Let's Get Back On Track

I've neglected this blog for a little while.  Not necessarily because I don't have things to say, but because life's gotten in the way...

"Let's get back on track".   That was the sombre advice from my Garmin app this morning after yet another appalling attempt at running.  "Let's get back on track"...

The truth is, I feel pretty broken at the moment.  For once in my life, the only thing that seems to be taking relatively little effort on my part is having diabetes.  That's a strange thing to write really - the thing that's a 24/7 fixture in my life is the easy bit.

As usual, there's a lot going on (which is of my own doing), but it all seems to have fallen at once so I'm stumbling from one thing to the next without much time to think.  That's not always a bad thing I guess - the pressure of working on a few, quite different things is interesting and definitely keeps me on my toes.

But it does mean a few things are getting squeezed out (I've not found a way to add a few extra hours in the day yet).  Worryingly, it seems to be any kind of exercise which I'm sacrificing at the moment.  Given my pathetic metabolism, that means I've invariably put on weight, and I seem to be obsessing about it rather a lot.

I look back at where I was 12 months ago, and I was running 100 miles a month, at my lowest weight for about a decade and feeling invincible.  Now I'm struggling to run 4 miles (partly due to a stubborn knee injury I sustained mid-April), I'm about 12lbs heavier than I have been in ages and quite frankly it's making me miserable.

I seem to have developed some kind of weight obsessed insomnia as well and I'm finding it tricky to switch off, which is a little frustrating given how tired I actually feel at the moment.  There's a lot running through my mind every night but I seem to go back to how frustrated I am that I can't run, and the effect it's having on me.

I've been travelling a lot lately for various reasons (social and otherwise) - London and back three times in six weeks (with another three in three weeks at the start of July)...

To be honest, I don't think there's much of a point to this blog, other than to write all this stuff down so it's one less thing in my head.

I should be able to shift some of this unwelcome weight which will make me feel a lot happier.  Body image problems can't be over-stated in my opinion and it's something I wrestle with a lot more than I let on.   I know my knee will come back to being somewhere partly sensible so I should be able to get out and find the enjoyment I got from running last year.  And hopefully I'll get some sleep too.

At least diabetes isn't causing me too many problems.  For once.

Until next time.

Weight watching

Mondays pretty much start the same way for me every week… The alarm goes off around 5:45am, and, silently cursing, I take stock of how I’m feeling… light-headed (hypo), a bit stiff (hyper) or just tired (‘in range’)?  I drag myself to the bathroom and stand on the bathroom scales.  And I sigh.

 

Diabetes is an enormous daily battle that I won’t rehash for the millionth time here and now.  I’ve lived with diabetes for long enough now to be able make most days ‘better’ days, though I’m not impervious to the bad days by any means.

 

I’ve started writing this blog post a few times and I’ve held back – I’m scared of straying into unchartered waters and accidentally throwing opinions around on things I (and many other people) don’t really understand.  But here we go.

 

I can tolerate Type 1 diabetes most of the time, but where I struggle every day is with my weight.

 

About 18 months ago I devoted a huge amount of energy and effort to tackling my weight and lost 3 (and a bit) stone to get to a position I was vaguely happy with.  I cut my diet back to about 1200 (net) calories a day, ran 20-30 miles a week as well as doing four or five mornings a week on my exercise bike.  It was exhausting and took over my life, but I did it.  But that’s when it started to get difficult…

 

I’ve always found it (kind of) manageable to lose weight, but I’ve equally found it far too easy to put it back on again within a few months.  This time I feel like something is a little different.  I’ve had fluctuations obviously, but I’ve pretty much avoided piling the pounds back on.  But it’s much harder work than it was to get to this position in the first place.

 

What I’ve discovered is that actually, my body only really needs around 120-1300 (net) calories a day anyway and regularly eating above that means I’ll put weight on.  My diabetes consultant refers to it as being a ‘thrifty phenotype’ – basically if there’s an apocalypse, you’ll probably starve before me (sorry), but basically I don’t need a lot of food to keep ticking over.

 

This creates a number of problems for me.  The first, and most obvious one is that I LOVE food so I feel like I’m constantly faced with the choice of skipping one meal in favour of another.  Or I have the chance to go out and run 6 miles to be able have something.  Whilst I both love and loathe running (it feels like life support to some degree), my life doesn’t allow the same number of opportunities a week to pound the pavement, so more and more I feel like I’m choosing breakfast plus one other meal.

 

The second problem is food guilt.  I’m sadly not immune to the temptations of an occasional takeaway.   Having skimped on calories for the rest of the day (and/or been for a run), I’ve been known to dabble in a chicken chow mein from time to time.  The thing is that pretty much as soon as I’ve eaten it, I have an overwhelming feeling of guilt about what it’ll do for my weight and I’ll compensate for days afterwards too.  I have genuine regret about something I’ve treated myself to, and I’m pretty sure it’s not healthy (the guilt that is, the takeaway definitely isn’t…).  If I’m eating out at restaurants, I’ll pick a salad more often than not because it’s not a guilt-inducing.  Having a hypo is a nightmare when I feel like this – I’m eating calories that I don’t want to correct it and I resent them for it. 

 

The last problem is how it makes me feel.  I’m writing this after stepping on the scales to find out I’ve put an improbable 4lbs on this week, and it’s pretty much all I’ve thought about all day.  I knew last week I would have put a few on (about 3lbs) as I’d been away for Easter and it’s a lot harder to stick to a calorie goal while you’re away.  But being back home hasn’t improved things.  I know I used to be a lot heavier, but I look in the mirror and I’m fundamentally unhappy with how I feel.  I hate the nagging from my inner voice before I eat anything…

 

I’m used to seeing food as numbers – it’s impossible not to when you’re doing mental arithmetic before you eat anything.  But I see calories everywhere too, and calories scare me a lot.   Having diabetes puts me at a greater risk of stroke, heart disease and cardio vascular disease, than people who aren’t ‘in the club’.  I’m about twice as likely to suffer from one or more of those as a result of my diabetes, and being overweight doesn’t help my chances much either.

 

I’ve noticed that gradually, I’ve stopped cooking new things almost entirely because I know I can rely on the knowledge that what I eat most days, falls into safe zone and I don’t want to stray from that safety.  I know when I do stray, I’ll have put weight on. And when I put weight on I’ll be miserable until I’ve lost it all.  I feel like I’m resigned to logging everything I eat for the rest of my life to be able to stay at a healthy(ish) weight, and the though of that exhausts me.

 

I wrote recently about how a day off from having diabetes would be nice.  Having a day off from this food guilt and unassailable obsession with my weight would be nice too.

Together, we will go our way

This is the 100th post on We Were Promised Hoverboards, and this time I'm handing over the reins to a couple of incredibly inspiring healthcare professionals.  

When Neil and Athinyaa spoke at DPC16 at the start of the month, everyone listened - it was a heartfelt, emotive talk about providing care to people, not patients.  This blog they've written continues that theme, and it's incredible.  Enjoy.

It'd been a few years since I attended Diabetes UK Annual Professional Conference. I used to find some of the sessions interesting and helpful, but really I preferred other conferences for technical content and it was foremost a networking event and somewhere to catch up with colleagues. Last year I had the chance to attend just one day after several year’s absence. This one was different and it tugged on a heartstring. You see, in the last several years, in the last years of my training and first years of being a consultant, I had also changed.

What was different about #APC2015? It was people, people with diabetes were there. How was I different? The answer is the same as why I thought the APC was different: the relationship with people living with diabetes. So, what changed in me? Had I been a bad doctor? Had I a bad attitude? The answer lies in a question. My colleague, Athinyaa Thiraviaraj and I were asked this question by Dani @danianddanzel a few weeks ago. The two of us had been working together for more than 3 years by this time. We'd been slowly bouncing thoughts and ideas past each other in reaction to the vagaries and trials of diabetes care, whether that was in the acute setting or clinic.

Dani asked what had motivated us to make changes. Was it our patients? She guessed that we wouldn't have made the change otherwise.  As we responded together, all the thoughts and ideas that we'd been talking over the last few years crystallised out.  Athinyaa said she thought it was both a difficult and easy question. She agreed that we both knew who had motivated us - people living with diabetes themselves. 

My first thought was about insight, or self-awareness, a sense that things weren't going right in what I was trying to do for people.  I'd chosen this life, spent years studying, doing exams and practicing medicine. Surely, if anyone, someone like me should know what is important in diabetes care and the medical risks involved. Why couldn't the people I saw in clinic see that these things were important? Why couldn't I get this across? Even at the end of my training I knew that sense of failure was inside me; I was already realising that I wasn't getting through to people like I thought I should. 

As I became established as a consultant, after a year or two, I gained something that I did not have as a trainee: continuity.  In seeing people again and again, relationships began to build as I got used to people and they got used to me. As that happened, I could see that people living with diabetes had needs that were different from what I was giving. I struggled with that knowledge. I had felt a failure. I had to admit that before I could change. That's the most difficult part. Nothing can change without admitting that there is a problem. Athinyaa has been really clear that where we were now in our careers was a factor; we were now consultants and so truly owned our decisions. It takes an empowered clinician to believe in empowerment.

So what were the actual changes? We started listening. It was as simple as that. We listened to the person sitting in front of us in clinic, the person in the ward and even in the high dependency unit. Listening was simply that: actually hearing what the person wanted to say, giving space, allowing them to say what they wanted.  In active listening we showed congruence, we were in the room with the person, not thinking about their numbers and risks.  It allowed us to express empathy. In accepting what they felt important at the time, understanding how people actually felt and what they wanted we learnt more about them, as a person. Yes, numbers and risks were important to us as clinicians and maybe to the person talking beside us, but maybe ‘the numbers’ weren't top of the agenda for the person themselves at that time. Looking back, we both had respected people with diabetes before, but now we had begun to demonstrate that respect better. 

Listening was a main factor in the other great catalyst, the diabetes online community. We listened there for weeks and months before actively taking part. It has helped change us further, adapting our attitude, behaviour and language. We both found that the more we changed, the more rewarding it seemed for both the people living with diabetes we were caring for, but also for us as healthcare professionals. It was a win-win scenario. 

It is very difficult to make these changes.  Medical training schools us to listen, extract information as a clinical history, analyse it and come to a conclusion about diagnoses and management plans.  As Athinyaa is fond of saying, the clinician needs to put aside the 'fixer'. Life's problems don't have simple fixes, unlike medical problems. We defined the medical / diabetes problem on our agenda, but what about the person, what about what they valued and wanted? You cannot separate diabetes from someone's life. As I heard pointed out recently, if you hate diabetes, you hate a part of yourself. 

The change was that we were listening to the person. We were separating the person and the problem, leaving aside the medical problem and the 'fixer' and listening to the person. Setting aside the medical problem as we saw it, it left us able to hear them. In doing so, we moved away from the traditional directive model of care to a partnership with the person with diabetes. A vital part of this partnership recognises the person with diabetes as the Expert.   Our role is to be one part of the person’s wider support, adding our own knowledge and skills as diabetes specialists to theirs. And yes, this relationship based on trust is about mutual respect, but we believe that the healthcare professional must offer this respect to the people living with diabetes before deserving or expecting it in return.

The people who we saw in our clinic responded with impromptu feedback. This was part of listening rather than a formal survey. It also happened through the diabetes online community.  They said the experience was better.  While we strongly believed in this engaged supportive care, it was out of step with other colleagues. The feedback was important to us as we needed that encouragement to keep going. Every person with diabetes we have come in contact with, real and virtual, over the last several years has motivated us to change and adapt.

This was an organic change, to a culture of partnerships based on honesty, transparency, active listening and above all, unconditional positive regard. Now, we were not awful physicians to begin with, but to acknowledge our weaknesses and apply these principles in a focused manner meant we were able to enter into meaningful engagement with the person living with diabetes.

So what changed? Just us - as individuals and as a team.

Why did we change? For the people who trust us with their health, because they always come first

@RNeilABlack

@athinyaa

#DiabetesWest

Libre - what do I reckon

I've been asked a few times (well, a couple of times), on Twitter what I think of the FreeStyle Libre so instead of sending a million tweets all at once, I've tried to summarise those thoughts here.  Remember this is just what I reckon* and bear in mind that at the time of writing, I've had a total of five weeks use out of their sensors.  For more thorough reviews over a much longer period of time, you should be reading Mike's blogs here.

* I'm going to keep linking to that video because a) it's funny and b) it's a reminder to keep grounded about our opinions on stuff generally

I've already written twice about the Libre:

- This is about how I felt before I started
- This is about my experiences of my first sensor

But I'll try and give some of my more general thoughts on it in case it proves helpful to anyone thinking of parting with the money for the first time.

• It gives you more information, and (here's the caveat), with the right understanding, more information is very powerful.  It's not about the number of results - with the right tolerance for pain, you can get the same amount of data but the information (about what direction your BG is heading) is a very important addition

• It can be a very motivating tool.  Diabetes isn't a game, but approaching it like one can be beneficial.  I get a big psychological boost from seeing the trace line staying within the bounds that I set spurs me on.  It also gives me confirmation that I know what I'm doing (at least some of the time), but...

• When things aren't going my way (particularly when I'm high), I find the Libre very demoralising to the degree that I think it almost has an adverse effect on me.  Recently my BG was rising and rising and rising and I'd ruled out illness, bad carb counting, bad insulin/cannula... everything.  And still it rose.  As it's so easy to swipe and test, that's what I do.  And it makes me unhappy and frustrated which doesn't help.  With a fingerprick, I feel like I make much more of a choice to test, and so I can switch off from it if I want.   I don't approach it in the same way with a Libre.

• It makes me feel more confident that I can correct from a relatively good reading (say 7.5mmol) to something 'better' like 6mmol and not go too low.  It's like it gives me the opportunity to nudge my BG either up or down to stay within my own target range.

• I feel like I've ended up eating fewer 'proper' meals and started snacking more as it gives me the chance to feel more in control of how my BG is behaving.  I'm not sure that this sort behavioural modification is a good thing or not, but it seems to be an unintentional side effect.

• It takes the stress out of some aspects of diabetes, particularly overnight basal testing.  Being able to get a full picture by swiping once every eight hours means I can test right before bed and first thing in the morning and start to identify any problem areas - I think that's a real positive.

• The graphs and data the software gives you are very helpful.  I've never seen my own "ambulatory glucose profile" before, but I feel a lot better being able to see it.  The HbA1c estimator is also pretty helpful, and (in my limited experience), not far off being accurate either.

• You have to decide for yourself how you define its accuracy.  I know what I kind of expect my BG meter to tell me when I start feeling low, and equally when I get that sticky feeling behind my eyes when I'm going high.  The Libre isn't always going to give me that same figure, but as long as I have that internal calibration, I feel pretty confident being able to dose or even correct from it's reading. But again...

• Knowing its limitations is important too.  Don't use if before driving (always finger prick), don't use it if you've got an arrow showing rapidly falling (or rising) glucose - you need blood to really understand what's going on.

As with everything related to diabetes, it's all very individual.  You might end up with a reaction to the sensor adhesive (as I know a few people do), you might find it helpful where I find it frustrating (and vice versa), or may not find it 'accurate' enough.

I wasn't sure before I started using it but I think it was worth the cost of the reader and one sensor to understand what I was going to get from it.  If you can spare about £100 then I'd probably say go for it, just to understand what your experience is.  After that it becomes a more informed decision - you understand more about whether what you get is worth it for you.

Hope that's helped someone somewhere!

Sugar and spice and all things in moderation

*Deep breath*

Sugar Tax.  I don't remember anything that has so divided that diabetes online community.  Sure we all have different views, that's what makes us a community.  Of course we don't all agree - where would the fun be in that?  But the announcement of the Sugar Tax has everyone scrambling for an opinion.

I'll admit a few things from the start.... firstly, I'm pro Sugar Tax (for reasons which I'll explain), and secondly, I'm not sure writing this blog is the best idea I've ever had - experience tells me it could end up with me taking a week off the internet....  It's important to realise that my opinion is no more valid than anyone else's.  I'm not right, but neither am I wrong.  It's just what I 'reckon'.  And who doesn't love a good reckon?

So I'm pro Sugar Tax... light your torches and grab your pitch forks.  Why am I in favour of it?  Incentivisation.  My academic background is in economics (so I'm also generally pro Free Markets too), and I like the theory of how individuals react to incentives.  That theory generally being that when faced with a choice over two 'identical' products, the rational choice is to choose the cheapest one.

Now Coke and Diet Coke aren't quite identical, but they're pretty close.  If one is cheaper than the other - the rational choice is to choose the cheapest one right?  Why pay over the odds for a Coke when Diet Coke is (almost) identical?  Add to that, the differences are that Coke has more sugar (and more calories) then you're almost winning twice.  Changing behaviour is difficult, but people acting rationally, understand the dis-incentive in choosing more expensive Coke, over cheaper Diet Coke - so it should work.

But this is where it gets tricky.  In theory, theory and practice are the same.  In practice, they aren't.

Sugar Tax comes with a whole host of other things to consider.  Is the level of tax going to be big enough to make everyone behave rationally?  Probably not (price elasticity of demand is what you're thinking of there).  Are there socio-economic implications of increasing tax on soft drinks?  Yes of course.  There are loads - too many to even begin to discuss here.

Is Jamie Oliver a bit annoying, and prone to the odd diabetes-related gaffe?  Yes of course.  Isn't it a half measure if it doesn't include sugary milkshakes?    Yeah.   What about my hypo treatment?  Agreed.  There are alternatives, but you need something that works for you.  Thankfully Diabetes UK have our back on that one.   Why not make fruit and veg a load cheaper instead?  Yeah why not?  Completely agree.  Ask a farmer how much he makes off a 20p cucumber...

In my humble opinion (which, remember, counts for no more and no less than yours), I think people hear the announcement of a Sugar Tax and assume it's the only solution being proposed.  I don't think it is, and don't see how it can be.  Affecting the behaviour of a huge number of consumers isn't going to happen overnight, and isn't going to be done by a 7p levy on a can of coke.

I think the majority of people know that being overweight and inactive is bad for you, but they don't change their lifestyle.  Many people also know that smoking is bad for you but people continue to do it.  Though that number continues to fall as tax rises and the number of places you can smoke decreases.  Multiple measures gradually affect behaviour.

We already have a limit on advertising junk food to kids.  Placing sweets near supermarket tills is on its way out.  Evidence shows that indeed in some parts of the world, sugar tax has some effect on changing behaviour.  It won't change the world overnight (not least because you won't see it for two years anyway).

It's easy to be cynical and say it's patronising, pointless, punishing those who are already worse off.  But it's also easy to think that we have a responsibility to ourselves to be healthy, to reduce our risk of cardiovascular disease, strokes and Type 2 diabetes.  And if we don't want to, that's fine, but you'll have to pay a small premium for it.

Anyway - it's just what I reckon...

Cheers.

I wish

I wish that "what's my blood?" wasn't the first thing I thought every morning.  I wish that sometimes, waking with the all too familiar feeling of a dry mouth didn't set the tone for my entire day.  I wish that feeling light-headed at 6am didn't mean scrabbling around in the dark for jelly babies before I can have a shower.

I wish I could drive whenever I wanted.

I wish that sticking a needle in my fingers seven or eight times a day wasn't necessary.  I wish I didn't have to stick a needle in my stomach twice a week.

I wish I could go away for the night, for the weekend, for a week, without it feeling like a military operation.

I wish that being ill was just that - and not an assault on my entire body.

I wish that I didn't have to carry so much stuff around with me all the time.  I wish I didn't have to keep spare sets of everything all over the place.

I wish I could go for a run without ziplock bags of jelly babies.

I wish my blood sugar didn't have to dictate my mood.  I wish my partner understood my mood-swings.

I wish I didn't look at a plate of food and see numbers.  I wish guilty pleasures didn't try to punish me for hours afterwards.  I wish that carbs didn't sometimes feel like my enemy.

I wish it wasn't a fight.

I wish my brain would switch if off sometimes.  I wish I didn't think about test results.  I wish I didn't have a familiar hospital routine.

I wish I could go to bed when I was tired without needing permission from a finger-prick.

I wish that this list didn't represent every day of my life.  I wish that sometimes it was just a little bit easier.  I wish I could have a day off.

Maculopathy and worry

I'm a worrier.  There - I said it.  I worry about things that I suspect most regular people don't worry about... I spend a fair proportion of my time convinced I've mortally offended someone, and that the sun might not come up tomorrow.

Having a long term condition like Type 1 diabetes unfortunately comes with a fair amount of worry as standard.  The longer you live with  it, the more aware you are of what can go wrong.  Whilst some of it lies within your own control (stable, lower HbA1c, attend regular checkups, good diet, active lifestyle etc.), sometimes life throws you a curve ball.

For me, that came a few weeks ago after my annual retinal eye screening appointment...

"Your latest eye screening showed results of diabetic maculopathy..."

What?  Worry levels set to max.

A small segue to talk about language... is that sentence above what anyone wants to read?  No.  Is it a bit clinical?  Yes.  Is there a better way of doing it though?  Not sure.  If there's something wrong - I want to know.  An alternative along the lines of "there was something wrong/abnormal on your last screening..." is more vague and isn't less comforting.  Language helps, but here I think it's a tough one to crack.

So I phoned up and made an appointment for the eye clinic.  You may have noticed I was in Glasgow last week so I had to wait until today for my appointment.  Worry levels dropped slightly, but remain constant.

My confirmation letter turned up before I went to Glasgow and didn't fill me with confidence...

Maybe it's a test?

So this morning I took my daughter to school and headed off to the eye clinic.  By this time, I'd had chance to talk to a few people who'd received similar letters and nothing had come from it.  Worry levels lowered.

Now the thing with the Eye Clinic is that it's very different to the diabetes clinic.  Different hospital, different environment, lots of people there for a lot of reasons.

Thankfully the sign is big enough

It's basically chaos.  The whole thing is overseen by a receptionist with 10 different paper lists which she updates as people hand over their different coloured appointment letters (all whilst she's sorting some other problem out on the phone).  It's not welcoming in the slightest.  Worry levels increasing...

I'd got there early (overly worried about being late) and was whisked away for an eye test and some drops.  Interesting point to note is that if you're ever asked to read a line on the eye chart, you don't have to just try and read the bottom one (I thought it was a game).  If there's a red line across the middle, that's the average - anything below there and you're doing well!

"Drops will take 20 minutes to work and wear off in 3-4 hours.  Through the grey double doors and wait outside room 8 please"

This is the door opposite room 8.  Worry levels increasing.

Reassuring...

The 20 minutes of purgatory you go through when waiting for the drops to work is a strange time.  Your vision gets gradually worse whilst you contemplate your vision getting worse.  It's also a time for people watching (the national diabetes sport).

There's a lot of things to dislike about waiting rooms.  I often feel they're a window into your future to some extent.  A few people turned up with orthotic shoes on.  Someone else had an eyepatch.  Everyone was older than I was and it seemed unfair (not for the first time), that this was happening to me.  Worry levels replaced by despair.

Finally I got the call.  I'd been in the building for almost 40 minutes.  I was in the consulting room for another six.

The doctor told me (with a smile on her face), that I was the first Type 1 patient she'd seen for a while.  I smiled back, but wasn't sure I'd got the joke.  She told me my previous HbA1c results were good (thanks!) and I mentioned I'd had it tested in Glasgow last week and it was 49mmol/mol (or 6.6% in old money)...

"Wow" she exclaimed.  "Be careful!  Do you have any hypos?  Do you drive?"

As we all know by now, that one exchange is a blog in itself.  My HbA1c is above NICE recommended guidelines (and will no doubt stay there).  Of course I have hypos, I inject a drug that causes them if I don't eat exactly the right amount/do any exercise/it's a bit warmer than usual.  Of course I drive.  Why wouldn't I?  Normally, I'd have said something, but I'd had enough.  All I wanted to know was how bad the results were.  Worry had returned.  Despair had fled.

"Look here" she said, indicating to the top of her ear, shining a bright light into my eye.  "Look up".  More shining.  "And down" eye drops and bright lights don't mix well.  "To the left".  Almost over.  "Aaand right".  Repeat for the other eye.

"OK, I'm happy to discharge you from this clinic" she announced brightly.  Eh?  What?  You sent me a letter that said maculopathy.  That's bad.  I've been worrying about this for over a fortnight.  That's it?

"How do you mean?"  I asked.  "Just go back to normal eye screening every 12 months?"

"Yes, yes that's fine!  I mean there's some bleeding..."

"What now?"

"Yes but it's perfectly normal" she said as I climbed down off the ceiling.  "Sometimes when you've had diabetes this long, you'll get small bleeds in the tiny blood vessels, but it's any leaking we're worried about.  There were a few spots on the scan, but I can't see them now so it's all fine".

OK.  I'm convinced by that I think.  I picked up my coat and bag and paused.  It's still my appointment right?

"Can I have a look at my scan?"  I asked.  No problem.  "Can I take a picture?"  She looked a bit taken aback this time, but again, no problem.

So here it is.  This is the thing that's had me worried for over two weeks.  You might be able to see a few tiny yellow spots to the left of centre (depends on how big the image goes for you).  The bleeds are a little to the right, as tiny red dots.

Eye eye

"Nothing to worry about".... tell me another one.

Thanks to everyone that spoke to me about their experience of "that letter" before I went for my appointment today.  I won't name you here, but if you're reading this, you should know who you are.  Your support was really helpful.  Thanks again.