Collard
New Deal for Communities Project on the Ocean Estate
This project facilitates diabetes care and raises awareness of diabetes and its complications in the Ocean Estate community.
It is run by a diabetes specialist nurse and Bengali diabetes link worker. For more information contact the Mile End Diabetes
Further copies can be obtained from:
Clinical Effectiveness GroupDepartment of General Practice & Primary CareBarts and the LondonQueen Mary’s School of Medicine and DentistryMile End RoadLondon E1 4NSTel: 020 7882 7954
Jo Tissier - Tower Hamlets FacilitatorTel: 020 7882 7925
Jo Law - Hackney FacilitatorTel: 020 7882 7952
Anne-Marie Maher - Primary Care Audit FacilitatorTel: 020 7882 7908
Keith Prescott - IT FacilitatorTel: 020 7882 6974
John Robson - Clinical LeadTel: 020 7882 7958
Kambiz Boomla - IT LeadTel: 020 7882 7958
Sally Hull - Mental Health Clinical LeadTel: 020 7882 7961
Gladys Fordjour - SecretaryTel: 020 7882 7954
SISTEMA NACIONAL DE VIGILANCIA EN SALUD PÚBLICA DATOS BÁSICOS 1. INFORMACIÓN GENERAL REG-R02.003.0000-001 V:02 AÑO 2012 1.1 Código de la UPGD Razón social de la unidad primaria generadora del dato 1.2 Nombre del evento Código del evento 1.3 Fecha de Notificación (dd/mm/aaaa) 2. IDENTIFICACIÓN DEL PACIENTE 2.1 Tipo de Documento 2.2 Número de Identificac
DON ÁLVARO DE LUNA TRAGEDIA EN CUATRO ACTOS Por Santiago Sevilla Larrea INTRODUCCIÓN Las coplas del insigne poeta Don Jorge Manrique, coetáneo de los Reyes Católicos, nos plantean ciertas preguntas filosóficas que han quedado hasta ahora, por más de quinientos años, sin una respuesta dramática: “¿Qué se hizo el rey don Juan? Los Infantes de Aragón, ¿qué se hicieron? ¿q