Our packages of care
This is a test routinely used to diagnose and assess average glucose levels over a 3 month period. At The London Diabetes Centre, a finger prick sample allows us to get the result within 6 minutes before a consultation.
Meter or CGM Download
Our nurses are trained to get information on all kinds of glucose testing either with meters or from glucose sensors worn continuously so that the information from them is available to your consultant on screen at the time of your consultation.
The urine albumin : creatinine ratio
This is a urine test which measures albumin leakage in the urine, a sensitive test for early kidney involvement in diabetes. It is done annually.
The Consultation with The Diabetes Specialist Nurse of Dietitian
Our team here are critically important in helping patients improve the management of their diabetes. They advise on what foods to eat, and are experts on the advanced technology of pumps and sensors that are used in diabetes care. In particular, they support and encourage and are a wonderful reservoir of knowledge on how to live successfully with diabetes.
The basic pathology screen here at London Medical is very comprehensive, including a number of extra tests (calcium and iron in particular) not done routinely elsewhere. In some of our protocols we also include ferritin, fasting insulin or c peptide, vitamin D and, in men over the age of 55 years, a prostate specific antigen test.
The imperative of avoiding gangrene and amputation lie behind the need for regular inspection of the feet. Establishing nerve damage and arterial insufficiency are key assessments. The tuning fork is crude and imprecise and only measures the large myelinated nerve fibres. Warm thermal thresholds give information on the important small unmyelinated C fibres and cold thresholds test the alpha delta nerve fibres. The London Diabetes Centre is the first clinic to include quantitative vibrametry and thermal tests on the feet. Your results can now be measured and improvement and deterioration followed quantitatively every year.
Ankle Brachial Index
The Ankle Brachial Pressure Index (ABPI) is the ratio of the blood pressure in the lower legs to the blood pressure in the arms. Lower blood pressure in the leg can be a sympton of blocked arteries (peripheral vascular disease). The ABPI test is a popular tool for the non-invasive assessment of peripheral vascular disease with good sensitivity and specificity for serious narrowing of the arteries. It is unreliable where there is arterial calcification.
Common Carotid intima media thickness and 3D Plaque study
Carotid intima–media thickness and plaque information can improve coronary heart disease and stroke risk prediction when added to traditional risk factors. Often perceived as a way of assessing arterial age, the intima media thickness measures the thickness of the two innermost layers of the common carotid artery while when thickening is more severe and concentrated, the accumulation of cholesterol in the artery is called a plaque. Clinical studies over the last 20 years have shown that after factoring for age, gender and ethnicity, individuals with advanced thickness or plaques have a greater risk of heart attack or stroke than those with normal readings. The test is safe, painless and involves no radiation as it is done with an ultrasound machine.
We have been using carotid intima media thickness and plaque measurements at London Medical, in a rigorously monitored protocol, for over 25 years as a non invasive way of assessing regression and progression of atherosclerosis in order to make appropriate and logical recommendations of treatment. Using the data from the massive ARIC study (Atherosclerosis Risk in Communities), 10 year coronary heart disease prediction models were found to be improved when carotid intima media and plaque information were included in risk prediction (The ARIC Coronary Heart Disease Risk Calculator that includes Carotid Ultrasound information is used in our clinic).
The Heart Disease Prevention service at London Medical is now able to assess plaque volume with a recently acquired 3D probe, one of the first clinics in Europe to use this new device. Our new protocol will measure plaque volumes, interadventitia common carotid diameter, and detailed measurements of the intima media thickness using edge detection which will make it the most advanced assessment of the progress or regression of atheroma in the carotid arteries in use currently. Regression of atherosclerosis is now quantifiable and seen with statins and the use of the new PCSK9 inhibitors in the prevention of arterial disease in patients with cholesterol problems, diabetes and a family history of early heart attack.
Eyes – visual acuity, intraocular pressures, fundus photography and optical coherence tomography (OCT)
Regular eye examinations are essential for good diabetes care. They are usually recommended annually and are offered to NHS patients. There are important differences in the protocol offered here at The London Diabetes Centre. Visual acuity and intraocular pressure measurements can reveal other eye pathology. The photos here are reviewed by an experienced consultant ophthalmologist for reporting. The optical coherence tomography, offered in our premium package, is the best way of picking up subtle macula oedema.
Heart Disease Prevention at London Medical
Uncovering increased risks for early heart disease early is the key to successful prevention of heart attacks and strokes. London Medical uses three main methods to make this assessment early and add refinement and greater precision to simply measuring a cholesterol level (50% of patients with a normal cholesterol still carry substantial increases in heart disease risk). The first is to use lipoprotein biomarkers known to be associated with future coronary artery disease risk. These include the nuclear magnetic resonance spectroscopy measurement of total and small dense LDL particle numbers, apolipoprotein B, lipoprotein (a) particle number, hs CRP, Lp-PLA2 and myeloperoxidase (and, more recently the ADMA /SDMA, F2 isoprostanes, and oxidised LDL cholesterol levels). The second is to use carotid ultrasound intima media thickness and 3D plaque measurements and lastly, the CT coronary artery calcification score. By comparing the data from the invesitation, we are able to match imaging progression and regression to our biochemically derived data.
Routine Advanced lipoprotein analysis and the London Medical Cardiovascular Panel
Most patients referred with raised cholesterol are offered treatment with a statin. Sometimes an assessment of risk is scored from information derived from statistical population studies (eg Framingham Risk Score or QRISK3 or SCORE assessments). None of these methods attempt to assess risk in an individual patient. Heart disease prevention is not simply a question of lowering blood cholesterol. Cholesterol carrying proteins in the blood are numerous and complex, including many good “lipoproteins” (HDL or high density lipoprotein) as well as bad ones (LDL or low density lipoprotein). Simple LDL and HDL testing though, is a very crude way of identifying patients at risk, as 50% of patients with a normal cholesterol still carry substantial increases in heart disease risk; even patients treated with a statin still carry a residual increased risk of premature heart attack.
Our Advanced Heart Profiles, in partnership with True Health Diagnostics Laboratory in the US, take into account new information from the NIH sponsored multi-ethnic study of atherosclerosis (MESA)*, which has revealed the importance of measuring LDL and HDL lipoprotein particle numbers using Nuclear Magnetic Resonance Spectroscopy. It is the LDL particle number, more than LDL cholesterol amount that is more strongly associated with the risk of cardiovascular events and with atherosclerosis or thickening of the arteries. Smaller LDL particles (small dense LDL particles) are more dangerous as they more effectively penetrate the cellular barrier and enter arterial walls where they initiate chemical process that contribute to atherosclerotic plaque and cardiovascular events. The LDL particle number / HDL particle number ratio was found to associate with coronary heart disease independent of total LDL cholesterol, non HDL cholesterol.
More than 20% of the population have cholesterol depleted LDL, a condition in which a patient’s cholesterol may be “normal” but their LDL lipoprotein particle number, and hence their actual risk, could be much higher than anticipated. This is especially common in persons whose triglycerides are high and HDL cholesterol is low, a particularly common pattern in diabetes called a dyslipidaemia. So, interpretation of success or failure of treatment depends on knowing lipoprotein particle number, and not just their cholesterol content. LDL particle number is among the most powerful tools we have to predict the risk of future heart attack. It provides much more powerful feedback on the adequacy of treatment and is therefore a tool for further reduction of risk. This panel, widely used for all our patients with diabetes and cholesterol problems and increased risk of heart disease, also includes an omega 3 / omega 6 assessment and measurements of cystatin and creatinine to give the most reliable estimate of renal function.
The Comprehensive London Medical Cardiovascular Panel
Provides a patient with a state of the art assessment of the latest and best biomarkers of cardiovascular risk. The Panel includes Lp-PLA2, myeloperoxidase, lipoprotein (a) particle number, HDL 2C fraction, homocysteine, ADMA /SDMA, F2- isoprostanes and oxidised LDL. There is increasing interest in medications that can reduce lipoprotein (a). High sensitivity CRP, Lp-PLA2 and myeloperoxidase are established inflammatory markers of the coronary artery disease pathology. ADMA / SDMA is a marker of endothelial damage. Oxidized LDL measures the kind of LDL cholesterol that gets into arteries where they initiate the inflammation that leads to heart attacks. F2 isoprostanes measurement are a measure of oxidative stress and known to be associated with atherosclerosis. Raised F2-IsoPs can cause blood vessels to constrict and promote blood clotting and are elevated at the earliest stages of plaque development in arteries and are made worse by smoking.
The Insulin Resistance Panel
Free fatty acid
Type 2 Diabetes is characterized by insulin resistance, often associated with obesity, and inadequate insulin secretion to overcome the insulin resistance. Insulin resistance is a multi-faceted disruption of the communication between insulin and the interior of a target cell. Using metabolomic screening in people without diabetes, the top biomarkers predictive of insulin resistance and the detection of diabetes risk are increased α-hydroxybutyrate (α-HB) and low linoleoyl-glycerophosphocholine (L-GPC) and this has been confirmed using sophisticated euglycemic hyperinsuliemic clamp studies. They were joint markers of insulin resistance and glucose intolerance. Alpha-hydroxybutyrate and linoleoyl-glycerolphosphocholine are also new markers of fatty liver disease.
Adiponectin is a protein hormone which is involved in regulating glucose levels as well as fatty acid breakdown. In humans it is secreted by adipose tissue. Levels of adiponectin are low in people who are overweight or in people with diabetes and high in those who are thin or losing weight. This hormone plays a part in suppressing the abnormalities that result in Type 2 diabetes, obesity, atherosclerosis and non alcoholic fatty liver disease. When given with leptin to mice it can completely reverse insulin resistance. High adiponectin levels are good, low are bad.
"The hormone of energy expenditure", is a hormone predominantly made by adipose cells that helps to regulate energy balance by inhibiting hunger. It is a mediator of long term regulation of energy balance, suppressing food intake and thereby inducing weight loss. Although leptin reduces appetite as a circulating signal, obese individuals generally exhibit a higher circulating concentration of leptin than normal weight individuals due to their higher percentage body fat. These people show resistance to leptin with the elevated levels failing to control hunger and modulate their weight. Children born with functional leptin deficiency who are severely obese respond with weight loss to therapy with leptin.
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