Endodiabology June 2009
ENDODIABOLOGY
NORTHEAST
NEWSLETTER
FOR SPRs AND BOSSES TRAPPED
IN THE NORTHERN DEANERY
JUNE 2009
Editors: Shaz Wahid (shahid.wahid@sthct.nhs.uk) and
Petros Perros (petros.perros@ncl.ac.uk) and Vijayaraman Arutchelvam (riarut@aol.com )
Associate Editors: Shafie Kamarrudin, Ravi Erukulapati
SpR PLACEMENTS (NTN year of training from 1st October 2008)
• RVI- Shafie Kamarrudin (3), Beas Bhattacharya (5), Asgar Madathil (4), Kathryn Stewart (2), Rohanna Wright (1), Chandima Idampitiya (4), Preeti Rao (2) (Kenneth Muir (1) & Ethol Kalathil (1) from Aug 09)
• North Tyneside/Wansbeck- Ravi Erukalapati(4), Sudeep Manohar (2)
• South Tyneside- Sukesh Chandran(5)
• Gateshead- Dr De Alwis (1)
• Sunderland- Jeevan Mettayil (3), Sarah Steven (1)
• North Tees/Hartlepool- Khaled Mansur-Dukhan (5), Stuart Little (1) (Catherine Napier from Aug 09 (1))
• Middlesbrough- Anjali Santhakumar (2), Arif Ullah (2), Yahya Maghoub
• Carlisle- Naveen Siddaramaiha (1)
• Bishop Auckland Srikanth Mada(2)
• Durham- Dr Munir (1) from Aug 09
• NGH/QEH- Freda Razvi (5)
• Research with numbers (supervisor)- Eelin Lim(5-Prof Taylor); Stuart Little (Dr Shaw) & Asgar Madathil (Dr Weaver)-both from Aug 09.
MEETINGS / LECTURES / ANNOUNCEMENTS
• 5th-9th June 2009 American Diabetes Association 69th Annual Scientific Sessions, New Orleans, USA. Contact meetings@diabetes.org .
• 10th-13th June 2009 ENDO 2009, Washington, USA. Contact endostaff@endo-societ.org or www.endo-society.org/scimeetings .
• 24th June 2009 Northern Endocrine & Diabetes Summer CME, Freeman Hospital. Contact mshafie_kamaruddin@yahoo.co.uk
• 26th June 2009 RCPE Symposium: Recent Advances in Medicine, University Hospital of North Tees. Contact sue.dent@nth.nhs.uk
• 1st July 2009 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk
• 9th July 2009 Association of Physicians, 6-9pm, Gateshead. Contact clive.kelly@ghnt.nhs.uk
• 10th September 2009 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk
• 27th September-1st October 2009 45th EASD Annual meeting, Vienna, Austria. Contact www.easd.org
• 1st October 2009 RCPE symposium; Diabetes & Endocrinology: Clinical challenges & expert advice, Edinburgh. Contact c.berwick@rcpe.ac.uk
• 12th October 2009 Northern Endocrine & Diabetes Autumn CME, JCUH, Middlesbrough. Contact mshafie_kamaruddin@yahoo.co.uk
• 2nd-4th November 2009 Society for Endocrinology Clinical Update 2009, Manchester. Contact www.endocrinology.org
• 2nd November 2009 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk
• 3rd November 2009 RCPL Medicine Update, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk
• 19th November 2009 1st Joint Meeting of The British Thyroid Association and British Association Of Endocrine and Thyroid Surgeons, St Thomas Hospital. Contact www.british-thyroid-association.org
• 19th-20th November 2009 ABCD autumn meeting, London. Contact www.diabetologists.org.uk followed by SpRs meeting 21-22nd November 2009.
• 25th November 2009 Northern Endocrine Region Research and Audit Group annual meeting, Lumley Castle, Durham 2pm-8pm. Contact shahid.wahid@sthct.nhs.uk
• 26th & 27th November 2009 Middlesbrough insulin pump course. Contact Rudy.Bilous@stees.nhs.uk
• 4th December 2009 Society for Endocrinology regional cases meeting, Edinburgh. Contact www.endocrinology.org
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.
A new Trainee Rep With Arut now having his CCT an opportunity for a new trainee rep has arisen on the STC. If you are interested please contact nicola.leech@nuth.northy.nhs.uk
Trainers & Trainees meeting (provisional date, will be confirmed) This will occur on Tuesday 23rd June 2009, 1600 at University Hospital of North Tees, Postgrad Centre. It will be followed by the SPARROWS feedback meeting from 1730. Contact nicola.leech@nuth.northy.nhs.uk
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 www.jrcptb.org.uk. 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. The e-portfolio for DM&ENDO is available now for StRs.
Assessment tools Please see 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.
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.
Case Based Discussions (CbD) The pilot form is available from the JRCPTB website. It is a must for trainers to use as a tool to document feedback in clinic. This has always been done informally, but now there is a method to formally document it. It can be used for when a SpR presents a new case in clinic.
Documenting CCU and ITU experience It is essential that trainees document their CCU and ITU experience. This is best done by keeping a summary log of the cases seen on CCU and ITU and linking it with reflection or assessment. This should then be signed off by your Educational Supervisor to be of any use at the Acute Medicine PYAs.
Audit Assessment tool This is now available in draft form on the JRCPTB website. Its use is highly recommended.
Management experience It is essential to have demonstrable evidence of management experience during your training, attending a course is not good enough. Undertaking a significant project for a Trust that leads to service change as a result of your management skills is probably the easiest method to demonstrate management activity. However, see Arut’s excellent letter below for more information and tips!
Training Committee Chair- Vacant; Regional Speciality Advisor- Shaz Wahid, shahid.wahid@sthct.nhs.uk; Programme Director- Nicky Leech nicola.leech@nuth.northy.nhs.uk; Consultant member (SAC rep)- Richard Quinton, Richard.Quinton@nuth.nhs.uk; Consultant member-Jean MacLeod, Jean.Macleod@nth.nhs.uk; Consultant member (Research Advisor)-Simon Pearce, s.h.s.pearce@ncl.ac.uk; Consultant member-Simon Eaton, simon.eaton@northumbria-healthcare.nhs.uk; SpR representative- Vacant; SpR representative- Jeevan Mettayil jmjeevan@yahoo.com
NEWS FROM THE NORTHEAST
• Congratulations to Sukesh Chandran on appointment to a Consultant post in Bishop Auckland from 1st October 2009. He will be an Acute Physician with an interest in Diabetes&Endo.
• Some of you may remember Liz McIntyre as a SpR. She is now a proud mother with a baby daughter.
• Philip Home has been invited by the ADA to lead his international team in presentation of the RECORD study (rosiglitazone) results at the ADAs Annual Meeting in New Orleans in June.
• Philip Home is to head up the A1chieve Study of 60000 people on five continents starting insulin.
• Richard Quinton to take over from Alan Patrick as SAC rep on the Diabetes/Endo Section of UEMS (European Union of Medical Specialists).
• 47 candidates have stumped up for the MRCP (Diabetes & Endocrinology) exam this year, half of them from the UK. Best of luck to our boys & girls.
• Jola Weaver has finished her term as STC Chair. Our thanks go to her for her hard work.
• Our thanks go to Arut for serving the needs of trainess as the SpR rep on the STC. He has handed the reins for the NEDS CME over to Rohanna Wright and Shafie Kamarrudin.
• Congratulations to Stuart Little (research with Dr Shaw) and Asgar Madathil (research with Dr Weaver) on their OOPEs to start ASAP.
LETTERS
A plug from Simon Pearce-There is a must-have book available now!! including chapters from yours truly on immunogenetics, Petros and Jane Dickinson on TAO, and Kate Owen and Tim Cheetham on polyendocrinopathy syndromes as well as a further 9 excellent chapters by international experts in the field..... Including: Evidence-based management of Graves' disease (Hegedus); Modern approaches to replacement in Addison's disease (Arlt); Immunomodulatory treatment of T1D (Herold), and lots more........ Its a snip at £49.00!! Pearce SHS, Ed. Autoimmune Endocrine Disorders: Endocrinology and Metabolism Clinics of North America 2009; 38 (2).
Research Update on the RADS (Rescue of Addison's Disease) study-Simon Peace. We have recruited 2 patients (of 5 referred), and both have tolerated rituximab well. It's too early to tell if its working yet, but there certainly isn't deterioration in the patient who has been retested. We are still keen to meet anyone with newly diagnosed Addison's disease within 4 weeks of diagnosis, to talk through the ins and outs of the study with them (just email me: s.h.s.pearce@ncl.ac.uk and we'll see the person within 5 days). The study will be recruiting for another 18 months, so more updates will be coming. Many thanks to those who have been pro-active in referring patients in so far.
New trial for medullary thyroid cancer-Petros Perros. Newcastle will soon be recruiting patients for a phase 3 randomized, placebo-controlled, double-blinded study of XL184 as single-agent oral therapy in patients with unresectable, locally advanced, or metastatic medullary thyroid cancer (MTC). The primary endpoint will be duration of progression-free survival. XL184 is a small molecule anticancer compound targeting the MET, RET, and VEGFR2 receptor tyrosine kinases. XL184 has exhibited dose-dependent tumour growth inhibition and tumour regression in a variety of tumour models, including breast cancer, colon cancer, MTC, non-small cell lung cancer, and glioblastoma. Main inclusion criteria are histologically confirmed MTC, and documented progressive disease on imaging within last 14 months. For further information or if you wish to discuss or refer potential participants please contact Dr P Perros 0191 2820590, or e-mail petros.perros@nuth.nhs.uk
Atul Gawande: a worthy read-Shaz Wahid (book review)
You have heard me bang on about the 7-habits (you wait till I start on the 8th habit), but these 2 books written by an Endocrine Surgeon in Boston USA (considered a GOD in the states) are a must read: Complications: a surgeon’s notes on an imperfect science; Better: a surgeon’s notes on performance. Both books cover a huge amount of ground in relation to hand hygiene, why we get sued, the difficult cases-sweating, obesity, why the computer is better than the world’s best Cardiologist at interpreting ECG (oh yes they are-as long as it is a perfect trace),systems management, chronic pain and much, much more. My favourite quote (that I have adjusted) is: “We (individuals or organisations) go into this work (medicine) thinking it is all a matter of canny diagnosis, technical prowess, slick technology, being the best, being the first AND some ability to empathise with people, but it is not.
We must grapple with systems, resources, circumstances, people-and our own shortcomings, as well. We face many variety of obstacles. But, somehow we must
– Advance
– Refine
– Improve
– PUT SIMPLY WE MUST STRIVE TO BE BETTER”
Management opportunities for SpRs within our regional specialty training programme-Vijayaraman Arutchelvam
Prof John Took in his report mentioned ‘The doctor's frequent role as head of the healthcare team and commander of considerable clinical resource requires that greater attention is paid to management and leadership skills regardless of specialism. An acknowledgement of the leadership role of medicine is increasingly evident. Role acknowledgement and aspiration to enhanced roles be they in subspecialty practice, management and leadership, education or research are likely to facilitate greater clinical engagement" (Tooke report 2008: Aspiring to Excellence)
We all are aware of the importance of developing management and leadership skills during our specialty training. The high standards and quality of training in the field of diabetes and endocrinology across our region is well recognised in the country. Equally importantly the opportunities we are provided with developing our leadership and managerial skills in our region are outstanding. This was pointed out to me by many SpR colleagues from other regions in recent times.
We have plenty of opportunities for formal training, and chances to put this training into practical experience and convert this experience into achievements. I herewith outline a few.
Formal training
We have a deanery approved 6 day course run by Mr Belton ( a former chief executive of a hospital ) at Durham thrice a year. This course comprehensively teaches you about all aspects of leadership and management with lots of practical group exercises. For example, groups are put in a task of real time negotiation to pick a charity to which all members will donate a negotiated amount of money. There were around 25 SpRs negotiating their heart out. In another exercise, you are expected to present a business case proposal to a team of managers, who choose 1 proposal which wins a prize( I felt proud to win that prize when I attended the course last year which boosted my confidence significantly). With help and support from our training programme director and regional specialty advisor, Shafie organised an accredited independent leadership course in April this year. 12 SpRs from our specialty attended this 3 day course and found it very useful.
The Northern deanery organises many management courses including courses on appraisal, good practice in educational supervision, feedback: heart of learning, Careers’ guidance for educational supervisors, recruitment and selection, developing effective educational plans and many more. You can book onto these courses online via the deanery website (http://mypimd.ncl.ac.uk/training).
I have attended many of these 1 day courses which had a direct impact on my performance. Organising ourselves onto these courses will need advanced planning and wise use of study leave during the whole training period. By itself it will demonstrate our management skills.
Opportunities to gain management experience
Specialty Training Committee : trainee representative
• 2 SpRs are elected by the STC to work within the STC for a minimum period of 2 years.
• Our STC encourages the trainee representative to be an active member and entrust them with responsibilities.
• Get to attend all the STC meetings, actively participate in the development of training modules, to collaborate with the Deanery in the local administration and delivery of specialist training (i.e. SpR/StR Programmes, recruitment and selection) within the regulations and guidelines of the College, to understand the rigorous ARCP process and understand the changes in training programmes at national level ( for example the chaos caused by MTAS).
• Communicating with SpR colleagues and represent their issues to the TPD and STC.
• More opportunities like representing in GIM STC meetings.
• Given a chance to get involved in developing the Medical education quality assessment report for the specialty and to attend this meeting with the post-graduate dean and other officials from the deanery.
• Given senior responsibilities like leading the JRCPTB pilot study.
• Encouraged to take positions at national level.
Interviewing skills:
• If you have done the courses on recruitment and selection AND equality and diversity you are given chances to get involved with the recruitment process for both specialty interviews and CMT interviews. I personally had the opportunity to sit in 3 specialty interview sessions and 4 CMT sessions.
CME organising committee:
• This is an unique feature of our region. SpRs are given total freedom in organising these tri-annual meetings across the region.
• The lead SpR will generate around £4000 annually by donations, maintain a cost centre account in the university and wisely manage it to cover the expenses.
• External and internal speakers are invited.
• Maintain excellent communication and conduct the meetings successfully covering the curriculum over a 3 year period.
• Register with the Royal college CPD programme and get approval for 5 CPD points.
• This is an excellent opportunity to improve our organisational skills, financial management, time management and networking skills.
• There will be challenging times and this will bring the best out of you ( to recollect an event, an external speaker cancelled with 6 days to go for the CME due to family reasons, we came out with an idea of a SpR presentation competition, arranged in that short period. This turned out to be an instant hit and now it has become an annual event).
Endodiabology:
• This is another unique opportunity in our region.
• You could start as an associate editor and you have the chance of becoming the senior editor.
• An excellent website remains functional. Being a web editor sharpens your IT skills as well.
PACES organising registrar:
• I got this opportunity when I was in James Cook University Hospital. Keep a watch as it is happening across the region as you are reading this.
Day with the Chief executive/ medical director
• Arrange to spend a day with the chief executive or medical director of the trust, attend meetings and learn practical management skills
All we need is initiative and enthusiasm to grasp these excellent opportunities provided by our region. All these experiences lead to satisfying achievements. To illustrate, with the CME when we received an average score of 4.4/ 5 on overall performances and demonstrated consistent improvement in attendance or when you register the increase in the endodiabology blog spot hit rate, trust me, it will all be very satisfying and rewarding. I have just outlined a few opportunities and there are plenty more available to fulfil our training needs and go beyond.
The Medical Leadership Competency Framework has been jointly developed by The Academy of Medical Royal Colleges and the NHS Institute for Innovation and Improvement, in conjunction with a wide range of stakeholders. This framework is built on the concept of shared leadership where leadership is not restricted to those who hold designated leadership roles, and where there is a shared sense of responsibility for the success of the organisation and its services. Acts of leadership can come from any individual in the organisation, as appropriate, at different times. Our region provide an opportunity to work with and improve on all these domains (figure 1). I suggest that we read more on these domains and each of its elements in the website http://www.institute.nhs.uk/assessment_tool/general/medical_leadership_competency_framework_-_homepage.html and continue to work on developing the relevant skills using the excellent opportunities available in the region..
Figure 1 The Medical Leadership Competency Framework
RECENT PUBLICATIONS FROM THE NORTHEAST
1. Randomised Controlled Trial to Assess the Impact of Continuous Glucose Monitoring on HbA1c in Insulin-Treated Diabetes (MITRE Study) D. Cooke, S.J. Hurel, A. Casbard, L. Steed, S. Walker, S. Meredith, A.J. Nunn, A.
Manca, M. Sculpher, M. Barnard, D. Kerr, J.U. Weaver, J. Ahlquist, S.P.
Newman Accepted Article Online: Diabetic Medicine Apr 4 2009.
2. Roycroft M, Fichna M, McDonald D, Owen K, Zurawek M, Gryczyńska M, Januszkiewicz-Lewandowska D, Fichna P, Cordell H, Donaldson P, Nowak J, Pearce S. The tryptophan 620 allele of the lymphoid tyrosine phosphatase (PTPN22 gene) predisposes to autoimmune Addison's disease. Clin Endocrinol (Oxf) 2009; 70: 358-362.
3. Owen CJ, Habeb A, Pearce SH, Wright M, Ichikawa S, Sorenson AH, Econs MJ, Cheetham TD. Discordance for X-linked hypophosphataemic rickets in identical twin girls. Horm Res. 2009;71:237-44.
4. Pearce SHS, Ed. Autoimmune Endocrine Disorders: Endocrinology and Metabolism Clinics of North America 2009; 38 (2).
5. Allahabadia A, Razvi S, Abraham P, Franklyn J. Diagnosis and treatment of primary hypothyroidism. BMJ. 2009 Mar 26;338:b725.
6. Magee G, Bilous RW, Cardwell CR,Hunter CJ,Kee F,Fogarty DG. Is hyperfiltration associated with the future risk of developing diabetic nephropathy? Diabetologia 2009 ; 52 ; 691 – 7.
7. Candesartan and Prevention of Microalbuminuria in Diabetes Effect of Candesartan on Microalbuminuria and Albumin Excretion Rate in Diabetes Three Randomized Trials (DIRECT – Renal) Rudy Bilous, MD; Nish Chaturvedi, MD; Anne Katrin Sjølie, MD; John Fuller, MD; Ronald Klein, MD; Trevor Orchard, MD; Massimo Porta, MD; and Hans-Henrik Parving, MD. Annals Internal Medicine 2009 ( in press).
8. Hill S, Arutchelvan V, Quinton R. 2009 Enclomiphene, an estrogen receptor antagonist for the treatment of testosterone deficiency in men. drugs. 12: 109-119.
9. Nicol M, Papacleovoulou G, Evans DB, Penning TM, Strachan MW, Advani A, Johnson SJ, Quinton R, Mason JI. 2009 Estrogen biosynthesis in human adrenocortical carcinoma cells. Molecular & Cellular Endocrinology. 300: 115-120.
RECENT PUBLICATIONS IN DIABETES & ENDOCRINOLOGY THAT HIT THE NEWS OR THAT MAY HAVE A SIGNIFICANT IMPACT ON MANAGEMENT
Defining polycystic ovary syndrome. Balen A, et al. BMJ 2009;338:426. Well worth a read and I would recommend that trainees bring it up on their PIU round to invoke debate/fisticuffs, rather like asking what is a normal short synacthen test.
Fatal thyrotoxic cardiomyopathy in a young man. Soh MC & Croxon M. BMJ 2009;338:476477. An excellent case report that you can hang thyrotoxic storm on, however I do manage it differently than discussed in the article.
HDL cholesterol and cardiovascular risk. Ghali WA & Rodondi N. BMJ 2009;338:488-489. I remember having to interpret a vignette from a paper discussing cholesterol transport and how raising HDL cholesterol may be beneficial in monkeys for my A-level biology exam. It is interesting to see how we have come full circle and the paradigm of raising HDL-c resulting in reduced cardiovascular disease has not come to fruition as eloquently discussed in this editorial.
Graves’ Ophthalmopathy. Bartalena L & Tanda ML. NEJM 2009;360:994-1001. A must read for trainees and those wishing a clinical practice update.
Dopamine agonists and hyperprolactinaemia. Martin N, et al. BMJ 2009;338:554-555. An excellent editorial with advice that I think is prudent: undertake an echo before starting cabergoline and then determine further echos depending on the cumulative dose. Worth a read.
Systemic management of diabetic retinopathy. Liew G, et al. BMJ 2009;338:612-613. An editorial discussing the ADVANCE, DIRECT and FIELD trials. Worth a read.
Thyroid eye disease. Perros P, Neoh C, Dickinson J. BMJ 2009;338:645-650. A practical update from a team of local Gurus in the field.
Investigating the thyroid nodule. Mehanna HM, et al. BMJ 2009;338:705-709 AND Rational Imaging: Incidental thyroid nodule. Patel CN, et al. BMJ 2009;338:713-715. Well worth a read of both articles that did lead to some controversy. I still say put 20 Endocrinologists in the same room……………………………………………………………………………………
An unusual cause of ventricular fibrillation. Gerritsen et al. Lancet 2009;373:1144. An excellent case report that gets you into topping up on the different causes of hypokalaemia and hyperkalaemia due to channelopathies.
Management of hirsutism. Koulouri O, Conway GS. BMJ 2009;338:823-826. AND Investigating hirsutism. Sathyapalan T, Atkin SL. BMJ 2009;338:1070-1072. 2 excellent practical articles well worth a read.
Late onset hypogonadism. Hugh Jones T. BMJ 2009;338:785-786. An editorial worthy of a read to guide further investigation of the literature.
The HRT controversy: observation studies and RCT fall in line. Vandenbroucke JP. Lancet 2009;373:1233-1235. An excellent editorial summarising the recent evidence on HRT and providing a wealth of references to aid further understanding.
Where are my testes? Kumar S, et al. Lancet 2009;373:1310. I write about this case report with a “smile”. It brings factor V leiden into the world of primary hypogonadism.
Practising safely in the foundation years. Long et al. BMJ 2009;338:887-890. A wonderful article that can be used as a teaching tool.
Prevention of Diabetic retinopathy. Anna Einarsdottir, Einar Stefansson. Lancet 2009;373:1316-1317. A review of the accompanying CALDIRET study with lessons to note.
Tight control of blood glucose in long standing type 2 diabetes. Richard Lehman. Lancet 2009;338:901-902. The view of QuOF on the reduction of target HbA1c from 7.5 to 7 %. I was expecting the howls of derision…………
Diagnosis and treatment of primary hypothyroidism. Amit Allahabadia, et al. BMJ 2009;338:1090-1091. The BTAs attempt to bring some semblance of control to the therapy of hypothyroidism.
Voglibose for prevention of type 2 diabetes mellitus. Andre J Scheen. Lancet 2009;373:1579-1580. An editorial that not only discusses the accompanying trial but also the issue of preventing diabetes using pharmacotherapy.
Genetics of Type 1A Diabetes. Patrick Concannon and Gerald Nepom. NEJM 2009;360:1646-1654. An excellent update on this important and ever expanding topic.
The Lancet 23-29th May 2009 volume 373 edition. A must read edition of the Lancet that is devoted to diabetes. 3 important trials on glitazones & hear disease, gestational diabetes and the Fenofibrate FIELD study are presented.
Zoledronic acid and risedronate in the prevention and treatment of glucocorticoid-induced osteoporosis (HORIZON): a multicentre, double-blind, double-dummy, randomised controlled trial. Reid DM,et al. Lancet. 2009 Apr 11;373(9671):1253-63. This 1-year randomised, double-blind, double-dummy, non-inferiority study of 54 centres around the world tested the effectiveness of 5 mg intravenous zoledronic acid versus 5 mg oral risedronate for prevention and treatment of glucocorticoid-induced osteoporosis. 833 patients were randomised 1:1 to receive zoledronic acid (n=416) or risedronate (n=417). Patients were stratified by sex, and allocated to prevention or treatment subgroups dependent on duration of glucocorticoid use immediately preceding the study. The treatment subgroup consisted of those treated for more than 3 months (272 patients on zoledronic acid and 273 on risedronate), and the prevention subgroup of those treated for less than 3 months (144 patients on each drug). The primary endpoint was percentage change from baseline in lumbar spine bone mineral density. Zoledronic acid was non-inferior and superior to risedronate for increase of lumbar spine bone mineral density in both the treatment ( mean difference 1.36% [95% CI 0.67-2.05], p=0.0001) and prevention (1.96% [1.04-2.88], p<0.0001) subgroups at 12 months. Adverse events were more frequent in patients given zoledronic acid than in those on risedronate, mainly because of transient symptoms during the first 3 days after infusion. Serious adverse events were worsening rheumatoid arthritis for the treatment subgroup and pyrexia for the prevention subgroup. This study has shown that a single 5 mg intravenous infusion of zoledronic acid is non-inferior, possibly more effective, and more patient friendly than is 5 mg of daily oral risedronate for the prevention and treatment of bone loss associated with glucocorticoid use. It is well worth reading the accompanying editorial by Luigi Gennari & John Belzezikian (Lancet 2009;373:1225-1226). Despite the clear evidence base for using annual zoledronic infusion in managing osteoporoses, I struggle to convince my Medical Director when I have asked for its use in certain individual circumstances. Because of cost I am pointed towards 6-monthly IV pamidronate.
Intensive versus conventional glucose control in critically ill patients. NICE-SUGAR Study Investigators. N Engl J Med. 2009 Mar 26;360(13):1283-97. In this trial 6104 adults within 24 hours after admission to an intensive care unit (ICU), who were expected to require treatment in the ICU on 3 or more consecutive days were randomly assigned to undergo either intensive glucose control (3054 patients), with a target blood glucose range of 4.5 to 6.0 mmol/l, or conventional glucose control (3050 patients), with a target of 10.0 mmol/l. The primary end point was death from any cause within 90 days after randomization. The two groups had similar characteristics at baseline. A total of 829 patients (27.5%) in the intensive-control group and 751 (24.9%) in the conventional-control group died (odds ratio for intensive control, 1.14 95%CI[1.02-1.28]; P=0.02). The treatment effect did not differ significantly between surgical and medical patients (odds ratio for death in the intensive-control group, 1.31 and 1.07, respectively; P=0.10). Severe hypoglycaemia (blood glucose level, < 2.3 mmol/l) was reported in 206 of 3016 patients(6.8%) in the intensive-control group and 15 of 3014 (0.5%) in the conventional-control group (P<0.001). There was no significant difference between the two treatment groups in the median number of days in the ICU (P=0.84) or hospital (P=0.86) or the median number of days of mechanical ventilation (P=0.56) or renal-replacement therapy (P=0.39). This trial found that intensive glucose control increased mortality among adults in the ICU: a blood glucose target of 10mmol/l or less had lower mortality than did a target of 4.5-6.0 mmol/l. A very important trial that I think outlines the important target of maintaining a blood glucose of 6-10 mmol/l in patients on an ICU. The accompanying editorial by Sylvio Inzucchi and Mark Siegel (NEJM 2009;360:1346-1349) is well worth a read. It is important that Intensivists do not go down the same route as many Cardiologists (following DIGAMI 2 and others) and abandon controlling hyperglycaemia, luckily “my crowd” still do mostly listen.
Catheter-based renal sympathetic denervation for resistant hypertension: a multicentre safety and proof-of-principle cohort study. Krum H, et al. Lancet. 2009 Apr 11;373(9671):1275-81. This proof-of-principle trial of therapeutic renal sympathetic denervation in 45-patients with resistant hypertension (ie, systolic blood pressure 159 mmHg on three or more antihypertensive medications, including a diuretic) assessed the latter procedures safety and blood-pressure reduction effectiveness. Patients received percutaneous radiofrequency catheter-based treatment between June, 2007 and November 2008, with follow-up to 1 year. The effectiveness of renal sympathetic denervation was assessed by measuring renal noradrenaline spillover in a subgroup of patients. Primary endpoints were office blood pressure and safety data before and at 1, 3, 6, 9, and 12 months after the procedure. Renal angiography was done before, immediately after, and 14-30 days after procedure, and magnetic resonance angiogram 6 months after procedure. In treated patients, baseline mean(SD) office blood pressure was 177/101(20/15) mmHg; mean 4.7 antihypertensive medications; mean(SD) eGFR was 81(23)ml/min; and mean reduction in renal noradrenaline spillover was 4795%CI 28-65)%. Office blood pressures after procedure were reduced by -14/-10, -21/-10, -22/-11, -24/-11, and -27/-17 mmHg at 1, 3, 6, 9, and 12 months, respectively. One intraprocedural renal artery dissection occurred before radiofrequency energy delivery, without further sequelae. There were no other renovascular complications. This preliminary trial has shown that catheter-based renal denervation causes substantial and sustained blood pressure reduction, without serious adverse events, in patients with resistant hypertension. However, prospective randomised clinical trials are needed. The accompanying editorial by Michael Doumas and Stella Douma is excellent (Lancet 2009;373:1228-1229).
Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. Sacks FM, et al. N Engl J Med. 2009 Feb 26;360(9):859-73. The authors randomly assigned 811 overweight adults to one of four diets where the targeted percentages of energy derived from fat, protein and carbohydrates in the four diets were 20, 15, and 65%; 20, 25, and 55%; 40, 15, and 45%; 40, 25, and 35%; and followed them up for 12-months. The diets consisted of similar foods and met guidelines for cardiovascular health. The participants were offered group and individual instructional sessions for 2 years. The primary outcome was the change in body weight after 2 years in two-by-two factorial comparisons of low fat versus high fat and average protein versus high protein and in the comparison of highest and lowest carbohydrate content. After 6-months participants assigned to each diet had lost an average of 6 kg, accounting for 7% of their initial weight; they began to regain weight after 12 months. By 2 years, weight loss remained similar in those who were assigned to a diet with 15% protein and those assigned to a diet with 25% protein (3.0 and 3.6 kg, respectively); in those assigned to a diet with 20% fat and those assigned to a diet with 40% fat (3.3 kg for both groups); and in those assigned to a diet with 65% carbohydrates and those assigned to a diet with 35% carbohydrates (2.9 and 3.4 kg, respectively) (P>0.20 for all comparisons). Among the 80% of participants who completed the trial, the average weight loss was 4 kg; 14 to 15% of the participants had a reduction of at least 10% of their initial body weight. Satiety, hunger, satisfaction with the diet, and attendance at group sessions were similar for all diets; attendance was strongly associated with weight loss (0.2 kg per session attended). The diets improved lipid-related risk factors and fasting insulin levels. The message from this study is to encourage calorie restriction to manage weight as weight loss occurred in this study regardless of which macronutrients they emphasised.
NEXT NEWSLETTER Due out beginning of October 2009 so keep the gossip coming.
NORTHEAST
NEWSLETTER
FOR SPRs AND BOSSES TRAPPED
IN THE NORTHERN DEANERY
JUNE 2009
Editors: Shaz Wahid (shahid.wahid@sthct.nhs.uk) and
Petros Perros (petros.perros@ncl.ac.uk) and Vijayaraman Arutchelvam (riarut@aol.com )
Associate Editors: Shafie Kamarrudin, Ravi Erukulapati
SpR PLACEMENTS (NTN year of training from 1st October 2008)
• RVI- Shafie Kamarrudin (3), Beas Bhattacharya (5), Asgar Madathil (4), Kathryn Stewart (2), Rohanna Wright (1), Chandima Idampitiya (4), Preeti Rao (2) (Kenneth Muir (1) & Ethol Kalathil (1) from Aug 09)
• North Tyneside/Wansbeck- Ravi Erukalapati(4), Sudeep Manohar (2)
• South Tyneside- Sukesh Chandran(5)
• Gateshead- Dr De Alwis (1)
• Sunderland- Jeevan Mettayil (3), Sarah Steven (1)
• North Tees/Hartlepool- Khaled Mansur-Dukhan (5), Stuart Little (1) (Catherine Napier from Aug 09 (1))
• Middlesbrough- Anjali Santhakumar (2), Arif Ullah (2), Yahya Maghoub
• Carlisle- Naveen Siddaramaiha (1)
• Bishop Auckland Srikanth Mada(2)
• Durham- Dr Munir (1) from Aug 09
• NGH/QEH- Freda Razvi (5)
• Research with numbers (supervisor)- Eelin Lim(5-Prof Taylor); Stuart Little (Dr Shaw) & Asgar Madathil (Dr Weaver)-both from Aug 09.
MEETINGS / LECTURES / ANNOUNCEMENTS
• 5th-9th June 2009 American Diabetes Association 69th Annual Scientific Sessions, New Orleans, USA. Contact meetings@diabetes.org .
• 10th-13th June 2009 ENDO 2009, Washington, USA. Contact endostaff@endo-societ.org or www.endo-society.org/scimeetings .
• 24th June 2009 Northern Endocrine & Diabetes Summer CME, Freeman Hospital. Contact mshafie_kamaruddin@yahoo.co.uk
• 26th June 2009 RCPE Symposium: Recent Advances in Medicine, University Hospital of North Tees. Contact sue.dent@nth.nhs.uk
• 1st July 2009 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk
• 9th July 2009 Association of Physicians, 6-9pm, Gateshead. Contact clive.kelly@ghnt.nhs.uk
• 10th September 2009 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk
• 27th September-1st October 2009 45th EASD Annual meeting, Vienna, Austria. Contact www.easd.org
• 1st October 2009 RCPE symposium; Diabetes & Endocrinology: Clinical challenges & expert advice, Edinburgh. Contact c.berwick@rcpe.ac.uk
• 12th October 2009 Northern Endocrine & Diabetes Autumn CME, JCUH, Middlesbrough. Contact mshafie_kamaruddin@yahoo.co.uk
• 2nd-4th November 2009 Society for Endocrinology Clinical Update 2009, Manchester. Contact www.endocrinology.org
• 2nd November 2009 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk
• 3rd November 2009 RCPL Medicine Update, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk
• 19th November 2009 1st Joint Meeting of The British Thyroid Association and British Association Of Endocrine and Thyroid Surgeons, St Thomas Hospital. Contact www.british-thyroid-association.org
• 19th-20th November 2009 ABCD autumn meeting, London. Contact www.diabetologists.org.uk followed by SpRs meeting 21-22nd November 2009.
• 25th November 2009 Northern Endocrine Region Research and Audit Group annual meeting, Lumley Castle, Durham 2pm-8pm. Contact shahid.wahid@sthct.nhs.uk
• 26th & 27th November 2009 Middlesbrough insulin pump course. Contact Rudy.Bilous@stees.nhs.uk
• 4th December 2009 Society for Endocrinology regional cases meeting, Edinburgh. Contact www.endocrinology.org
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.
A new Trainee Rep With Arut now having his CCT an opportunity for a new trainee rep has arisen on the STC. If you are interested please contact nicola.leech@nuth.northy.nhs.uk
Trainers & Trainees meeting (provisional date, will be confirmed) This will occur on Tuesday 23rd June 2009, 1600 at University Hospital of North Tees, Postgrad Centre. It will be followed by the SPARROWS feedback meeting from 1730. Contact nicola.leech@nuth.northy.nhs.uk
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 www.jrcptb.org.uk. 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. The e-portfolio for DM&ENDO is available now for StRs.
Assessment tools Please see 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.
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.
Case Based Discussions (CbD) The pilot form is available from the JRCPTB website. It is a must for trainers to use as a tool to document feedback in clinic. This has always been done informally, but now there is a method to formally document it. It can be used for when a SpR presents a new case in clinic.
Documenting CCU and ITU experience It is essential that trainees document their CCU and ITU experience. This is best done by keeping a summary log of the cases seen on CCU and ITU and linking it with reflection or assessment. This should then be signed off by your Educational Supervisor to be of any use at the Acute Medicine PYAs.
Audit Assessment tool This is now available in draft form on the JRCPTB website. Its use is highly recommended.
Management experience It is essential to have demonstrable evidence of management experience during your training, attending a course is not good enough. Undertaking a significant project for a Trust that leads to service change as a result of your management skills is probably the easiest method to demonstrate management activity. However, see Arut’s excellent letter below for more information and tips!
Training Committee Chair- Vacant; Regional Speciality Advisor- Shaz Wahid, shahid.wahid@sthct.nhs.uk; Programme Director- Nicky Leech nicola.leech@nuth.northy.nhs.uk; Consultant member (SAC rep)- Richard Quinton, Richard.Quinton@nuth.nhs.uk; Consultant member-Jean MacLeod, Jean.Macleod@nth.nhs.uk; Consultant member (Research Advisor)-Simon Pearce, s.h.s.pearce@ncl.ac.uk; Consultant member-Simon Eaton, simon.eaton@northumbria-healthcare.nhs.uk; SpR representative- Vacant; SpR representative- Jeevan Mettayil jmjeevan@yahoo.com
NEWS FROM THE NORTHEAST
• Congratulations to Sukesh Chandran on appointment to a Consultant post in Bishop Auckland from 1st October 2009. He will be an Acute Physician with an interest in Diabetes&Endo.
• Some of you may remember Liz McIntyre as a SpR. She is now a proud mother with a baby daughter.
• Philip Home has been invited by the ADA to lead his international team in presentation of the RECORD study (rosiglitazone) results at the ADAs Annual Meeting in New Orleans in June.
• Philip Home is to head up the A1chieve Study of 60000 people on five continents starting insulin.
• Richard Quinton to take over from Alan Patrick as SAC rep on the Diabetes/Endo Section of UEMS (European Union of Medical Specialists).
• 47 candidates have stumped up for the MRCP (Diabetes & Endocrinology) exam this year, half of them from the UK. Best of luck to our boys & girls.
• Jola Weaver has finished her term as STC Chair. Our thanks go to her for her hard work.
• Our thanks go to Arut for serving the needs of trainess as the SpR rep on the STC. He has handed the reins for the NEDS CME over to Rohanna Wright and Shafie Kamarrudin.
• Congratulations to Stuart Little (research with Dr Shaw) and Asgar Madathil (research with Dr Weaver) on their OOPEs to start ASAP.
LETTERS
A plug from Simon Pearce-There is a must-have book available now!! including chapters from yours truly on immunogenetics, Petros and Jane Dickinson on TAO, and Kate Owen and Tim Cheetham on polyendocrinopathy syndromes as well as a further 9 excellent chapters by international experts in the field..... Including: Evidence-based management of Graves' disease (Hegedus); Modern approaches to replacement in Addison's disease (Arlt); Immunomodulatory treatment of T1D (Herold), and lots more........ Its a snip at £49.00!! Pearce SHS, Ed. Autoimmune Endocrine Disorders: Endocrinology and Metabolism Clinics of North America 2009; 38 (2).
Research Update on the RADS (Rescue of Addison's Disease) study-Simon Peace. We have recruited 2 patients (of 5 referred), and both have tolerated rituximab well. It's too early to tell if its working yet, but there certainly isn't deterioration in the patient who has been retested. We are still keen to meet anyone with newly diagnosed Addison's disease within 4 weeks of diagnosis, to talk through the ins and outs of the study with them (just email me: s.h.s.pearce@ncl.ac.uk and we'll see the person within 5 days). The study will be recruiting for another 18 months, so more updates will be coming. Many thanks to those who have been pro-active in referring patients in so far.
New trial for medullary thyroid cancer-Petros Perros. Newcastle will soon be recruiting patients for a phase 3 randomized, placebo-controlled, double-blinded study of XL184 as single-agent oral therapy in patients with unresectable, locally advanced, or metastatic medullary thyroid cancer (MTC). The primary endpoint will be duration of progression-free survival. XL184 is a small molecule anticancer compound targeting the MET, RET, and VEGFR2 receptor tyrosine kinases. XL184 has exhibited dose-dependent tumour growth inhibition and tumour regression in a variety of tumour models, including breast cancer, colon cancer, MTC, non-small cell lung cancer, and glioblastoma. Main inclusion criteria are histologically confirmed MTC, and documented progressive disease on imaging within last 14 months. For further information or if you wish to discuss or refer potential participants please contact Dr P Perros 0191 2820590, or e-mail petros.perros@nuth.nhs.uk
Atul Gawande: a worthy read-Shaz Wahid (book review)
You have heard me bang on about the 7-habits (you wait till I start on the 8th habit), but these 2 books written by an Endocrine Surgeon in Boston USA (considered a GOD in the states) are a must read: Complications: a surgeon’s notes on an imperfect science; Better: a surgeon’s notes on performance. Both books cover a huge amount of ground in relation to hand hygiene, why we get sued, the difficult cases-sweating, obesity, why the computer is better than the world’s best Cardiologist at interpreting ECG (oh yes they are-as long as it is a perfect trace),systems management, chronic pain and much, much more. My favourite quote (that I have adjusted) is: “We (individuals or organisations) go into this work (medicine) thinking it is all a matter of canny diagnosis, technical prowess, slick technology, being the best, being the first AND some ability to empathise with people, but it is not.
We must grapple with systems, resources, circumstances, people-and our own shortcomings, as well. We face many variety of obstacles. But, somehow we must
– Advance
– Refine
– Improve
– PUT SIMPLY WE MUST STRIVE TO BE BETTER”
Management opportunities for SpRs within our regional specialty training programme-Vijayaraman Arutchelvam
Prof John Took in his report mentioned ‘The doctor's frequent role as head of the healthcare team and commander of considerable clinical resource requires that greater attention is paid to management and leadership skills regardless of specialism. An acknowledgement of the leadership role of medicine is increasingly evident. Role acknowledgement and aspiration to enhanced roles be they in subspecialty practice, management and leadership, education or research are likely to facilitate greater clinical engagement" (Tooke report 2008: Aspiring to Excellence)
We all are aware of the importance of developing management and leadership skills during our specialty training. The high standards and quality of training in the field of diabetes and endocrinology across our region is well recognised in the country. Equally importantly the opportunities we are provided with developing our leadership and managerial skills in our region are outstanding. This was pointed out to me by many SpR colleagues from other regions in recent times.
We have plenty of opportunities for formal training, and chances to put this training into practical experience and convert this experience into achievements. I herewith outline a few.
Formal training
We have a deanery approved 6 day course run by Mr Belton ( a former chief executive of a hospital ) at Durham thrice a year. This course comprehensively teaches you about all aspects of leadership and management with lots of practical group exercises. For example, groups are put in a task of real time negotiation to pick a charity to which all members will donate a negotiated amount of money. There were around 25 SpRs negotiating their heart out. In another exercise, you are expected to present a business case proposal to a team of managers, who choose 1 proposal which wins a prize( I felt proud to win that prize when I attended the course last year which boosted my confidence significantly). With help and support from our training programme director and regional specialty advisor, Shafie organised an accredited independent leadership course in April this year. 12 SpRs from our specialty attended this 3 day course and found it very useful.
The Northern deanery organises many management courses including courses on appraisal, good practice in educational supervision, feedback: heart of learning, Careers’ guidance for educational supervisors, recruitment and selection, developing effective educational plans and many more. You can book onto these courses online via the deanery website (http://mypimd.ncl.ac.uk/training).
I have attended many of these 1 day courses which had a direct impact on my performance. Organising ourselves onto these courses will need advanced planning and wise use of study leave during the whole training period. By itself it will demonstrate our management skills.
Opportunities to gain management experience
Specialty Training Committee : trainee representative
• 2 SpRs are elected by the STC to work within the STC for a minimum period of 2 years.
• Our STC encourages the trainee representative to be an active member and entrust them with responsibilities.
• Get to attend all the STC meetings, actively participate in the development of training modules, to collaborate with the Deanery in the local administration and delivery of specialist training (i.e. SpR/StR Programmes, recruitment and selection) within the regulations and guidelines of the College, to understand the rigorous ARCP process and understand the changes in training programmes at national level ( for example the chaos caused by MTAS).
• Communicating with SpR colleagues and represent their issues to the TPD and STC.
• More opportunities like representing in GIM STC meetings.
• Given a chance to get involved in developing the Medical education quality assessment report for the specialty and to attend this meeting with the post-graduate dean and other officials from the deanery.
• Given senior responsibilities like leading the JRCPTB pilot study.
• Encouraged to take positions at national level.
Interviewing skills:
• If you have done the courses on recruitment and selection AND equality and diversity you are given chances to get involved with the recruitment process for both specialty interviews and CMT interviews. I personally had the opportunity to sit in 3 specialty interview sessions and 4 CMT sessions.
CME organising committee:
• This is an unique feature of our region. SpRs are given total freedom in organising these tri-annual meetings across the region.
• The lead SpR will generate around £4000 annually by donations, maintain a cost centre account in the university and wisely manage it to cover the expenses.
• External and internal speakers are invited.
• Maintain excellent communication and conduct the meetings successfully covering the curriculum over a 3 year period.
• Register with the Royal college CPD programme and get approval for 5 CPD points.
• This is an excellent opportunity to improve our organisational skills, financial management, time management and networking skills.
• There will be challenging times and this will bring the best out of you ( to recollect an event, an external speaker cancelled with 6 days to go for the CME due to family reasons, we came out with an idea of a SpR presentation competition, arranged in that short period. This turned out to be an instant hit and now it has become an annual event).
Endodiabology:
• This is another unique opportunity in our region.
• You could start as an associate editor and you have the chance of becoming the senior editor.
• An excellent website remains functional. Being a web editor sharpens your IT skills as well.
PACES organising registrar:
• I got this opportunity when I was in James Cook University Hospital. Keep a watch as it is happening across the region as you are reading this.
Day with the Chief executive/ medical director
• Arrange to spend a day with the chief executive or medical director of the trust, attend meetings and learn practical management skills
All we need is initiative and enthusiasm to grasp these excellent opportunities provided by our region. All these experiences lead to satisfying achievements. To illustrate, with the CME when we received an average score of 4.4/ 5 on overall performances and demonstrated consistent improvement in attendance or when you register the increase in the endodiabology blog spot hit rate, trust me, it will all be very satisfying and rewarding. I have just outlined a few opportunities and there are plenty more available to fulfil our training needs and go beyond.
The Medical Leadership Competency Framework has been jointly developed by The Academy of Medical Royal Colleges and the NHS Institute for Innovation and Improvement, in conjunction with a wide range of stakeholders. This framework is built on the concept of shared leadership where leadership is not restricted to those who hold designated leadership roles, and where there is a shared sense of responsibility for the success of the organisation and its services. Acts of leadership can come from any individual in the organisation, as appropriate, at different times. Our region provide an opportunity to work with and improve on all these domains (figure 1). I suggest that we read more on these domains and each of its elements in the website http://www.institute.nhs.uk/assessment_tool/general/medical_leadership_competency_framework_-_homepage.html and continue to work on developing the relevant skills using the excellent opportunities available in the region..
Figure 1 The Medical Leadership Competency Framework
RECENT PUBLICATIONS FROM THE NORTHEAST
1. Randomised Controlled Trial to Assess the Impact of Continuous Glucose Monitoring on HbA1c in Insulin-Treated Diabetes (MITRE Study) D. Cooke, S.J. Hurel, A. Casbard, L. Steed, S. Walker, S. Meredith, A.J. Nunn, A.
Manca, M. Sculpher, M. Barnard, D. Kerr, J.U. Weaver, J. Ahlquist, S.P.
Newman Accepted Article Online: Diabetic Medicine Apr 4 2009.
2. Roycroft M, Fichna M, McDonald D, Owen K, Zurawek M, Gryczyńska M, Januszkiewicz-Lewandowska D, Fichna P, Cordell H, Donaldson P, Nowak J, Pearce S. The tryptophan 620 allele of the lymphoid tyrosine phosphatase (PTPN22 gene) predisposes to autoimmune Addison's disease. Clin Endocrinol (Oxf) 2009; 70: 358-362.
3. Owen CJ, Habeb A, Pearce SH, Wright M, Ichikawa S, Sorenson AH, Econs MJ, Cheetham TD. Discordance for X-linked hypophosphataemic rickets in identical twin girls. Horm Res. 2009;71:237-44.
4. Pearce SHS, Ed. Autoimmune Endocrine Disorders: Endocrinology and Metabolism Clinics of North America 2009; 38 (2).
5. Allahabadia A, Razvi S, Abraham P, Franklyn J. Diagnosis and treatment of primary hypothyroidism. BMJ. 2009 Mar 26;338:b725.
6. Magee G, Bilous RW, Cardwell CR,Hunter CJ,Kee F,Fogarty DG. Is hyperfiltration associated with the future risk of developing diabetic nephropathy? Diabetologia 2009 ; 52 ; 691 – 7.
7. Candesartan and Prevention of Microalbuminuria in Diabetes Effect of Candesartan on Microalbuminuria and Albumin Excretion Rate in Diabetes Three Randomized Trials (DIRECT – Renal) Rudy Bilous, MD; Nish Chaturvedi, MD; Anne Katrin Sjølie, MD; John Fuller, MD; Ronald Klein, MD; Trevor Orchard, MD; Massimo Porta, MD; and Hans-Henrik Parving, MD. Annals Internal Medicine 2009 ( in press).
8. Hill S, Arutchelvan V, Quinton R. 2009 Enclomiphene, an estrogen receptor antagonist for the treatment of testosterone deficiency in men. drugs. 12: 109-119.
9. Nicol M, Papacleovoulou G, Evans DB, Penning TM, Strachan MW, Advani A, Johnson SJ, Quinton R, Mason JI. 2009 Estrogen biosynthesis in human adrenocortical carcinoma cells. Molecular & Cellular Endocrinology. 300: 115-120.
RECENT PUBLICATIONS IN DIABETES & ENDOCRINOLOGY THAT HIT THE NEWS OR THAT MAY HAVE A SIGNIFICANT IMPACT ON MANAGEMENT
Defining polycystic ovary syndrome. Balen A, et al. BMJ 2009;338:426. Well worth a read and I would recommend that trainees bring it up on their PIU round to invoke debate/fisticuffs, rather like asking what is a normal short synacthen test.
Fatal thyrotoxic cardiomyopathy in a young man. Soh MC & Croxon M. BMJ 2009;338:476477. An excellent case report that you can hang thyrotoxic storm on, however I do manage it differently than discussed in the article.
HDL cholesterol and cardiovascular risk. Ghali WA & Rodondi N. BMJ 2009;338:488-489. I remember having to interpret a vignette from a paper discussing cholesterol transport and how raising HDL cholesterol may be beneficial in monkeys for my A-level biology exam. It is interesting to see how we have come full circle and the paradigm of raising HDL-c resulting in reduced cardiovascular disease has not come to fruition as eloquently discussed in this editorial.
Graves’ Ophthalmopathy. Bartalena L & Tanda ML. NEJM 2009;360:994-1001. A must read for trainees and those wishing a clinical practice update.
Dopamine agonists and hyperprolactinaemia. Martin N, et al. BMJ 2009;338:554-555. An excellent editorial with advice that I think is prudent: undertake an echo before starting cabergoline and then determine further echos depending on the cumulative dose. Worth a read.
Systemic management of diabetic retinopathy. Liew G, et al. BMJ 2009;338:612-613. An editorial discussing the ADVANCE, DIRECT and FIELD trials. Worth a read.
Thyroid eye disease. Perros P, Neoh C, Dickinson J. BMJ 2009;338:645-650. A practical update from a team of local Gurus in the field.
Investigating the thyroid nodule. Mehanna HM, et al. BMJ 2009;338:705-709 AND Rational Imaging: Incidental thyroid nodule. Patel CN, et al. BMJ 2009;338:713-715. Well worth a read of both articles that did lead to some controversy. I still say put 20 Endocrinologists in the same room……………………………………………………………………………………
An unusual cause of ventricular fibrillation. Gerritsen et al. Lancet 2009;373:1144. An excellent case report that gets you into topping up on the different causes of hypokalaemia and hyperkalaemia due to channelopathies.
Management of hirsutism. Koulouri O, Conway GS. BMJ 2009;338:823-826. AND Investigating hirsutism. Sathyapalan T, Atkin SL. BMJ 2009;338:1070-1072. 2 excellent practical articles well worth a read.
Late onset hypogonadism. Hugh Jones T. BMJ 2009;338:785-786. An editorial worthy of a read to guide further investigation of the literature.
The HRT controversy: observation studies and RCT fall in line. Vandenbroucke JP. Lancet 2009;373:1233-1235. An excellent editorial summarising the recent evidence on HRT and providing a wealth of references to aid further understanding.
Where are my testes? Kumar S, et al. Lancet 2009;373:1310. I write about this case report with a “smile”. It brings factor V leiden into the world of primary hypogonadism.
Practising safely in the foundation years. Long et al. BMJ 2009;338:887-890. A wonderful article that can be used as a teaching tool.
Prevention of Diabetic retinopathy. Anna Einarsdottir, Einar Stefansson. Lancet 2009;373:1316-1317. A review of the accompanying CALDIRET study with lessons to note.
Tight control of blood glucose in long standing type 2 diabetes. Richard Lehman. Lancet 2009;338:901-902. The view of QuOF on the reduction of target HbA1c from 7.5 to 7 %. I was expecting the howls of derision…………
Diagnosis and treatment of primary hypothyroidism. Amit Allahabadia, et al. BMJ 2009;338:1090-1091. The BTAs attempt to bring some semblance of control to the therapy of hypothyroidism.
Voglibose for prevention of type 2 diabetes mellitus. Andre J Scheen. Lancet 2009;373:1579-1580. An editorial that not only discusses the accompanying trial but also the issue of preventing diabetes using pharmacotherapy.
Genetics of Type 1A Diabetes. Patrick Concannon and Gerald Nepom. NEJM 2009;360:1646-1654. An excellent update on this important and ever expanding topic.
The Lancet 23-29th May 2009 volume 373 edition. A must read edition of the Lancet that is devoted to diabetes. 3 important trials on glitazones & hear disease, gestational diabetes and the Fenofibrate FIELD study are presented.
Zoledronic acid and risedronate in the prevention and treatment of glucocorticoid-induced osteoporosis (HORIZON): a multicentre, double-blind, double-dummy, randomised controlled trial. Reid DM,et al. Lancet. 2009 Apr 11;373(9671):1253-63. This 1-year randomised, double-blind, double-dummy, non-inferiority study of 54 centres around the world tested the effectiveness of 5 mg intravenous zoledronic acid versus 5 mg oral risedronate for prevention and treatment of glucocorticoid-induced osteoporosis. 833 patients were randomised 1:1 to receive zoledronic acid (n=416) or risedronate (n=417). Patients were stratified by sex, and allocated to prevention or treatment subgroups dependent on duration of glucocorticoid use immediately preceding the study. The treatment subgroup consisted of those treated for more than 3 months (272 patients on zoledronic acid and 273 on risedronate), and the prevention subgroup of those treated for less than 3 months (144 patients on each drug). The primary endpoint was percentage change from baseline in lumbar spine bone mineral density. Zoledronic acid was non-inferior and superior to risedronate for increase of lumbar spine bone mineral density in both the treatment ( mean difference 1.36% [95% CI 0.67-2.05], p=0.0001) and prevention (1.96% [1.04-2.88], p<0.0001) subgroups at 12 months. Adverse events were more frequent in patients given zoledronic acid than in those on risedronate, mainly because of transient symptoms during the first 3 days after infusion. Serious adverse events were worsening rheumatoid arthritis for the treatment subgroup and pyrexia for the prevention subgroup. This study has shown that a single 5 mg intravenous infusion of zoledronic acid is non-inferior, possibly more effective, and more patient friendly than is 5 mg of daily oral risedronate for the prevention and treatment of bone loss associated with glucocorticoid use. It is well worth reading the accompanying editorial by Luigi Gennari & John Belzezikian (Lancet 2009;373:1225-1226). Despite the clear evidence base for using annual zoledronic infusion in managing osteoporoses, I struggle to convince my Medical Director when I have asked for its use in certain individual circumstances. Because of cost I am pointed towards 6-monthly IV pamidronate.
Intensive versus conventional glucose control in critically ill patients. NICE-SUGAR Study Investigators. N Engl J Med. 2009 Mar 26;360(13):1283-97. In this trial 6104 adults within 24 hours after admission to an intensive care unit (ICU), who were expected to require treatment in the ICU on 3 or more consecutive days were randomly assigned to undergo either intensive glucose control (3054 patients), with a target blood glucose range of 4.5 to 6.0 mmol/l, or conventional glucose control (3050 patients), with a target of 10.0 mmol/l. The primary end point was death from any cause within 90 days after randomization. The two groups had similar characteristics at baseline. A total of 829 patients (27.5%) in the intensive-control group and 751 (24.9%) in the conventional-control group died (odds ratio for intensive control, 1.14 95%CI[1.02-1.28]; P=0.02). The treatment effect did not differ significantly between surgical and medical patients (odds ratio for death in the intensive-control group, 1.31 and 1.07, respectively; P=0.10). Severe hypoglycaemia (blood glucose level, < 2.3 mmol/l) was reported in 206 of 3016 patients(6.8%) in the intensive-control group and 15 of 3014 (0.5%) in the conventional-control group (P<0.001). There was no significant difference between the two treatment groups in the median number of days in the ICU (P=0.84) or hospital (P=0.86) or the median number of days of mechanical ventilation (P=0.56) or renal-replacement therapy (P=0.39). This trial found that intensive glucose control increased mortality among adults in the ICU: a blood glucose target of 10mmol/l or less had lower mortality than did a target of 4.5-6.0 mmol/l. A very important trial that I think outlines the important target of maintaining a blood glucose of 6-10 mmol/l in patients on an ICU. The accompanying editorial by Sylvio Inzucchi and Mark Siegel (NEJM 2009;360:1346-1349) is well worth a read. It is important that Intensivists do not go down the same route as many Cardiologists (following DIGAMI 2 and others) and abandon controlling hyperglycaemia, luckily “my crowd” still do mostly listen.
Catheter-based renal sympathetic denervation for resistant hypertension: a multicentre safety and proof-of-principle cohort study. Krum H, et al. Lancet. 2009 Apr 11;373(9671):1275-81. This proof-of-principle trial of therapeutic renal sympathetic denervation in 45-patients with resistant hypertension (ie, systolic blood pressure 159 mmHg on three or more antihypertensive medications, including a diuretic) assessed the latter procedures safety and blood-pressure reduction effectiveness. Patients received percutaneous radiofrequency catheter-based treatment between June, 2007 and November 2008, with follow-up to 1 year. The effectiveness of renal sympathetic denervation was assessed by measuring renal noradrenaline spillover in a subgroup of patients. Primary endpoints were office blood pressure and safety data before and at 1, 3, 6, 9, and 12 months after the procedure. Renal angiography was done before, immediately after, and 14-30 days after procedure, and magnetic resonance angiogram 6 months after procedure. In treated patients, baseline mean(SD) office blood pressure was 177/101(20/15) mmHg; mean 4.7 antihypertensive medications; mean(SD) eGFR was 81(23)ml/min; and mean reduction in renal noradrenaline spillover was 4795%CI 28-65)%. Office blood pressures after procedure were reduced by -14/-10, -21/-10, -22/-11, -24/-11, and -27/-17 mmHg at 1, 3, 6, 9, and 12 months, respectively. One intraprocedural renal artery dissection occurred before radiofrequency energy delivery, without further sequelae. There were no other renovascular complications. This preliminary trial has shown that catheter-based renal denervation causes substantial and sustained blood pressure reduction, without serious adverse events, in patients with resistant hypertension. However, prospective randomised clinical trials are needed. The accompanying editorial by Michael Doumas and Stella Douma is excellent (Lancet 2009;373:1228-1229).
Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. Sacks FM, et al. N Engl J Med. 2009 Feb 26;360(9):859-73. The authors randomly assigned 811 overweight adults to one of four diets where the targeted percentages of energy derived from fat, protein and carbohydrates in the four diets were 20, 15, and 65%; 20, 25, and 55%; 40, 15, and 45%; 40, 25, and 35%; and followed them up for 12-months. The diets consisted of similar foods and met guidelines for cardiovascular health. The participants were offered group and individual instructional sessions for 2 years. The primary outcome was the change in body weight after 2 years in two-by-two factorial comparisons of low fat versus high fat and average protein versus high protein and in the comparison of highest and lowest carbohydrate content. After 6-months participants assigned to each diet had lost an average of 6 kg, accounting for 7% of their initial weight; they began to regain weight after 12 months. By 2 years, weight loss remained similar in those who were assigned to a diet with 15% protein and those assigned to a diet with 25% protein (3.0 and 3.6 kg, respectively); in those assigned to a diet with 20% fat and those assigned to a diet with 40% fat (3.3 kg for both groups); and in those assigned to a diet with 65% carbohydrates and those assigned to a diet with 35% carbohydrates (2.9 and 3.4 kg, respectively) (P>0.20 for all comparisons). Among the 80% of participants who completed the trial, the average weight loss was 4 kg; 14 to 15% of the participants had a reduction of at least 10% of their initial body weight. Satiety, hunger, satisfaction with the diet, and attendance at group sessions were similar for all diets; attendance was strongly associated with weight loss (0.2 kg per session attended). The diets improved lipid-related risk factors and fasting insulin levels. The message from this study is to encourage calorie restriction to manage weight as weight loss occurred in this study regardless of which macronutrients they emphasised.
NEXT NEWSLETTER Due out beginning of October 2009 so keep the gossip coming.
posted by Arutchelvam at 9:53 PM
