Endodiabology February 2008
ENDODIABOLOGY
Endodiabology.blogspot.com
FEBRUARY 2008
Editors: Shaz Wahid
Associate Editors: Arut Vijayaraman, Shafie Kamarrudin, Beas Bhattacharya, Ravi Erukulapati
SpR PLACEMENTS (NTN year of training from 1st October 2007)
· RVI- Andrew Advani (5), Arutchelvan Vijayaraman (4), Jeevan Mettayil (3), Muthu Jayapaul(5), Khaled Mansur-Dukhan (4)
· Freeman- Chandima Idampitiya (3), Ravikumar Balasubramanian (5), Kerry Livingstone (2)
· North Tyneside/Wansbeck- Akheel Syed(5), Sukesh Chandran(4)
· South Tyneside- Kathryn Stewart (1)
· Gateshead- Asgar Madathil (4)
· Sunderland- Shafie Kamarrudin (2),
· North Tees/Hartlepool- Beas Bhatacharya (4), Anjali Santhakumar (1)
· Middlesbrough- Srikanth Mada(1), Ravi Erukalapati(3), Preeti Rao
· Carlisle- Sudeep Manohar
· Bishop Auckland / Durham- , Arif Ullah (1)
· NGH/QEH- Freda Razvi (3)
· Research with numbers (supervisor)- Eelin Lim(4-Prof Taylor)
MEETINGS / LECTURES / ANNOUNCEMENTS
· Endocrinology & Diabetes section of the RSM (www.rsm.ac.uk/endocrinology) offers the following meetings beginning at Wednesday 27 Feb 08: Diabetes in the Elderly (joint with ABCD) Wednesday 28 May 08: Evidence-based Endocrinology
· 26th February 2008 Clinical Cases Meeting, Society for Endocrinology, London. Contact http://www.endocrinology.org/
· 5th-7th March 2008 DUK Annual Professional Conference, Birmingham. Contact http://www.diabetes.org.uk/
· 8th March 2008 Association of Physicians meeting, University Hospital North Tyneside. Contact
· 17th March 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 7th-10th April 2008 BES 2008, Harrogate. Contact http://www.endocrinology.org/
· 10th-11th April 2008 ABCD Spring Meeting (follows straight after BES), Harrogate, http://www.diabetologists.org.uk/
· 17th April 2008 NovoNordisk Symposium 2008-Diabetes and the Liver, 1330-1800 Lumley Castle. Contact
· 30th April 2008 RCP Acute Medical Emergencies conference, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 6th May 2008 Northern Endocrine & Diabetes Summer CME, Freeman Hospital. Contact
· 14th May 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 16th-17th May 2008 21st European Diabetic Nephropathy Study Group meeting, Germany. Contact
· 22nd-23rd May 2008 RCP National Conference: General Medicine for the Physician, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 21st May 2008 North East Obesity Forum meeting. Wolfson Research Unit, Queens Campus, Thornaby from 4pm. Childhood obesity. Contact
· 6th-10th June 2008 American Diabetes Association 68th Annual Scientific Sessions, San Francisco, USA. Contact.
· 15th-18th June 2007 ENDO 2008, San Francisco. Contact endostaff@endo-societ.org or www.endo-society.org/scimeetings .
· 24th June 2008 Joint Trainers & Trainees meeting from 1600, University Hospital North Tees. This follows the STC meeting and the SPARROWS feedback meeting will begin from 1730. Contact
· 9th July 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 7th-11th September 2008 44th EASD Annual meeting, Rome, Italy. Contact http://www.easd.org/
· 15th September 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 8th October 2008 Northern Endocrine & Diabetes Autumn CME, James Cook University Hospital. Contact
· 12th November 2008 North East Obesity Forum meeting. Obesogenic environment. Contact
· 12th November 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 10th December 2008 RCP Updates in G(I)M, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
TRAINING ISSUES
DIABETES & ENDOCRINOLOGY PIMD WEBSITE Our specialty website is available on http://mypimd.ncl.ac.uk/PIMDDev . Click onto the specialty training tab then follow to Diabetes & Endocrinology. This site is essential reading, especially for ARCP preparation.
Registering with PMETB It is essential that all new SpRs/StRs (even LATs) register with the PMETB through the newly created Joint Royal Colleges of Physicians Training Board (formally the JCHMT) on http://www.jrcptb.org.uk/ although it is still possible to link with this site using the old http://www.jchmt.org.uk/ link. Not doing so means your training is not counted.
Log Book/Portfolio Documentation It is a trainee’s responsibility to make sure their portfolio/log book is prospectively completed and the necessary signatures obtained. Any experience that is not signed off by your educational supervisor at the time cannot be counted towards training.
Assessment tools Please see http://www.jrcptb.org.uk/, It is the trainee’s responsibility to give all the appropriate forms to their Educational or Clinical Supervisor. It is the trainee’s responsibility to make sure that the appropriate assessment summaries are available in their portfolio for ARCP purposes, e.g. MSF Summary Form.
ANOTHER CURRICULUM Trainees who have been recently appointed now have a new curriculum for both the specialty, Acute Medicine to Level 2 and a generic curriculum. Essentially there is no difference other than the sections being reorganised into the subsections of OBJECTIVE/COMPETENCY, KNOWLEDGE, SKILLS, ATTITUDE. They are essential reading and can be accessed on http://www.jrcptb.org.uk/ .
The GOLD Guide This replaces the Orange guide, and is the definitive guide to all aspects of training in the UK. It can be accessed on http://www.jrcptb.org.uk/SiteCollectionDocuments/Gold%20Guide.pdf . A massive document that I delve into when the need arises, e.g. interdeanery transfers.
Acute Care Assessment Tool The ACAT is a tool that is commendable. It provides a method of assessing how Trainees managed their on-call period. It is recommended that at least one is available for ARCP purposes. It can be downloaded from the JRCPTB website.
Carbohydrate Counting Visit http://www.bdec-e-learning.com/ an essential resource that is free for now. Highly recommended for all caring for patients with Diabetes and something that could be considered mandatory for trainees.
ARCP (RITAs 2008) Will be held on Weds 14th, Thursday 15th and Friday 16th May 2008. The PYAS are planned for Thursday am 15th May 2008. Time tables and instructions have been circulated. Documents needed for the ARCP panel are:
1. Portfolio (If you have developed one)
2. Training Log Book (to include any assessments, e.g. MSF, Mini-CEX)
3. Three copies of an Educational Supervisor Report (appended electronically)
4. Three copies of an Annual Appraisal Record (appended electronically)
5. Structured CV (format appended electronically)
6. 4 mandatory Mini-CEXs (unless you have already had your PYA when they are optional)
7. A mandatory up to date MSF report (not seen in your last RITA), unless you have already had your PYA
8. Evidence in your folder/portfolio demonstrating competence in at least 6 Core Diabetes & Endocrinology Topics (not seen at your last RITA). If you are having a PYA you should have evidence of competence in your folder for at least 90% of the core topics
Recruitment & Selection for Diabetes & Endocrinology 2008
ROUND ONE-25th and 27th Feb 2008
Local selection of ST2s to try and fill 3 of our NTNs. Any that are not filled will go through to round 2. Those NTNs that are filled will be started ASAP to plug current gaps in the rotation ASAP. Shaz Wahid will be on the selection panel.
ROUND TWO-date to be confirmed
Will be led NATIONALLY by the Severn Deanery. We have 1 NTN in this round for definite with the option to carry NTNs through from round one. The fact that we have at least one of our NTNs accepted for this round is very good news for the LATs in the region and gives them a fighting chance. Shaz Wahid has been put forward by Nancy Redfern to help in the process if the Lead Dean wishes for external help.
ROUND THREE-Friday 13th June 2008
A local mopping up round to fill any LAT or NTN vacancies. NTN vacancies may arise because the ST2s who had accepted a post in round one may then have been successful in round 2, hence relinquishing their original offer which is acceptable under the current rules.
A School of Medicine The Northern Deanery has adopted a School of Medicine to oversee training in all medical specialties as well as core training in Medicine. Our STC will feed into the School of Medicine Board and the Head of School is Harriet Mitchison. From now on all Training Programme Directors will be interviewed by the Head of School.
Training Committee Chair- Jola Weaver,; Regional Speciality Advisor- Richard Quinton,; Programme Director- Shaz Wahid,; Consultant member-Jean McLeod,; Consultant member (Research Advisor)-Simon Pearce,; Consultant member-Simon Eaton, Consultant member-Nicky Leech ; SpR representative- Arutchelvan Vijayaraman ; SpR representative- Jeevan Mettayil
NEWS FROM THE NORTHEAST
· Beas Bhattacharya, Shafie Kamarrudin and Ravi Erukulapati have joined the ENDODIABOLOGY Editorial team.
· Shafie Kamaruddin has joined the NEDs CME committee.
· Congratulations to Latika Sibal & Prof Home AND John Parr & Team on having abstracts accepted for oral presentation at this years DUK APC.
· Ravi Erukalapati, Eelin Lim and Arut will be attending the ADA through the SPARROWS programme this year.
· Newcastle Diabetes Centre has entered into collaboration with Shanghai- the Newcastle Diabetes Centre Shanghai collaboration. Gillian Hawthorne visited Shanghai in November to see their diabetes service and to speak at a conference; she was accompanied by Deirdre Kyne the clinical nurse lead. The venture is supported by One NorthEast.
· Congratulations to Simon Ashwell on his engagement to Amelia Lake who is an Academic Nutritionist.
· Congratulations to Richard Quinton & Family on the birth of James Philip Richard Quinton born 13 Dec 2007.
· Congratulations to Jeevan Mettayil on his oral presentation for the Caledonian Society for Endocrinology in Nov 07. Also, Jeevan has joined the STC as the trainee rep in place of Andrew Advani.
· Congratulations to Akheel Syed on passing his PhD viva.
· Congratulations to Ibrahim on appointment to the Consultant post at University Hospital at North Durham.
LETTERS
The Addison's Disease Self-Help Group- Simon Pearce
Simon Pearce is a member of the advisory panel & visit http://www.addisons.org.uk/ for a useful set of patient/education materials on management of the Addison's patient. The core publications have been authored by a panel of the UK's leading adrenal specialists and cover:
1. Surgery and dentistry, glucocorticoid requirements
2. Emergency treatment of hypoadrenalism
3. The role of the GP
4. Information for newly-diagnosed Addison's patients
They can be download these from the website or they can send print copies, eg to a training event, if you can let them know how many and where.
Diabetes Year of Care Project-Northumbria Team
The Year of Care Project is a national pilot project across 3 sites funded and supported by the National Diabetes Support Team in partnership with Diabetes UK, the Department of Health and the Health Foundation. NHS North of Tyne, Northumbria Healthcare, North Tyneside PCT and Northumberland Care Trust have been selected as one of these sites.
The purpose of the project is essentially twofold. Firstly it will look at the opportunities and challenges of introducing a Care Planning approach across a diabetes network, based to a great extent on work that has been done in primary care in Northumberland and North Tyneside and in specialist clinics in North Tyneside. It also, and importantly, also looks at ways in which this can be linked to how services are commissioned across the network.
As a result Year of Care describes all the planned care, personal and network wide, that a person with diabetes should expect to receive, usually over the course of a year. Within the Care Planning process, patients will have a greater say in what planned services they would find helpful and this will be agreed within the Care Planning process. This will form the basis of a ‘menu’ of choices that patients can access that can develop with time as new opportunities and options arise. This menu will also inform the development of commissioning structures that support and guide the development of diabetes services, using the views and preferences of patients to provide services that best suit the needs of the local population. This means that for the first time, patient choices can directly influence not only their personal care, but the services that are available to them.
Each pilot site has been chosen to represent different types of community and bring different skills to the project. Our partners in Tower Hamlets and Kirklees & Calderdale will help us to see how these approaches can be used in densely populated populations with high proportions of ethnic minority groups and where English is frequently either not a first language or may not be spoken at all. So far the local contribution has focussed in large part on the development of consultation skills and care processes needed for Care Planning and the training for this in primary care is already under way. Alongside this a Care Planning Guide for Clinicians has been developed and will shortly be available via the NDST website. There are a number of other strands to the pilot including patient involvement, information and evaluation, commissioning and detailed examination of the challenges for clinicians and patients in moving to this new approach to care.
This project will be challenging and may change the way we all go about delivering diabetes care. It has already excited a good deal of national interest. For further enquiries contact our Project Officer, Rachel Turnbull, by e-mail or phone
Timing of Thyroxine ingestion, do we need to change our practices? Beas Bhattacharya
Hypothyroidism remains one of the commonest endocrine pathologies. Its physiology and replacement relatively simple compared to other endocrinopathies. Thyroxine replacement is taken to be straight forward and it remains one of the most prescribed medications. Patients are usually advised to take their thyroxine in the morning, half an hour before breakfast time. Other significant pointers brought into attention are its enteral absorption, particularly small bowel and interference by cholestyramine, resin, sucralphate, iron, food and herbal remedies. Fibre rich diet has been shown to have effect in absorption.
A recent article in Clinical Endocrinology draws our attention to the basic question of timing of Thyroxine replacement and bioavailability and as a consequence brings out some rather fascinating points regarding thyroid biochemistry. This original article, Effects of evening: morning thyroxine ingestion on serum Thyroid hormone profiles in hypothyroid patients (Clinical Endocrinology,66,43-48), is small study done with 12 patients studied on two occasions, once on stable thyroxine dose in the morning and two months after switching to night time with the same dose. It was noted that serum TSH levels decreased and T3 increased significantly after changing timings to bedtime. In the discussion it is mentioned that thyroid hormone profiles improve on changing the timings and practical benefits for patients are cited: it is well known breakfast may interfere with intestinal absorption of thyroxine even if eaten half an hour later and with bedtime ingestion this problem will not occur; night time bowel motility is slower and prolonged exposure of thyroxine to the intestinal mucosa may mean better uptake.
Physiological factors can also play a part in why bed time dosing effects thyroid hormone profiles: the deiodinases vary according to thyroid status and also maintain a circadian rhythm; inactivating pathways of T4 metabolism, such as glucuronidation and sulphation may vary during the day, and may have some influence in the greater bioavailability at night; bioavailability of TSH has a circadian variation with less bioactive and differently glycosylated TSH molecules secreted during the night.
Though a small study it makes interesting reading and proves rather thought provoking, dealing with what is almost bread and butter part of our speciality. We should reflect on this .
Motivational Interviewing Workshop-Jola Weaver
Clinical Psychology for non psychologists First regional workshop on techniques in Motivational Interviewing (sponsored by Sanofi ) was held in Gateshead. It attracted attendance from GP, SpRs, Nurse Practitioners in Diabetes, Practice Nurses and Hospital Consultants. Techniques for improved communication included rolling with resistance, supporting self efficiency, eliciting change talk, building motivation for change were practiced amongst many others. Further similar workshops are planned for future If interested please contact Jola Weaver
Selecting a Consultant Colleague-Shaz Wahid
This was new to me! It took some thought, but for the short-listing process I used the following scoring framework:
SPECIALIST (CLINIC) INTEREST
5-Excellent-supported with research, publications, audit, courses and service interaction
4-Good-supported with activity during training including courses, audit/publications
3-Standard as part of training
2-Poor
1-None evident
MDT & SERVICE MANAGEMENT EXPERIENCE
5-Excellent-MUST HAVE POTENTIAL TO DEVELOP SERVICE and supported with activity across a district & demonstrable evidence within application of an understanding of DISTRICT CARE or attempts to audit such care
4-Good- MUST HAVE POTENTIAL TO DEVELOP SERVICE and evidence within application of interaction with care across a district
3-Standard as part of training and MUST HAVE POTENTIAL TO DEVELOP SERVICE
2-Poor with no real potential to develop service
1-None evident
TEACHING EXPERIENCE
5-Excellent-formal qualification with regular teaching activities & Evidence of acting as an “educator in diabetes” & evidence of Managing Teaching
4-Good- formal qualification OR courses attended to enhance skills with regular teaching activities
3-Standard as part of training
2-Poor
1-None evident
GOVERNANCE EXPERIENCE
5-Excellent-demonstrable evidence of AUDIT that makes a difference, courses attended including Management course & activity contributing to governance
4-Good-demonstrable evidence of AUDIT that makes a difference, courses attended including Management course
3-Standard as part of training
2-Poor
1-None evident
RESEARCH EXPERIENCE
5-Excellent-formal qualification & peer reviewed publications
4-Good-peer reviewed publications with regional and international meeting presentations
3-Standard as part of training
2-Poor
1-None evident
GENERAL MEDICINE EXPERIENCE
5-Excellent-regular out-patient experience, regular Acute Medicine exposure, ALS or equivalent, have attended national/international courses AND have audits AND publications in relation to acute medicine.
4-Good- regular out-patient experience, regular Acute Medicine exposure, ALS or equivalent, have attended national/international courses OR have audits OR publications in relation to acute medicine.
3-Standard as part of training
2-Poor
1-None evident
COMMITMENT TO THIS POST
5-Excellent-Have visited STDH and discussed the post AND their special interest augments the service needs.
4-Good-Have visited STDH and discussed the post, but special interests are ambiguous
3-Reasonable-have verbally enquired about the job and stated an interest they would wish to develop at STNHSFT
2-Poor- have verbally enquired about the job, but special interests are ambiguous OR already catered for
1-None evident- have made no enquiry about the job
EXTRA-CURRICULAR ACTIVITIES
5-Excellent-have had direct responsibilities for a national AND regional role. Have evidence of effectiveness in this role.
4-Good-have had direct responsibilities for a national OR regional role. Have evidence of effectiveness in this role.
3-Reasonable- have had direct responsibilities for a national OR regional role.
2-Ok- have had indirect responsibilities for a national OR regional role.
1-None evident
Trainees applying for Consultant posts may find this useful.
Newcastle young persons service needs ……….An Enthusiastic, Committed and broad minded SpR in diabetes to add inspirational clinical skills to the team-Nicky Leech
An excellent opportunity has arisen for training in Adolescent Diabetes. Commitment: 4-7.30pm Thursday evenings about once per month for 3-6 months No previous experience of young persons clinics necessary – we train!!!! Feedback on consultation skills by clinical psychologist provided. Experience in working with young persons discussion groups in the clinic provided. As much opportunity to reflect and push the field of adolescent diabetes as you wish. Kathryn Stewart has taken up the 1st block of training and if you are interested in following her contact Dr Nicky Leech tel 01912820114.
RECENT PUBLICATIONS FROM THE NORTHEAST
1. Al-Ozairi E, Michael E, Quinton R. Insulin-resistance causing severe postmenopausal hyperandrogenism. Int. J. Gynaecol Obstet. 2007 Nov 13 [Epub ahead of print]. doi:10.1016/j.ijgo.2007.08.017
2. Syed AA & Quinton R. Congenital radioulnar synostosis, azoospermia, and pseudodicentric Y chromosome. Fertility & Sterility. 2008 Jan 2; [Epub ahead of print]
3. Wellcome Trust Case Control Consortium & The Australo-Anglo-American Spondylitis Consortium. 269 authors including Pearce SH. Association scan of 14,500 nonsynonymous SNPs in four diseases identifies autoimmunity variants. Nat Genet 2007; 39: 1329-1337.
4. Vaidya B, Abraham P, Williams GR, Pearce SHS. National survey of radioiodine use in benign thyroid disease. Clin Endocrinol 2007; (In press) PMID: 17973939
5. David R. Woods The Skeletal Muscle RAS in Health and Disease, chapter 11, Frontiers in Research of the Renin-Angiotensin System on Human Disease.
6. DR Woods, S Allen, TR Betts, D Gardiner, H Montgomery, JM Morgan, PR Roberts. High Altitude Arrhythmias. Cardiology, 2008, in press.
7. James Dunbar, Ben Cooper, Tim Hodgetts, Yskandar Halabi, Pieter van Thiel, Steve Whelan, Justin Taylor, David R Woods. An outbreak of human external ophthalmomyiasis due to Oestrus ovis in Southern Afghanistan. Clinical Infectious Diseases 2008, in press.
RECENT PUBLICATIONS IN DIABETES & ENDOCRINOLOGY THAT HIT THE NEWS OR THAT MAY HAVE A SIGNIFICANT IMPACT ON MANAGEMENT
Haemochromatosis. Paul C Adams, James C Barton. Lancet 2007;370:1855-60. An excellent update for trainers and trainees.
Management of Thyroid Dysfunction during Pregnancy and Postpartum: An Endocrine Society Clinical Practice Guideline. Essential reading that provides a compendium of all the evidence to try and inform clinical practice.
CETP INHIBITION is not dead! It is well worth reading the editorials by Patrick Duriez (Lancet 2007;370:1882-1883) and Daniel Rader (NEJM 2007;357:2180-2183) in relation to the future role of inhibiting CETP and hence raising HDL for cardiovascular risk protection.
Childhood Obesity-The Shape of Things to Come An excellent, thought provoking article by David Ludwig (NEJM 2007;357:2325-2327). Essential reading for trainees, including the accompanying articles in the same edition.
Metformin for the treatment of the polycystic ovary syndrome An enthusiast writes about this emotive topic (John E Nestler NEJM 2008;358:47-54) providing an evidence base well worth reading about.
Clinical Update: bariatric surgery An excellent update by Michael Korenkov & Stefan Sauerland (Lancet 2007;370:1988-1990). It illuminates an obvious service gap in the UK!
Glucocorticoid chronotherapy in rheumatoid arthritis An excellent editorial by Johannes Bijlsma and Johannes Jacobs (Lancet 2208;371:183-184) along with the accompanying paper ( Buttgereit F, et al. Lancet 2008;371:205-214). It has relevance to glucocorticoid replacement therapy and well worth a read.Addition of biphasic, prandial, or basal insulin to oral therapy in type 2 diabetes. Holman RR, Thorne KI, Farmer AJ et al. N Engl J Med. 2007;357:1716-30. This open-label, controlled, multicentre trial randomly assigned 708 patients with a suboptimal HbA1c (7.0 to 10.0%) who were receiving maximally tolerated doses of metformin and sulphonylurea to receive biphasic insulin aspart twice daily, prandial insulin aspart three times daily, or basal insulin detemir once daily (twice if required). At 1 year, mean HbA1c levels were similar in the biphasic group (7.3%) and the prandial group (7.2%) (P=0.08) but higher in the basal group (7.6%, P<0.001 for both comparisons). The respective proportions of patients with an HbA1c level of 6.5% or less were 17.0%, 23.9%, and 8.1%; respective mean numbers of hypoglycaemic events per patient per year were 5.7, 12.0, and 2.3; and respective mean weight gains were 4.7 kg, 5.7 kg, and 1.9 kg. Rates of adverse events were similar among the three groups. The authors conclude that a single analogue-insulin formulation added to metformin and sulphonylurea resulted in an HbA1c level of 6.5% or less in a minority of patients at 1 year. The addition of biphasic or prandial insulin aspart reduced levels more than the addition of basal insulin detemir but was associated with greater risks of hypoglycaemia and weight gain. For me personally, the message that I take from this trial is that it does not matter how you start insulin as long as it is started early instead of the average 5-yr “wait”. It also does not change my standard practice of individualizing as the main priority with the majority use of Novomix 30 twice-daily with metformin, followed by the addition of an extra dose at lunch time or a switch to basal bolus depending upon the individual’s eating practice. I am sure that there will be those of you who disagree! (Shaz)Effect of fenofibrate on the need for laser treatment for diabetic retinopathy (FIELD study): a randomised controlled trial. Keech AC, Mitchell P, Summanen PA et al. Lancet. 2007;370:1687-97. The Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study randomised 9795 patients aged 50-75 years with type 2 diabetes mellitus to receive fenofibrate 200 mg/day (n=4895) or matching placebo (n=4900) followed up for an average of 5-yrs. At each clinic visit, information concerning laser treatment for diabetic retinopathy was gathered. Adjudication by ophthalmologists masked to treatment allocation defined instances of laser treatment for macular oedema, proliferative retinopathy, or other eye conditions. In a substudy of 1012 patients, standardised retinal photography was done and photographs graded with Early Treatment Diabetic Retinopathy Study(TDRS) criteria to determine the cumulative incidence of diabetic retinopathy and its component lesions. Laser treatment was needed more frequently in participants with poorer glycaemic or blood pressure control than in those with good control of these factors, and in those with a greater burden of clinical microvascular disease, but the need for such treatment was not affected by plasma lipid concentrations. The requirement for first laser treatment for all retinopathy was significantly lower in the fenofibrate group than in the placebo group (3.4% patients on fenofibrate vs 4.9% on placebo; hazard ratio [HR] 0.69, 95% CI 0.56-0.84; p=0.0002). In the ophthalmology substudy, the primary endpoint of 2-step progression of retinopathy grade did not differ significantly between the two groups overall (9.6% patients on fenofibrate vs 12.3% on placebo; p=0.19) or in the subset of patients without pre-existing retinopathy (11.4% vs 11.7%; p=0.87). By contrast, in patients with pre-existing retinopathy, significantly fewer patients on fenofibrate had a 2-step progression than did those on placebo (3.1% patients vs 14.6%; p=0.004). An exploratory composite endpoint of 2-step progression of retinopathy grade, macular oedema, or laser treatments was significantly lower in the fenofibrate group than in the placebo group (HR 0.66, 95% CI 0.47-0.94; p=0.022). In conclusion, in this study treatment with fenofibrate in individuals with type 2 diabetes mellitus reduces the need for laser treatment for diabetic retinopathy and the mechanism of this effect does not seem to be related to plasma concentrations of lipids. A very interesting study that needs to be replicated in a group of patients at higher risk for retinopathy or in a study with a much longer follow-up period than 5-yrs. The weaknesses in the study include lack of baseline retinal photography as a routine, heterogeneous criteria between study centres defining the need for laser treatment and the small number of events in the substudy. Further clinical and experimental studies are needed before adding fenofibrate to the armamentarium to treat diabetic retinopathy.Zoledronic acid and clinical fractures and mortality after hip fracture. Lyles KW, Colón-Emeric CS, Magaziner JS et al. N Engl J Med. 2007;357:1799-809. This randomised, double-blind, placebo-controlled trial, assigned 1065 patients to receive yearly intravenous zoledronic acid (at a dose of 5 mg), and 1062 patients to receive placebo. The infusions were first administered within 90 days after surgical repair of a hip fracture. All patients (mean age, 74.5 years) received supplemental vitamin D and calcium. The median follow-up was 1.9 years. The primary end point was a new clinical fracture. The rates of any new clinical fracture were 8.6% in the zoledronic acid group and 13.9% in the placebo group, a 35% risk reduction with zoledronic acid (P=0.001); the respective rates of a new clinical vertebral fracture were 1.7% and 3.8% (P=0.02), and the respective rates of new nonvertebral fractures were 7.6% and 10.7% (P=0.03). In the safety analysis, 101 of 1054 patients in the zoledronic acid group (9.6%) and 141 of 1057 patients in the placebo group (13.3%) died, a reduction of 28% in deaths from any cause in the zoledronic acid group (P=0.01). The most frequent adverse events in patients receiving zoledronic acid were pyrexia, myalgia, and bone and musculoskeletal pain. No cases of osteonecrosis of the jaw were reported, and no adverse effects on the healing of fractures were noted. The rates of renal and cardiovascular adverse events, including atrial fibrillation and stroke, were similar in the two groups. This study suggests that an annual infusion of zoledronic acid within 90 days after repair of a low-trauma hip fracture was associated with a reduction in the rate of new clinical fractures and with improved survival. An interesting study that will produce plenty of hype from the drug company! I think that the important message here is that preventing further fractures by what ever means in patients presenting with a hip fracture is essential to help improve morbidity and mortality in this vulnerable group of patients. I do not find it surprising that preventing refractures in patients with hip fractures improves mortality. The first step would be for all orthogeriatric services to undertake a robust audit of secondary prevention and as evidence gathers in the field the consensus treatment, taking into account cost-effectiveness, can be used.Intensive insulin therapy and pentastarch resuscitation in severe sepsis. Brunkhorst FM, Engel C, N Engl J Med. 2008;358:125-39. In this multicentre, two-by-two factorial trial patients with severe sepsis were randomised to receive either intensive insulin therapy to maintain euglycaemia or conventional insulin therapy and either 10% pentastarch, a low-molecular-weight hydroxyethyl starch (HES 200/0.5), or modified Ringer's lactate for fluid resuscitation. The trial was stopped early for safety reasons. Among 537 patients who could be evaluated, the mean morning blood glucose level was lower in the intensive-therapy group (6.2 mmol/l) than in the conventional-therapy group (8.4 mmol/l], P<0.001). However, at 28 days, there was no significant difference between the two groups in the rate of death or the mean score for organ failure. The rate of severe hypoglycaemia (glucose level, < or = to 2.2 mmol/l) was higher in the intensive-therapy group than in the conventional-therapy group (17.0% vs. 4.1%, P<0.001), as was the rate of serious adverse events (10.9% vs. 5.2%, P=0.01). HES therapy was associated with higher rates of acute renal failure and renal-replacement therapy than was Ringer's lactate. In this trial the use of intensive insulin therapy placed critically ill patients with sepsis at increased risk for serious adverse events related to hypoglycaemia and HES was harmful, and its toxicity increased with accumulating doses. I (Shaz) am an enthusiast for the appropriate management of hyperglycaemia in acute illness. This trial confirms the concerns of increased hypo risk from another large trial of medical patients on ITU. I suppose what we should be looking at is what is the optimum range to maintain blood glucose in ITU patients. It certainly should not be 10-20 mmol/l as suggested by an intensivist I recently chatted to!
NEXT NEWSLETTER Due out beginning of February 2008 so keep the gossip coming.
Endodiabology.blogspot.com
FEBRUARY 2008
Editors: Shaz Wahid
Associate Editors: Arut Vijayaraman, Shafie Kamarrudin, Beas Bhattacharya, Ravi Erukulapati
SpR PLACEMENTS (NTN year of training from 1st October 2007)
· RVI- Andrew Advani (5), Arutchelvan Vijayaraman (4), Jeevan Mettayil (3), Muthu Jayapaul(5), Khaled Mansur-Dukhan (4)
· Freeman- Chandima Idampitiya (3), Ravikumar Balasubramanian (5), Kerry Livingstone (2)
· North Tyneside/Wansbeck- Akheel Syed(5), Sukesh Chandran(4)
· South Tyneside- Kathryn Stewart (1)
· Gateshead- Asgar Madathil (4)
· Sunderland- Shafie Kamarrudin (2),
· North Tees/Hartlepool- Beas Bhatacharya (4), Anjali Santhakumar (1)
· Middlesbrough- Srikanth Mada(1), Ravi Erukalapati(3), Preeti Rao
· Carlisle- Sudeep Manohar
· Bishop Auckland / Durham- , Arif Ullah (1)
· NGH/QEH- Freda Razvi (3)
· Research with numbers (supervisor)- Eelin Lim(4-Prof Taylor)
MEETINGS / LECTURES / ANNOUNCEMENTS
· Endocrinology & Diabetes section of the RSM (www.rsm.ac.uk/endocrinology) offers the following meetings beginning at Wednesday 27 Feb 08: Diabetes in the Elderly (joint with ABCD) Wednesday 28 May 08: Evidence-based Endocrinology
· 26th February 2008 Clinical Cases Meeting, Society for Endocrinology, London. Contact http://www.endocrinology.org/
· 5th-7th March 2008 DUK Annual Professional Conference, Birmingham. Contact http://www.diabetes.org.uk/
· 8th March 2008 Association of Physicians meeting, University Hospital North Tyneside. Contact
· 17th March 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 7th-10th April 2008 BES 2008, Harrogate. Contact http://www.endocrinology.org/
· 10th-11th April 2008 ABCD Spring Meeting (follows straight after BES), Harrogate, http://www.diabetologists.org.uk/
· 17th April 2008 NovoNordisk Symposium 2008-Diabetes and the Liver, 1330-1800 Lumley Castle. Contact
· 30th April 2008 RCP Acute Medical Emergencies conference, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 6th May 2008 Northern Endocrine & Diabetes Summer CME, Freeman Hospital. Contact
· 14th May 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 16th-17th May 2008 21st European Diabetic Nephropathy Study Group meeting, Germany. Contact
· 22nd-23rd May 2008 RCP National Conference: General Medicine for the Physician, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 21st May 2008 North East Obesity Forum meeting. Wolfson Research Unit, Queens Campus, Thornaby from 4pm. Childhood obesity. Contact
· 6th-10th June 2008 American Diabetes Association 68th Annual Scientific Sessions, San Francisco, USA. Contact.
· 15th-18th June 2007 ENDO 2008, San Francisco. Contact endostaff@endo-societ.org or www.endo-society.org/scimeetings .
· 24th June 2008 Joint Trainers & Trainees meeting from 1600, University Hospital North Tees. This follows the STC meeting and the SPARROWS feedback meeting will begin from 1730. Contact
· 9th July 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 7th-11th September 2008 44th EASD Annual meeting, Rome, Italy. Contact http://www.easd.org/
· 15th September 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 8th October 2008 Northern Endocrine & Diabetes Autumn CME, James Cook University Hospital. Contact
· 12th November 2008 North East Obesity Forum meeting. Obesogenic environment. Contact
· 12th November 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 10th December 2008 RCP Updates in G(I)M, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
TRAINING ISSUES
DIABETES & ENDOCRINOLOGY PIMD WEBSITE Our specialty website is available on http://mypimd.ncl.ac.uk/PIMDDev . Click onto the specialty training tab then follow to Diabetes & Endocrinology. This site is essential reading, especially for ARCP preparation.
Registering with PMETB It is essential that all new SpRs/StRs (even LATs) register with the PMETB through the newly created Joint Royal Colleges of Physicians Training Board (formally the JCHMT) on http://www.jrcptb.org.uk/ although it is still possible to link with this site using the old http://www.jchmt.org.uk/ link. Not doing so means your training is not counted.
Log Book/Portfolio Documentation It is a trainee’s responsibility to make sure their portfolio/log book is prospectively completed and the necessary signatures obtained. Any experience that is not signed off by your educational supervisor at the time cannot be counted towards training.
Assessment tools Please see http://www.jrcptb.org.uk/, It is the trainee’s responsibility to give all the appropriate forms to their Educational or Clinical Supervisor. It is the trainee’s responsibility to make sure that the appropriate assessment summaries are available in their portfolio for ARCP purposes, e.g. MSF Summary Form.
ANOTHER CURRICULUM Trainees who have been recently appointed now have a new curriculum for both the specialty, Acute Medicine to Level 2 and a generic curriculum. Essentially there is no difference other than the sections being reorganised into the subsections of OBJECTIVE/COMPETENCY, KNOWLEDGE, SKILLS, ATTITUDE. They are essential reading and can be accessed on http://www.jrcptb.org.uk/ .
The GOLD Guide This replaces the Orange guide, and is the definitive guide to all aspects of training in the UK. It can be accessed on http://www.jrcptb.org.uk/SiteCollectionDocuments/Gold%20Guide.pdf . A massive document that I delve into when the need arises, e.g. interdeanery transfers.
Acute Care Assessment Tool The ACAT is a tool that is commendable. It provides a method of assessing how Trainees managed their on-call period. It is recommended that at least one is available for ARCP purposes. It can be downloaded from the JRCPTB website.
Carbohydrate Counting Visit http://www.bdec-e-learning.com/ an essential resource that is free for now. Highly recommended for all caring for patients with Diabetes and something that could be considered mandatory for trainees.
ARCP (RITAs 2008) Will be held on Weds 14th, Thursday 15th and Friday 16th May 2008. The PYAS are planned for Thursday am 15th May 2008. Time tables and instructions have been circulated. Documents needed for the ARCP panel are:
1. Portfolio (If you have developed one)
2. Training Log Book (to include any assessments, e.g. MSF, Mini-CEX)
3. Three copies of an Educational Supervisor Report (appended electronically)
4. Three copies of an Annual Appraisal Record (appended electronically)
5. Structured CV (format appended electronically)
6. 4 mandatory Mini-CEXs (unless you have already had your PYA when they are optional)
7. A mandatory up to date MSF report (not seen in your last RITA), unless you have already had your PYA
8. Evidence in your folder/portfolio demonstrating competence in at least 6 Core Diabetes & Endocrinology Topics (not seen at your last RITA). If you are having a PYA you should have evidence of competence in your folder for at least 90% of the core topics
Recruitment & Selection for Diabetes & Endocrinology 2008
ROUND ONE-25th and 27th Feb 2008
Local selection of ST2s to try and fill 3 of our NTNs. Any that are not filled will go through to round 2. Those NTNs that are filled will be started ASAP to plug current gaps in the rotation ASAP. Shaz Wahid will be on the selection panel.
ROUND TWO-date to be confirmed
Will be led NATIONALLY by the Severn Deanery. We have 1 NTN in this round for definite with the option to carry NTNs through from round one. The fact that we have at least one of our NTNs accepted for this round is very good news for the LATs in the region and gives them a fighting chance. Shaz Wahid has been put forward by Nancy Redfern to help in the process if the Lead Dean wishes for external help.
ROUND THREE-Friday 13th June 2008
A local mopping up round to fill any LAT or NTN vacancies. NTN vacancies may arise because the ST2s who had accepted a post in round one may then have been successful in round 2, hence relinquishing their original offer which is acceptable under the current rules.
A School of Medicine The Northern Deanery has adopted a School of Medicine to oversee training in all medical specialties as well as core training in Medicine. Our STC will feed into the School of Medicine Board and the Head of School is Harriet Mitchison. From now on all Training Programme Directors will be interviewed by the Head of School.
Training Committee Chair- Jola Weaver,; Regional Speciality Advisor- Richard Quinton,; Programme Director- Shaz Wahid,; Consultant member-Jean McLeod,; Consultant member (Research Advisor)-Simon Pearce,; Consultant member-Simon Eaton, Consultant member-Nicky Leech ; SpR representative- Arutchelvan Vijayaraman ; SpR representative- Jeevan Mettayil
NEWS FROM THE NORTHEAST
· Beas Bhattacharya, Shafie Kamarrudin and Ravi Erukulapati have joined the ENDODIABOLOGY Editorial team.
· Shafie Kamaruddin has joined the NEDs CME committee.
· Congratulations to Latika Sibal & Prof Home AND John Parr & Team on having abstracts accepted for oral presentation at this years DUK APC.
· Ravi Erukalapati, Eelin Lim and Arut will be attending the ADA through the SPARROWS programme this year.
· Newcastle Diabetes Centre has entered into collaboration with Shanghai- the Newcastle Diabetes Centre Shanghai collaboration. Gillian Hawthorne visited Shanghai in November to see their diabetes service and to speak at a conference; she was accompanied by Deirdre Kyne the clinical nurse lead. The venture is supported by One NorthEast.
· Congratulations to Simon Ashwell on his engagement to Amelia Lake who is an Academic Nutritionist.
· Congratulations to Richard Quinton & Family on the birth of James Philip Richard Quinton born 13 Dec 2007.
· Congratulations to Jeevan Mettayil on his oral presentation for the Caledonian Society for Endocrinology in Nov 07. Also, Jeevan has joined the STC as the trainee rep in place of Andrew Advani.
· Congratulations to Akheel Syed on passing his PhD viva.
· Congratulations to Ibrahim on appointment to the Consultant post at University Hospital at North Durham.
LETTERS
The Addison's Disease Self-Help Group- Simon Pearce
Simon Pearce is a member of the advisory panel & visit http://www.addisons.org.uk/ for a useful set of patient/education materials on management of the Addison's patient. The core publications have been authored by a panel of the UK's leading adrenal specialists and cover:
1. Surgery and dentistry, glucocorticoid requirements
2. Emergency treatment of hypoadrenalism
3. The role of the GP
4. Information for newly-diagnosed Addison's patients
They can be download these from the website or they can send print copies, eg to a training event, if you can let them know how many and where.
Diabetes Year of Care Project-Northumbria Team
The Year of Care Project is a national pilot project across 3 sites funded and supported by the National Diabetes Support Team in partnership with Diabetes UK, the Department of Health and the Health Foundation. NHS North of Tyne, Northumbria Healthcare, North Tyneside PCT and Northumberland Care Trust have been selected as one of these sites.
The purpose of the project is essentially twofold. Firstly it will look at the opportunities and challenges of introducing a Care Planning approach across a diabetes network, based to a great extent on work that has been done in primary care in Northumberland and North Tyneside and in specialist clinics in North Tyneside. It also, and importantly, also looks at ways in which this can be linked to how services are commissioned across the network.
As a result Year of Care describes all the planned care, personal and network wide, that a person with diabetes should expect to receive, usually over the course of a year. Within the Care Planning process, patients will have a greater say in what planned services they would find helpful and this will be agreed within the Care Planning process. This will form the basis of a ‘menu’ of choices that patients can access that can develop with time as new opportunities and options arise. This menu will also inform the development of commissioning structures that support and guide the development of diabetes services, using the views and preferences of patients to provide services that best suit the needs of the local population. This means that for the first time, patient choices can directly influence not only their personal care, but the services that are available to them.
Each pilot site has been chosen to represent different types of community and bring different skills to the project. Our partners in Tower Hamlets and Kirklees & Calderdale will help us to see how these approaches can be used in densely populated populations with high proportions of ethnic minority groups and where English is frequently either not a first language or may not be spoken at all. So far the local contribution has focussed in large part on the development of consultation skills and care processes needed for Care Planning and the training for this in primary care is already under way. Alongside this a Care Planning Guide for Clinicians has been developed and will shortly be available via the NDST website. There are a number of other strands to the pilot including patient involvement, information and evaluation, commissioning and detailed examination of the challenges for clinicians and patients in moving to this new approach to care.
This project will be challenging and may change the way we all go about delivering diabetes care. It has already excited a good deal of national interest. For further enquiries contact our Project Officer, Rachel Turnbull, by e-mail or phone
Timing of Thyroxine ingestion, do we need to change our practices? Beas Bhattacharya
Hypothyroidism remains one of the commonest endocrine pathologies. Its physiology and replacement relatively simple compared to other endocrinopathies. Thyroxine replacement is taken to be straight forward and it remains one of the most prescribed medications. Patients are usually advised to take their thyroxine in the morning, half an hour before breakfast time. Other significant pointers brought into attention are its enteral absorption, particularly small bowel and interference by cholestyramine, resin, sucralphate, iron, food and herbal remedies. Fibre rich diet has been shown to have effect in absorption.
A recent article in Clinical Endocrinology draws our attention to the basic question of timing of Thyroxine replacement and bioavailability and as a consequence brings out some rather fascinating points regarding thyroid biochemistry. This original article, Effects of evening: morning thyroxine ingestion on serum Thyroid hormone profiles in hypothyroid patients (Clinical Endocrinology,66,43-48), is small study done with 12 patients studied on two occasions, once on stable thyroxine dose in the morning and two months after switching to night time with the same dose. It was noted that serum TSH levels decreased and T3 increased significantly after changing timings to bedtime. In the discussion it is mentioned that thyroid hormone profiles improve on changing the timings and practical benefits for patients are cited: it is well known breakfast may interfere with intestinal absorption of thyroxine even if eaten half an hour later and with bedtime ingestion this problem will not occur; night time bowel motility is slower and prolonged exposure of thyroxine to the intestinal mucosa may mean better uptake.
Physiological factors can also play a part in why bed time dosing effects thyroid hormone profiles: the deiodinases vary according to thyroid status and also maintain a circadian rhythm; inactivating pathways of T4 metabolism, such as glucuronidation and sulphation may vary during the day, and may have some influence in the greater bioavailability at night; bioavailability of TSH has a circadian variation with less bioactive and differently glycosylated TSH molecules secreted during the night.
Though a small study it makes interesting reading and proves rather thought provoking, dealing with what is almost bread and butter part of our speciality. We should reflect on this .
Motivational Interviewing Workshop-Jola Weaver
Clinical Psychology for non psychologists First regional workshop on techniques in Motivational Interviewing (sponsored by Sanofi ) was held in Gateshead. It attracted attendance from GP, SpRs, Nurse Practitioners in Diabetes, Practice Nurses and Hospital Consultants. Techniques for improved communication included rolling with resistance, supporting self efficiency, eliciting change talk, building motivation for change were practiced amongst many others. Further similar workshops are planned for future If interested please contact Jola Weaver
Selecting a Consultant Colleague-Shaz Wahid
This was new to me! It took some thought, but for the short-listing process I used the following scoring framework:
SPECIALIST (CLINIC) INTEREST
5-Excellent-supported with research, publications, audit, courses and service interaction
4-Good-supported with activity during training including courses, audit/publications
3-Standard as part of training
2-Poor
1-None evident
MDT & SERVICE MANAGEMENT EXPERIENCE
5-Excellent-MUST HAVE POTENTIAL TO DEVELOP SERVICE and supported with activity across a district & demonstrable evidence within application of an understanding of DISTRICT CARE or attempts to audit such care
4-Good- MUST HAVE POTENTIAL TO DEVELOP SERVICE and evidence within application of interaction with care across a district
3-Standard as part of training and MUST HAVE POTENTIAL TO DEVELOP SERVICE
2-Poor with no real potential to develop service
1-None evident
TEACHING EXPERIENCE
5-Excellent-formal qualification with regular teaching activities & Evidence of acting as an “educator in diabetes” & evidence of Managing Teaching
4-Good- formal qualification OR courses attended to enhance skills with regular teaching activities
3-Standard as part of training
2-Poor
1-None evident
GOVERNANCE EXPERIENCE
5-Excellent-demonstrable evidence of AUDIT that makes a difference, courses attended including Management course & activity contributing to governance
4-Good-demonstrable evidence of AUDIT that makes a difference, courses attended including Management course
3-Standard as part of training
2-Poor
1-None evident
RESEARCH EXPERIENCE
5-Excellent-formal qualification & peer reviewed publications
4-Good-peer reviewed publications with regional and international meeting presentations
3-Standard as part of training
2-Poor
1-None evident
GENERAL MEDICINE EXPERIENCE
5-Excellent-regular out-patient experience, regular Acute Medicine exposure, ALS or equivalent, have attended national/international courses AND have audits AND publications in relation to acute medicine.
4-Good- regular out-patient experience, regular Acute Medicine exposure, ALS or equivalent, have attended national/international courses OR have audits OR publications in relation to acute medicine.
3-Standard as part of training
2-Poor
1-None evident
COMMITMENT TO THIS POST
5-Excellent-Have visited STDH and discussed the post AND their special interest augments the service needs.
4-Good-Have visited STDH and discussed the post, but special interests are ambiguous
3-Reasonable-have verbally enquired about the job and stated an interest they would wish to develop at STNHSFT
2-Poor- have verbally enquired about the job, but special interests are ambiguous OR already catered for
1-None evident- have made no enquiry about the job
EXTRA-CURRICULAR ACTIVITIES
5-Excellent-have had direct responsibilities for a national AND regional role. Have evidence of effectiveness in this role.
4-Good-have had direct responsibilities for a national OR regional role. Have evidence of effectiveness in this role.
3-Reasonable- have had direct responsibilities for a national OR regional role.
2-Ok- have had indirect responsibilities for a national OR regional role.
1-None evident
Trainees applying for Consultant posts may find this useful.
Newcastle young persons service needs ……….An Enthusiastic, Committed and broad minded SpR in diabetes to add inspirational clinical skills to the team-Nicky Leech
An excellent opportunity has arisen for training in Adolescent Diabetes. Commitment: 4-7.30pm Thursday evenings about once per month for 3-6 months No previous experience of young persons clinics necessary – we train!!!! Feedback on consultation skills by clinical psychologist provided. Experience in working with young persons discussion groups in the clinic provided. As much opportunity to reflect and push the field of adolescent diabetes as you wish. Kathryn Stewart has taken up the 1st block of training and if you are interested in following her contact Dr Nicky Leech tel 01912820114.
RECENT PUBLICATIONS FROM THE NORTHEAST
1. Al-Ozairi E, Michael E, Quinton R. Insulin-resistance causing severe postmenopausal hyperandrogenism. Int. J. Gynaecol Obstet. 2007 Nov 13 [Epub ahead of print]. doi:10.1016/j.ijgo.2007.08.017
2. Syed AA & Quinton R. Congenital radioulnar synostosis, azoospermia, and pseudodicentric Y chromosome. Fertility & Sterility. 2008 Jan 2; [Epub ahead of print]
3. Wellcome Trust Case Control Consortium & The Australo-Anglo-American Spondylitis Consortium. 269 authors including Pearce SH. Association scan of 14,500 nonsynonymous SNPs in four diseases identifies autoimmunity variants. Nat Genet 2007; 39: 1329-1337.
4. Vaidya B, Abraham P, Williams GR, Pearce SHS. National survey of radioiodine use in benign thyroid disease. Clin Endocrinol 2007; (In press) PMID: 17973939
5. David R. Woods The Skeletal Muscle RAS in Health and Disease, chapter 11, Frontiers in Research of the Renin-Angiotensin System on Human Disease.
6. DR Woods, S Allen, TR Betts, D Gardiner, H Montgomery, JM Morgan, PR Roberts. High Altitude Arrhythmias. Cardiology, 2008, in press.
7. James Dunbar, Ben Cooper, Tim Hodgetts, Yskandar Halabi, Pieter van Thiel, Steve Whelan, Justin Taylor, David R Woods. An outbreak of human external ophthalmomyiasis due to Oestrus ovis in Southern Afghanistan. Clinical Infectious Diseases 2008, in press.
RECENT PUBLICATIONS IN DIABETES & ENDOCRINOLOGY THAT HIT THE NEWS OR THAT MAY HAVE A SIGNIFICANT IMPACT ON MANAGEMENT
Haemochromatosis. Paul C Adams, James C Barton. Lancet 2007;370:1855-60. An excellent update for trainers and trainees.
Management of Thyroid Dysfunction during Pregnancy and Postpartum: An Endocrine Society Clinical Practice Guideline. Essential reading that provides a compendium of all the evidence to try and inform clinical practice.
CETP INHIBITION is not dead! It is well worth reading the editorials by Patrick Duriez (Lancet 2007;370:1882-1883) and Daniel Rader (NEJM 2007;357:2180-2183) in relation to the future role of inhibiting CETP and hence raising HDL for cardiovascular risk protection.
Childhood Obesity-The Shape of Things to Come An excellent, thought provoking article by David Ludwig (NEJM 2007;357:2325-2327). Essential reading for trainees, including the accompanying articles in the same edition.
Metformin for the treatment of the polycystic ovary syndrome An enthusiast writes about this emotive topic (John E Nestler NEJM 2008;358:47-54) providing an evidence base well worth reading about.
Clinical Update: bariatric surgery An excellent update by Michael Korenkov & Stefan Sauerland (Lancet 2007;370:1988-1990). It illuminates an obvious service gap in the UK!
Glucocorticoid chronotherapy in rheumatoid arthritis An excellent editorial by Johannes Bijlsma and Johannes Jacobs (Lancet 2208;371:183-184) along with the accompanying paper ( Buttgereit F, et al. Lancet 2008;371:205-214). It has relevance to glucocorticoid replacement therapy and well worth a read.Addition of biphasic, prandial, or basal insulin to oral therapy in type 2 diabetes. Holman RR, Thorne KI, Farmer AJ et al. N Engl J Med. 2007;357:1716-30. This open-label, controlled, multicentre trial randomly assigned 708 patients with a suboptimal HbA1c (7.0 to 10.0%) who were receiving maximally tolerated doses of metformin and sulphonylurea to receive biphasic insulin aspart twice daily, prandial insulin aspart three times daily, or basal insulin detemir once daily (twice if required). At 1 year, mean HbA1c levels were similar in the biphasic group (7.3%) and the prandial group (7.2%) (P=0.08) but higher in the basal group (7.6%, P<0.001 for both comparisons). The respective proportions of patients with an HbA1c level of 6.5% or less were 17.0%, 23.9%, and 8.1%; respective mean numbers of hypoglycaemic events per patient per year were 5.7, 12.0, and 2.3; and respective mean weight gains were 4.7 kg, 5.7 kg, and 1.9 kg. Rates of adverse events were similar among the three groups. The authors conclude that a single analogue-insulin formulation added to metformin and sulphonylurea resulted in an HbA1c level of 6.5% or less in a minority of patients at 1 year. The addition of biphasic or prandial insulin aspart reduced levels more than the addition of basal insulin detemir but was associated with greater risks of hypoglycaemia and weight gain. For me personally, the message that I take from this trial is that it does not matter how you start insulin as long as it is started early instead of the average 5-yr “wait”. It also does not change my standard practice of individualizing as the main priority with the majority use of Novomix 30 twice-daily with metformin, followed by the addition of an extra dose at lunch time or a switch to basal bolus depending upon the individual’s eating practice. I am sure that there will be those of you who disagree! (Shaz)Effect of fenofibrate on the need for laser treatment for diabetic retinopathy (FIELD study): a randomised controlled trial. Keech AC, Mitchell P, Summanen PA et al. Lancet. 2007;370:1687-97. The Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study randomised 9795 patients aged 50-75 years with type 2 diabetes mellitus to receive fenofibrate 200 mg/day (n=4895) or matching placebo (n=4900) followed up for an average of 5-yrs. At each clinic visit, information concerning laser treatment for diabetic retinopathy was gathered. Adjudication by ophthalmologists masked to treatment allocation defined instances of laser treatment for macular oedema, proliferative retinopathy, or other eye conditions. In a substudy of 1012 patients, standardised retinal photography was done and photographs graded with Early Treatment Diabetic Retinopathy Study(TDRS) criteria to determine the cumulative incidence of diabetic retinopathy and its component lesions. Laser treatment was needed more frequently in participants with poorer glycaemic or blood pressure control than in those with good control of these factors, and in those with a greater burden of clinical microvascular disease, but the need for such treatment was not affected by plasma lipid concentrations. The requirement for first laser treatment for all retinopathy was significantly lower in the fenofibrate group than in the placebo group (3.4% patients on fenofibrate vs 4.9% on placebo; hazard ratio [HR] 0.69, 95% CI 0.56-0.84; p=0.0002). In the ophthalmology substudy, the primary endpoint of 2-step progression of retinopathy grade did not differ significantly between the two groups overall (9.6% patients on fenofibrate vs 12.3% on placebo; p=0.19) or in the subset of patients without pre-existing retinopathy (11.4% vs 11.7%; p=0.87). By contrast, in patients with pre-existing retinopathy, significantly fewer patients on fenofibrate had a 2-step progression than did those on placebo (3.1% patients vs 14.6%; p=0.004). An exploratory composite endpoint of 2-step progression of retinopathy grade, macular oedema, or laser treatments was significantly lower in the fenofibrate group than in the placebo group (HR 0.66, 95% CI 0.47-0.94; p=0.022). In conclusion, in this study treatment with fenofibrate in individuals with type 2 diabetes mellitus reduces the need for laser treatment for diabetic retinopathy and the mechanism of this effect does not seem to be related to plasma concentrations of lipids. A very interesting study that needs to be replicated in a group of patients at higher risk for retinopathy or in a study with a much longer follow-up period than 5-yrs. The weaknesses in the study include lack of baseline retinal photography as a routine, heterogeneous criteria between study centres defining the need for laser treatment and the small number of events in the substudy. Further clinical and experimental studies are needed before adding fenofibrate to the armamentarium to treat diabetic retinopathy.Zoledronic acid and clinical fractures and mortality after hip fracture. Lyles KW, Colón-Emeric CS, Magaziner JS et al. N Engl J Med. 2007;357:1799-809. This randomised, double-blind, placebo-controlled trial, assigned 1065 patients to receive yearly intravenous zoledronic acid (at a dose of 5 mg), and 1062 patients to receive placebo. The infusions were first administered within 90 days after surgical repair of a hip fracture. All patients (mean age, 74.5 years) received supplemental vitamin D and calcium. The median follow-up was 1.9 years. The primary end point was a new clinical fracture. The rates of any new clinical fracture were 8.6% in the zoledronic acid group and 13.9% in the placebo group, a 35% risk reduction with zoledronic acid (P=0.001); the respective rates of a new clinical vertebral fracture were 1.7% and 3.8% (P=0.02), and the respective rates of new nonvertebral fractures were 7.6% and 10.7% (P=0.03). In the safety analysis, 101 of 1054 patients in the zoledronic acid group (9.6%) and 141 of 1057 patients in the placebo group (13.3%) died, a reduction of 28% in deaths from any cause in the zoledronic acid group (P=0.01). The most frequent adverse events in patients receiving zoledronic acid were pyrexia, myalgia, and bone and musculoskeletal pain. No cases of osteonecrosis of the jaw were reported, and no adverse effects on the healing of fractures were noted. The rates of renal and cardiovascular adverse events, including atrial fibrillation and stroke, were similar in the two groups. This study suggests that an annual infusion of zoledronic acid within 90 days after repair of a low-trauma hip fracture was associated with a reduction in the rate of new clinical fractures and with improved survival. An interesting study that will produce plenty of hype from the drug company! I think that the important message here is that preventing further fractures by what ever means in patients presenting with a hip fracture is essential to help improve morbidity and mortality in this vulnerable group of patients. I do not find it surprising that preventing refractures in patients with hip fractures improves mortality. The first step would be for all orthogeriatric services to undertake a robust audit of secondary prevention and as evidence gathers in the field the consensus treatment, taking into account cost-effectiveness, can be used.Intensive insulin therapy and pentastarch resuscitation in severe sepsis. Brunkhorst FM, Engel C, N Engl J Med. 2008;358:125-39. In this multicentre, two-by-two factorial trial patients with severe sepsis were randomised to receive either intensive insulin therapy to maintain euglycaemia or conventional insulin therapy and either 10% pentastarch, a low-molecular-weight hydroxyethyl starch (HES 200/0.5), or modified Ringer's lactate for fluid resuscitation. The trial was stopped early for safety reasons. Among 537 patients who could be evaluated, the mean morning blood glucose level was lower in the intensive-therapy group (6.2 mmol/l) than in the conventional-therapy group (8.4 mmol/l], P<0.001). However, at 28 days, there was no significant difference between the two groups in the rate of death or the mean score for organ failure. The rate of severe hypoglycaemia (glucose level, < or = to 2.2 mmol/l) was higher in the intensive-therapy group than in the conventional-therapy group (17.0% vs. 4.1%, P<0.001), as was the rate of serious adverse events (10.9% vs. 5.2%, P=0.01). HES therapy was associated with higher rates of acute renal failure and renal-replacement therapy than was Ringer's lactate. In this trial the use of intensive insulin therapy placed critically ill patients with sepsis at increased risk for serious adverse events related to hypoglycaemia and HES was harmful, and its toxicity increased with accumulating doses. I (Shaz) am an enthusiast for the appropriate management of hyperglycaemia in acute illness. This trial confirms the concerns of increased hypo risk from another large trial of medical patients on ITU. I suppose what we should be looking at is what is the optimum range to maintain blood glucose in ITU patients. It certainly should not be 10-20 mmol/l as suggested by an intensivist I recently chatted to!
NEXT NEWSLETTER Due out beginning of February 2008 so keep the gossip coming.
posted by Arutchelvam at 7:41 AM
