Endodiabology February 2010
ENDODIABOLOGY
Endodiabology.blogspot.com
NORTHEAST
NEWSLETTER
FOR SPRs AND BOSSES TRAPPED
IN THE NORTHERN DEANERY
FEBRUARY 2010
Editors: Shaz Wahid (shahid.wahid@sthct.nhs.uk) and
Petros Perros (petros.perros@ncl.ac.uk) and Arut Vijayaraman (riarut@aol.com )
Associate Editors: Shafie Kamarrudin, Ravi Erukulapati
SpR PLACEMENTS (NTN year of training from 1st October 2008)
• Newcastle- Ravi Erukalapati(5), Sudeep Manohar (3), Nimanth De Alwis (1), Arif Ullah (3), Srikanth Mada(3) Naveen Siddaramaiha (2), Sarah Steven (2)
• North Tyneside/Wansbeck- Anjali Santhakumar (3), Kathryn Stewart (3)
• South Tyneside- Rohanna Wright (2),
• Gateshead- Preeti Rao (3)
• Sunderland- Beas Bhattacharya (5) then Naveen Aggarwal (1), Chandima Idampitiya (5)
• North Tees/Hartlepool- Shafie Kamarrudin (4), Hamza Ali Khan (1)
• Middlesbrough- Freda Razvi (5), Atif Munir (1), Sajid Ethol Kalathil (1), Catherine Napier (1)
• Bishop Auckland Khaled Mansur-Dukhan (5)
• Durham- Jeevan Mettayil (4)
• NGH/QEH- Vacant
• Research with numbers (supervisor)- Eelin Lim(5-Prof Taylor); Stuart Little (2-Dr Shaw) & Asgar Madathil (4-Dr Weaver)
MEETINGS / LECTURES / ANNOUNCEMENTS
• 23rd February 2010 SfE National Clinical Cases meeting, venue TBC. Contact www.endocrinology.org
• 3rd- 5th March 2010 DUK Annual Professional Conference, Liverpool. Contact www.diabetes.org.uk
• 6th March 2010 Association of Physicians, 9am-1pm, Bishop Auckland. Contact clive.kelly@ghnt.nhs.uk
• 15th – 18th March 2010 BES 2010, Manchester. Contact www.endocrinology.org.
• 17th March 2010 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
• 28th April 2010 RCP Acute Medicine symposium, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
• 6th-7th May 2010 ABCD Spring Meeting, The Hilton, GATESHEAD. Contact www.diabetologists.org.uk
• 12th May 2010 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
• 8th June 2010 Northern Endocrine & Diabetes Spring CME, Freeman Hospital. Contact
• 19th – 22nd June 2010 ENDO 2010, San Diego, USA. Contact endostaff@endo-societ.org or www.endo-society.org/scimeetings .
• 25th – 29th June 2010 American Diabetes Association 70th Annual Scientific Sessions, Orlando, Florida, USA. Contact meetings@diabetes.org .
• 14th July 2010 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
• 15th September 2010 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
• 20th – 24th September 2010 46th EASD Annual meeting, Stockholm, Sweden. Contact www.easd.org
• 8th-10th November 2010 Society for Endocrinology Clinical Update, venue TBC. Contact www.endocrinology.org
• 9th November 2010 RCP Updates in Medicine, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
• 17th November 2010 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
• 18th-19th November 2010 ABCD autumn meeting, London. Contact www.diabetologists.org.uk followed by SpRs meeting 19th-21st November 2010.
• 24th November 2010 Northern Endocrine Region Research and Audit Group annual meeting, Lumley Castle, Durham 2pm-8pm. Contact shahid.wahid@sthct.nhs.uk
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.
SPR management training session: “what works in the NHS and what does not”-David Hambleton. Lumley Castle 6-8pm 24th February 2010. Contact anjalisan@yahoo.com for more information.
ARCP (RITA) The next round was due on Weds 12th, Thurs 13th & Fri 15th May 2010, however due to clashes this may be changed to week beginning 24th May 2010. Trainees please keep these dates free as possible. Those trainees transferring on to the new GIM curriculum will have a separate ARCP on 18th May 2010. More information to follow.
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.
General Internal Medicine Curriculum is now updated and available on www.jrcptb.org.uk. All trainees appointed ST3 from August 2009 will be offered entry to train for this CCT. Trainees before this date can easily apply to train in this CCT (i.e. dual accredit), again detailed in the website. Reviewing the new curriculum for G(I)M each trainee will need 6 ACATs, 4-CBDs and 4 Mini-CEXs in G(I)M as well as the specialty work based assessments. The publication of this curriculum and the formation of a National SAC in G(I)M separate from the Acute Medicine SAC really does mean that in practical terms the 2 specialties will be split. Our current G(I)M/Acute Medicine STC is preparing for this split this year. It is important that trainees keep a record of all GIM patients they have seen either as emergency or out-patient. There are plans to introduce an audit system.
MRCP Diabetes & Endocrinology This exam has to be completed and passed by all trainees appointed after August 2007 before their PYA. We recommend sitting it ASAP and well before your PYA.
INFORMATION for QA Could each individual trainer send the following to Simon Pearce: educational qualifications, any training positions held and any educational courses attended.
MORE INFORMATION for QA Could each unit’s Training Lead please send to Simon Pearce a completed training unit information report and an updated SpR/StR job description as per Nicky Leech’s e-mail.
Trainers & Trainees meeting The next T&T is on 24th June 2010. Details to be confirmed nearer the time, but please note in your diary.
Training Committee Chair- Simon Pearce, s.h.s.pearce@ncl.ac.uk; 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-Arutchelvam Vijayaraman Vijayaraman.Arutchelvam@stees.nhs.uk ; Consultant member-Simon Eaton, simon.eaton@northumbria-healthcare.nhs.uk; SpR representative- Anjali Santhakumar anjalisan@yahoo.com ; SpR representative- Jeevan Mettayil jmjeevan@yahoo.com
NEWS FROM THE NORTHEAST
• Congratulations to Anjali Santhakumar as our new Trainee rep.
• Arut will be remaining on the STC as a Consultant member.
• Congratulations to Ana Jovanovic on her MD.
• Congratulations to Latika Sibal on her PhD, she is currently in a Locum Consultant post at Adenbrookes.
• ABCD is coming to town. Please note that this excellent national meeting will be visiting the region on 6-7th May 2010 at the Hilton in Gateshead. See above.
• In Nov 2009, RQ spent 3 days in November 09 as Elliot B. Shoolman visiting lecturer/professor at the Reproductive Endocrinology Unit of Harvard University/Massachusetts General Hospital. Stayed in Boston with Balasubramanian Ravikumar, former NorthEast trainee, who is now a Research Fellow in that Unit.
• Welcome to Dr SoPye who was started work 21st December 2009 at University Hospital Hartlepool. He trained in Leicester. He is appointed as an Acute Physician with interest in D & E.
LETTERS
Book review-Shaz Wahid: Clinical Leadership-Bridging the Divide by Emma Stanton, Claire Lerner and James Mountford published by Quay Books.
An excellent short book that I regard as essential reading for all trainees and a must for Consultants to dip into. It is written by trainees supported by experienced NHS leaders. Its style of exploring history and putting it into context in the modern NHS reads very well. Its tips on personal development are superb. It focuses on the individual followed by the team followed by the organization and then National strategy. After reading it I am sure everyone would be interested in something they read in it and follow this up with further reading and courses. Reading this book has taught me new tricks and changed my practice. I have often been asked by trainees how do I demonstrate management skills when applying for jobs. Firstly, management skills are really leadership skills. Well on page 94 there is a wonderful template that lists workplace opportunities to develop leadership skills as a postgrad trainee. The broad areas identified are (in brackets I have put personal examples from when I were a lad (SpR)):
-Identifying areas for change (foot care at QEH)
-Rota Management (The Diabetes centre and Freeman hospital clinic rota)
-Department induction (Inducing juniors to the ward)
-Guideline development (glucose Mx in MI at QEH)
-Teaching/education/supervision (final year teaching course at North Tees)
-People and performance management (looking after the yunguns!)
-Attending and contributing to meetings (NEDS CME organizer)
-Operational matters (Associate College Tutor at QEH)
-Service quality and improvements (multiple service delivery audits)
-Identifying key players in the Trust (have sat down with CDs, Execs at Hartlepool)
-Understanding Trust Strategy (LDSAGs, Physicians meetings)
-National Strategy (NRDSAG)
I hope this review has provoked interest and action.
Efficient Clinical Coding- A Means to Improving Costing- Dr.Ravi Erukulapati
What is Clinical Coding?
The translation of medical terminology, as written by the clinician, to describe a patient’s complaint, problem, diagnosis, treatment or reason for seeking medical attention, into a coded format which is nationally and internationally recognised.
Why do we do it?
• Forms the basis of medical research and medical audit
• Population healthcare needs analysis by Health Authorities
• Essential for internal management by directorates
• Vital in examining local and national trends
• Used for research and epidemiology
• Forms the basis of case mix groups and Healthcare Resource Groups (HRG's)
Clinical Coding and Commissioning
The introduction of Payment by Results means that all Trusts in England will use a fixed price tariff for specific treatments. At the heart of these financial flows is coded clinical information. The advent of such tariffs has had an impact on the Primary Care Trusts (PCTs) and others who commission services using coded clinical data. Previously a PCT commissioned health care services without necessarily requiring a full understanding of coded clinical data, its structure, how it is gathered and how the rules and conventions are applied. The coded clinical data is grouped to meet the reporting structure of Payment by Results to ensure the trusts are paid accurately for activity. The increased importance of clinical coded data means that all commissioners of patient services now need to comprehend clinical coded data to be able to understand what they are commissioning and what the providers are saying they are delivering. Without this understanding various ‘hot topics’ related to clinical coding can arise which can result in misunderstandings between provider and commissioner. The NHS requires input of accurate data to reflect clinical activity and trusts now have a financial incentive to ensure that coding is accurate, comprehensive and timely.
How is Clinical Coding derived? The source documentation used for coding varies from hospital to hospital, but is normally the patient’s case notes.
The case notes hold:
• Discharge summaries
• Proformas
• Clinical work sheets
• Hospital, patient and GP documentation
The coding process
Patient admitted to hospital.
↓
Patient discharged following treatment.
↓
Information extracted from case notes and translated into coded format using Classifications (ICD-10 and OPCS-4)
↓
Coded information recorded on hospital’s Patient Administration System (PAS), with copy of Coding placed in case notes for doctor to verify or query.
How clinicians can help coders to achieve complete and accurate clinical coding
• Ask to meet the Clinical Coders and assist them when there is a query about a diagnosis or procedure
• Ensure that the discharge summary is complete at discharge
• Follow the guidelines when completing the Discharge summary
How is the information in case notes translated into Codes?
For Example:
Patient admitted with a closed fracture left distal radius after falling from a chair at home. The patient is a non-insulin diabetic and suffers from chronic ischaemic heart disease. Patient’s fracture treated with manipulation and skeletal traction.
The coding screen on the Trust’s Patient Administration System
(PAS) will contain the following:
DIAGNOSES:
S52.50 Fracture lower end radius, closed
W07.0 Fall involving chair, home
E11.9 Non-insulin dependant diabetes mellitus
I25.9 Chronic ischaemic heart disease
PROCEDURE:
W26.1 Manipulation of fracture of bone and skeletal traction
Z70.5 Lower end of radius
Z94.3 Left sided operation
Recording vague diagnoses
• Use of Probable vs. Possible
• Clinical coding can only be as accurate as the information that clinicians record in the patient case notes.
• If clinician records diagnoses as follows:
This patient has Chest Pain ? Angina
Then the clinical coder will only code the Chest Pain/not the Angina
• If clinician records Possible MI then the clinical coder will only code the patient’s symptoms, not the MI.
• However, if clinician records Probable MI then the clinical coder will code the MI
References and further reading
1.) Improving clinical records and clinical coding together - A project with the Audit Commission, Royal College of Physicians, August 2008, www.audit-commission.gov.uk
2.) Frequently Asked Question - Telephone Activity — NHS Connecting for Health http://www.connectingforhealth.nhs.uk/systemsandservices/data/nhsdmds/help/faqs
3.) http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/noncoders/clinicians
4.) http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/noncoders/commissioners
5.) http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/noncoders
6.) Hospital Activity Data, A Guide for Clinicians, Produced by the RCP Information Laboratory (lab)
Maximising Efficiency the “Lean” Way M S Kamaruddin
In the current economic climate, the National Heath Service (NHS) will undoubtedly face challenging times especially when massive budget cuts to the NHS is anticipated. How do we rise to this challenge without compromising quality of care? In line with the recently published NHS Operating Framework for 2010/11, it emphasises the need to maintain high quality of care despite a tighter economic climate through a process that focuses on quality, innovation, productivity and prevention.1
This reminds me of how the automotive industry revolutionised their manufacturing principles by eliminating waste. This concept have been widely adopted and practiced in the manufacturing sector and is also increasingly used in health care. Lean is a term adopted from Japanese manufacturing principles defining a philosophy that abhors waste in any form and relentlessly strives to improve quality. Waste is defined as any action that does not add value to the product; in health care terms this should be the patient experience.2 The Lean concept also empowers its staff and provide them with the tools to make changes. In the context of health care, doctors and other allied health care professionals become focused not only on taking care of the patient, but also on finding better ways to take better care of patients. They are in a position to do so as frontline staff has better insight to the task at hand.
The Lean approach in improving efficiency is first done by studying every step of the process that is being evaluated. To site an example that have been tried and tested successfully in a local hospital in North East recently is the process of a patient attending the endoscopy unit. The whole patient experience and journey from arrival to leaving the unit was evaluated at every step i.e. from arrival in the waiting room to nursing documentation, consent and right down to the procedure itself and discharge. The time line for each step is quantified into value added and non-value added (waste) steps. The team will then identify which step adds value to the patient experience and which step incurs unnecessary cost and resources.
In this case (figure 1) the unnecessary nursing documentation of details, which are often irrelevant, could be eliminated. Essential patient details such as drug allergy can be obtained during consent. The patient waiting time could also be minimized to improve patient experience. The additional nursing staff originally used for documentation could be mobilised to the discharge or recovery area. In essence the reduction of 12 minutes per case could essentially accommodate additional procedures for the session hence increasing productivity without compromising patient care.
Figure 1. Flow of patient movement through the endoscopy unit before & after application of Lean principles.
This principle could easily be applied to a typical busy acute medical admission setting. A patient typically goes through repetitive steps right from beginning in accident & emergency only to be repeated again in the medical admission unit. With careful planning much time could be saved and the patient journey could be improved upon.
References:
1. Department of Health. Guidance; The NHS operating framework for England for 2010/11. 16th December 2009
2. Eric W. Dickson, et al. Application of Lean Manufacturing Techniques in the Emergency Department.
RECENT PUBLICATIONS FROM THE NORTHEAST
1. Raivio T, Sidis Y, Plummer L, Chen H, Ma J, Mukherjee A, Jacobson-Dickman E, Quinton R, Van Vliet G, Lavoie H, Hughes VA, Dwyer AA, Hayes FJ, Xu S, Sparks S, Kaiser UB, Mohammadi M, Pitteloud N. 2009 Impaired fibroblast growth factor receptor 1 signaling as a cause of normosmic idiopathic hypogonadotropic hypogonadism. Journal of Clinical Endocrinology & Metabolism. 94: 4380-4390.
2. Hill S, Arutchelvan V, Quinton R. 2009 Enclomiphene, an estrogen receptor antagonist for the treatment of testosterone deficiency in men. Idrugs. 12: 109-119.
3. Syed AA, Jones NAG, Bliss R, Roberts T, Mallick U, Johnson S, Douglas F, Perros P, Quinton R. 2009 Metachronous testicular teratoma, testicular seminoma and papillary thyroid carcinoma occurring in a single individual: a report of two unrelated cases. European Journal of Cancer Care. Nov 11. [Epub ahead of print].
4. Gan EH, Wahid ST, Quinton R. 2009 Hypercalcaemia: two myths. BMJ. 339: b5649.
5. Quinton R. 2009 The story of Axel Munthe. Clinical Medicine. 9: 504-505.
6. Shakoor SK, Aldibbiat A, Ingoe LE, Campbell SC, Sibal L, Shaw J, et al. Endothelial Progenitor Cells in Subclinical Hypothyroidism: The Effect of Thyroid Hormone Replacement Therapy. J Clin Endocrinol Metab 2009.
7. Ramchurn N, Mashamba C, Leitch E, Arutchelvam V, Narayanan K, Weaver J, et al. Upper limb musculoskeletal abnormalities and poor metabolic control in diabetes. Eur J Intern Med 2009;20(7):718-21.
8. Cooke D, Hurel SJ, Casbard A, Steed L, Walker S, Meredith S, et al. Randomized controlled trial to assess the impact of continuous glucose monitoring on HbA(1c) in insulin-treated diabetes (MITRE Study). Diabet Med 2009;26(5):540-7.
9. Sibal L, Aldibbiat A, Agarwal SC, Mitchell G, Oates C, Razvi S, et al. Circulating endothelial progenitor cells, endothelial function, carotid intima-media thickness and circulating markers of endothelial dysfunction in people with type 1 diabetes without macrovascular disease or microalbuminuria. Diabetologia 2009;52(8):1464-73.
10. V Arutchelvam, T Heise, S Dellweg, B Elbroend, I Minns and PD Home. Plasma glucose and hypoglycaemia following exercise in people with Type 1 diabetes: a comparison of three basal insulins. Diabetic medicine 2009:26; 1027-1032.
RECENT PUBLICATIONS IN DIABETES & ENDOCRINOLOGY THAT HIT THE NEWS OR THAT MAY HAVE A SIGNIFICANT IMPACT ON MANAGEMENT
Hyperkalaemia. Moffat et al. BMJ 2009;339:1019-1024. An excellent practical review. Well worth a read.
Is haemoglobin A1c a step forward for diagnosing diabetes? Eric Kilpatrick et al. BMJ 2009;339:1288-1290. A must read review. My personal answer, NO but it does have a role. Example 75-yr old with 2 fasting glucoses of 7.0 and 6.9 mmol/l AND a HbA1c of 59 mmol/mol probably does have diabetes, hence saving an OGTT.
Aspirin for primary prevention of vascular disease in people with diabetes. Balance of benefits versus risks is unclear. Richard Haynes et al. BMJ 2009;339:1210-1211. A good editorial with the linked meta-analysis worth a read.
Metformin associated lactic acidosis. Emma Fitzgerald et al. BMJ 2009;339:1254-1256. A timely reminder case report that includes a wonderful diagrame explaining the phenomenon biochemically.
Surgery for obesity in adulthood. Daniel Richard Leff and Dugal Heath. BMJ 2009;339:740-746. An excellent review and update.
Sarcoidosis. Owen J Dempsey et al. BMJ 2009;339:620-625. An excellent review that is practical.
Osteoporosis associated with neutralizing autoantibodies against osteoprotegerin. Philip Riches et al. NEJM 2009;361:1459-1465. An interesting case report.
Renal-artery stenosis. Lance Dworkin and Christopher Cooper. NEJM 2009;361:1972-1978. A wonderful review article. Practical and useful for diabetic renal clinic.
Pre-eclampsia, soluble fms-like tyrosine kinase 1, and the risk of reduced thyroid function: nested case-control and population based study. Levine RJ, et al. BMJ. 2009 Nov 17;339:b4336. This Nested case-control study during pregnancy and population based follow-up study after pregnancy as part of the Calcium for Pre-eclampsia Prevention trial of healthy pregnant nulliparous women in the United States during 1992-5 and a Norwegian population based study(Nord-Trondelag Health Study or HUNT-2) during 1995-7 with linkage to the medical birth registry of Norway, studied serum measurements of in 141 women before 21 weeks' gestation(baseline) and after onset of pre-eclampsia (before delivery); 141 normotensive controls with serum measurements at similar gestational ages, and 7121 women in the Nord-Trondelag Health Study whose first birth had occurred in 1967 or later and in whom serum levels of TSH had been subsequently measured. The main outcome measures were: thyroid function tests and human chorionic gonadotrophin and soluble fms-like tyrosine kinase 1 concentrations in the Calcium for Pre-eclampsia Prevention cohort and odds ratios for levels of TSH above the reference range, according to pre-eclampsia status in singleton pregnancies before the Nord-Trondelag Health Study. In predelivery specimens of the Calcium for Pre-eclampsia Prevention cohort after the onset of pre-eclampsia, TSH levels increased 2.42 times above baseline compared with a 1.48 times increase in controls. The ratio of the predelivery to baseline ratio of cases to that of the controls was 1.64 [95%CI 1.29-2.08]. Free T3 decreased more in the women with pre-eclampsia than in the controls (case ratio to control ratio 0.96[0.92-0.99]. The predelivery specimens but not baseline samples from women with pre-eclampsia were more likely than those from controls to have TSH levels above the reference range (adjusted odds ratio 2.2[1.1-4.4]. Both in women who developed pre-eclampsia and in normotensive controls the increase in TSH concentration between baseline and predelivery specimens was strongly associated with increasing quarters of predelivery soluble fms-like tyrosine kinase 1 (P for trend 0.002 and <0.001, respectively). In the Nord-Trondelag Health Study, women with a history of pre-eclampsia in their first pregnancy were more likely than other women(adjusted odds ratio 1.7[1.1-2.2] to have TSH levels above the reference range. In particular, they were more likely to have high concentrations of TSH without thyroid peroxidase antibodies (adjusted odds ratio 2.6[1.3-5.0], suggesting hypothyroidism in the absence of an autoimmune process. This association was especially strong (5.8[1.3-25.5] if pre-eclampsia had occurred in both the first and the secondpregnancies. This study suggests that increased serum concentration of soluble fms-like tyrosine kinase 1 during pre-eclampsia is associated with subclinical hypothyroidism during pregnancy. Pre-eclampsia may also predispose to reduced thyroid function in later years. Should we screen all women with pre-eclampsia for hypothyroidism?
Three-year efficacy of complex insulin regimens in type 2 diabetes. Holman RR, et al. N Engl J Med. 2009 Oct 29;361(18):1736-47. In this 3-year open-label, multicentre trial 708 patients who had suboptimal glycaemic control while taking metformin and sulfonylurea therapy were randomly assigned to receive biphasic insulin aspart twice daily, prandial insulin aspart three times daily, or basal insulin detemir once daily (twice if required). Sulfonylurea therapy was replaced by a second type of insulin if hyperglycaemia became unacceptable during the first year of the study or subsequently if HbA1c more than 6.5%. The median HbA1c levels were similar for patients receiving biphasic (7.1%), prandial (6.8%), and basal (6.9%) insulin-based regimens (P=0.28). However, fewer patients had a level of 6.5% or less in the biphasic group (31.9%) than in the prandial group (44.7%, P=0.006) or in the basal group (43.2%, P=0.03), with 67.7%, 73.6%, and 81.6%, respectively, taking a second type of insulin (P=0.002). Median rates of hypoglycemia per patient per year were lowest in the basal group (1.7), higher in the biphasic group (3.0), and highest in the prandial group (5.7) (P<0.001 for the overall comparison). The mean weight gain was higher in the prandial group than in either the biphasic group or the basal group. Other adverse event rates were similar in the three groups. In conclusion it can be said that patients who added a basal or prandial insulin-based regimen to oral therapy had better glycaemic control than patients who added a biphasic insulin-based regimen. Fewer hypoglycemic episodes and less weight gain occurred in patients adding basal insulin. However, 68-82% of patients in the trial received an additional type of insulin to achieve a median HbA1c < 6.9%. Hence, in effect most patients were on “complex” insulin regimens regardless of their starting point. Does this study change my practice? No, it simply reaffirms my belief that we should aggressively lower HbA1c in patients with Type 2 diabetes to a target of < 53mmol/mol (7%) using the regimen that best suits the patients lifestyle and individual circumstances. Trying to introduce an algorithm that can be used as a one glove fits all may pamper towards pharmacia and government drive agendas, but ultimately what is required is an experienced MDT that can manage the circumstances of any individual regardless of affiliation.
NEXT NEWSLETTER Due out beginning of June 2010 so keep the gossip coming.
Endodiabology.blogspot.com
NORTHEAST
NEWSLETTER
FOR SPRs AND BOSSES TRAPPED
IN THE NORTHERN DEANERY
FEBRUARY 2010
Editors: Shaz Wahid (shahid.wahid@sthct.nhs.uk) and
Petros Perros (petros.perros@ncl.ac.uk) and Arut Vijayaraman (riarut@aol.com )
Associate Editors: Shafie Kamarrudin, Ravi Erukulapati
SpR PLACEMENTS (NTN year of training from 1st October 2008)
• Newcastle- Ravi Erukalapati(5), Sudeep Manohar (3), Nimanth De Alwis (1), Arif Ullah (3), Srikanth Mada(3) Naveen Siddaramaiha (2), Sarah Steven (2)
• North Tyneside/Wansbeck- Anjali Santhakumar (3), Kathryn Stewart (3)
• South Tyneside- Rohanna Wright (2),
• Gateshead- Preeti Rao (3)
• Sunderland- Beas Bhattacharya (5) then Naveen Aggarwal (1), Chandima Idampitiya (5)
• North Tees/Hartlepool- Shafie Kamarrudin (4), Hamza Ali Khan (1)
• Middlesbrough- Freda Razvi (5), Atif Munir (1), Sajid Ethol Kalathil (1), Catherine Napier (1)
• Bishop Auckland Khaled Mansur-Dukhan (5)
• Durham- Jeevan Mettayil (4)
• NGH/QEH- Vacant
• Research with numbers (supervisor)- Eelin Lim(5-Prof Taylor); Stuart Little (2-Dr Shaw) & Asgar Madathil (4-Dr Weaver)
MEETINGS / LECTURES / ANNOUNCEMENTS
• 23rd February 2010 SfE National Clinical Cases meeting, venue TBC. Contact www.endocrinology.org
• 3rd- 5th March 2010 DUK Annual Professional Conference, Liverpool. Contact www.diabetes.org.uk
• 6th March 2010 Association of Physicians, 9am-1pm, Bishop Auckland. Contact clive.kelly@ghnt.nhs.uk
• 15th – 18th March 2010 BES 2010, Manchester. Contact www.endocrinology.org.
• 17th March 2010 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
• 28th April 2010 RCP Acute Medicine symposium, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
• 6th-7th May 2010 ABCD Spring Meeting, The Hilton, GATESHEAD. Contact www.diabetologists.org.uk
• 12th May 2010 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
• 8th June 2010 Northern Endocrine & Diabetes Spring CME, Freeman Hospital. Contact
• 19th – 22nd June 2010 ENDO 2010, San Diego, USA. Contact endostaff@endo-societ.org or www.endo-society.org/scimeetings .
• 25th – 29th June 2010 American Diabetes Association 70th Annual Scientific Sessions, Orlando, Florida, USA. Contact meetings@diabetes.org .
• 14th July 2010 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
• 15th September 2010 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
• 20th – 24th September 2010 46th EASD Annual meeting, Stockholm, Sweden. Contact www.easd.org
• 8th-10th November 2010 Society for Endocrinology Clinical Update, venue TBC. Contact www.endocrinology.org
• 9th November 2010 RCP Updates in Medicine, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
• 17th November 2010 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
• 18th-19th November 2010 ABCD autumn meeting, London. Contact www.diabetologists.org.uk followed by SpRs meeting 19th-21st November 2010.
• 24th November 2010 Northern Endocrine Region Research and Audit Group annual meeting, Lumley Castle, Durham 2pm-8pm. Contact shahid.wahid@sthct.nhs.uk
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.
SPR management training session: “what works in the NHS and what does not”-David Hambleton. Lumley Castle 6-8pm 24th February 2010. Contact anjalisan@yahoo.com for more information.
ARCP (RITA) The next round was due on Weds 12th, Thurs 13th & Fri 15th May 2010, however due to clashes this may be changed to week beginning 24th May 2010. Trainees please keep these dates free as possible. Those trainees transferring on to the new GIM curriculum will have a separate ARCP on 18th May 2010. More information to follow.
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.
General Internal Medicine Curriculum is now updated and available on www.jrcptb.org.uk. All trainees appointed ST3 from August 2009 will be offered entry to train for this CCT. Trainees before this date can easily apply to train in this CCT (i.e. dual accredit), again detailed in the website. Reviewing the new curriculum for G(I)M each trainee will need 6 ACATs, 4-CBDs and 4 Mini-CEXs in G(I)M as well as the specialty work based assessments. The publication of this curriculum and the formation of a National SAC in G(I)M separate from the Acute Medicine SAC really does mean that in practical terms the 2 specialties will be split. Our current G(I)M/Acute Medicine STC is preparing for this split this year. It is important that trainees keep a record of all GIM patients they have seen either as emergency or out-patient. There are plans to introduce an audit system.
MRCP Diabetes & Endocrinology This exam has to be completed and passed by all trainees appointed after August 2007 before their PYA. We recommend sitting it ASAP and well before your PYA.
INFORMATION for QA Could each individual trainer send the following to Simon Pearce: educational qualifications, any training positions held and any educational courses attended.
MORE INFORMATION for QA Could each unit’s Training Lead please send to Simon Pearce a completed training unit information report and an updated SpR/StR job description as per Nicky Leech’s e-mail.
Trainers & Trainees meeting The next T&T is on 24th June 2010. Details to be confirmed nearer the time, but please note in your diary.
Training Committee Chair- Simon Pearce, s.h.s.pearce@ncl.ac.uk; 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-Arutchelvam Vijayaraman Vijayaraman.Arutchelvam@stees.nhs.uk ; Consultant member-Simon Eaton, simon.eaton@northumbria-healthcare.nhs.uk; SpR representative- Anjali Santhakumar anjalisan@yahoo.com ; SpR representative- Jeevan Mettayil jmjeevan@yahoo.com
NEWS FROM THE NORTHEAST
• Congratulations to Anjali Santhakumar as our new Trainee rep.
• Arut will be remaining on the STC as a Consultant member.
• Congratulations to Ana Jovanovic on her MD.
• Congratulations to Latika Sibal on her PhD, she is currently in a Locum Consultant post at Adenbrookes.
• ABCD is coming to town. Please note that this excellent national meeting will be visiting the region on 6-7th May 2010 at the Hilton in Gateshead. See above.
• In Nov 2009, RQ spent 3 days in November 09 as Elliot B. Shoolman visiting lecturer/professor at the Reproductive Endocrinology Unit of Harvard University/Massachusetts General Hospital. Stayed in Boston with Balasubramanian Ravikumar, former NorthEast trainee, who is now a Research Fellow in that Unit.
• Welcome to Dr SoPye who was started work 21st December 2009 at University Hospital Hartlepool. He trained in Leicester. He is appointed as an Acute Physician with interest in D & E.
LETTERS
Book review-Shaz Wahid: Clinical Leadership-Bridging the Divide by Emma Stanton, Claire Lerner and James Mountford published by Quay Books.
An excellent short book that I regard as essential reading for all trainees and a must for Consultants to dip into. It is written by trainees supported by experienced NHS leaders. Its style of exploring history and putting it into context in the modern NHS reads very well. Its tips on personal development are superb. It focuses on the individual followed by the team followed by the organization and then National strategy. After reading it I am sure everyone would be interested in something they read in it and follow this up with further reading and courses. Reading this book has taught me new tricks and changed my practice. I have often been asked by trainees how do I demonstrate management skills when applying for jobs. Firstly, management skills are really leadership skills. Well on page 94 there is a wonderful template that lists workplace opportunities to develop leadership skills as a postgrad trainee. The broad areas identified are (in brackets I have put personal examples from when I were a lad (SpR)):
-Identifying areas for change (foot care at QEH)
-Rota Management (The Diabetes centre and Freeman hospital clinic rota)
-Department induction (Inducing juniors to the ward)
-Guideline development (glucose Mx in MI at QEH)
-Teaching/education/supervision (final year teaching course at North Tees)
-People and performance management (looking after the yunguns!)
-Attending and contributing to meetings (NEDS CME organizer)
-Operational matters (Associate College Tutor at QEH)
-Service quality and improvements (multiple service delivery audits)
-Identifying key players in the Trust (have sat down with CDs, Execs at Hartlepool)
-Understanding Trust Strategy (LDSAGs, Physicians meetings)
-National Strategy (NRDSAG)
I hope this review has provoked interest and action.
Efficient Clinical Coding- A Means to Improving Costing- Dr.Ravi Erukulapati
What is Clinical Coding?
The translation of medical terminology, as written by the clinician, to describe a patient’s complaint, problem, diagnosis, treatment or reason for seeking medical attention, into a coded format which is nationally and internationally recognised.
Why do we do it?
• Forms the basis of medical research and medical audit
• Population healthcare needs analysis by Health Authorities
• Essential for internal management by directorates
• Vital in examining local and national trends
• Used for research and epidemiology
• Forms the basis of case mix groups and Healthcare Resource Groups (HRG's)
Clinical Coding and Commissioning
The introduction of Payment by Results means that all Trusts in England will use a fixed price tariff for specific treatments. At the heart of these financial flows is coded clinical information. The advent of such tariffs has had an impact on the Primary Care Trusts (PCTs) and others who commission services using coded clinical data. Previously a PCT commissioned health care services without necessarily requiring a full understanding of coded clinical data, its structure, how it is gathered and how the rules and conventions are applied. The coded clinical data is grouped to meet the reporting structure of Payment by Results to ensure the trusts are paid accurately for activity. The increased importance of clinical coded data means that all commissioners of patient services now need to comprehend clinical coded data to be able to understand what they are commissioning and what the providers are saying they are delivering. Without this understanding various ‘hot topics’ related to clinical coding can arise which can result in misunderstandings between provider and commissioner. The NHS requires input of accurate data to reflect clinical activity and trusts now have a financial incentive to ensure that coding is accurate, comprehensive and timely.
How is Clinical Coding derived? The source documentation used for coding varies from hospital to hospital, but is normally the patient’s case notes.
The case notes hold:
• Discharge summaries
• Proformas
• Clinical work sheets
• Hospital, patient and GP documentation
The coding process
Patient admitted to hospital.
↓
Patient discharged following treatment.
↓
Information extracted from case notes and translated into coded format using Classifications (ICD-10 and OPCS-4)
↓
Coded information recorded on hospital’s Patient Administration System (PAS), with copy of Coding placed in case notes for doctor to verify or query.
How clinicians can help coders to achieve complete and accurate clinical coding
• Ask to meet the Clinical Coders and assist them when there is a query about a diagnosis or procedure
• Ensure that the discharge summary is complete at discharge
• Follow the guidelines when completing the Discharge summary
How is the information in case notes translated into Codes?
For Example:
Patient admitted with a closed fracture left distal radius after falling from a chair at home. The patient is a non-insulin diabetic and suffers from chronic ischaemic heart disease. Patient’s fracture treated with manipulation and skeletal traction.
The coding screen on the Trust’s Patient Administration System
(PAS) will contain the following:
DIAGNOSES:
S52.50 Fracture lower end radius, closed
W07.0 Fall involving chair, home
E11.9 Non-insulin dependant diabetes mellitus
I25.9 Chronic ischaemic heart disease
PROCEDURE:
W26.1 Manipulation of fracture of bone and skeletal traction
Z70.5 Lower end of radius
Z94.3 Left sided operation
Recording vague diagnoses
• Use of Probable vs. Possible
• Clinical coding can only be as accurate as the information that clinicians record in the patient case notes.
• If clinician records diagnoses as follows:
This patient has Chest Pain ? Angina
Then the clinical coder will only code the Chest Pain/not the Angina
• If clinician records Possible MI then the clinical coder will only code the patient’s symptoms, not the MI.
• However, if clinician records Probable MI then the clinical coder will code the MI
References and further reading
1.) Improving clinical records and clinical coding together - A project with the Audit Commission, Royal College of Physicians, August 2008, www.audit-commission.gov.uk
2.) Frequently Asked Question - Telephone Activity — NHS Connecting for Health http://www.connectingforhealth.nhs.uk/systemsandservices/data/nhsdmds/help/faqs
3.) http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/noncoders/clinicians
4.) http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/noncoders/commissioners
5.) http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/noncoders
6.) Hospital Activity Data, A Guide for Clinicians, Produced by the RCP Information Laboratory (lab)
Maximising Efficiency the “Lean” Way M S Kamaruddin
In the current economic climate, the National Heath Service (NHS) will undoubtedly face challenging times especially when massive budget cuts to the NHS is anticipated. How do we rise to this challenge without compromising quality of care? In line with the recently published NHS Operating Framework for 2010/11, it emphasises the need to maintain high quality of care despite a tighter economic climate through a process that focuses on quality, innovation, productivity and prevention.1
This reminds me of how the automotive industry revolutionised their manufacturing principles by eliminating waste. This concept have been widely adopted and practiced in the manufacturing sector and is also increasingly used in health care. Lean is a term adopted from Japanese manufacturing principles defining a philosophy that abhors waste in any form and relentlessly strives to improve quality. Waste is defined as any action that does not add value to the product; in health care terms this should be the patient experience.2 The Lean concept also empowers its staff and provide them with the tools to make changes. In the context of health care, doctors and other allied health care professionals become focused not only on taking care of the patient, but also on finding better ways to take better care of patients. They are in a position to do so as frontline staff has better insight to the task at hand.
The Lean approach in improving efficiency is first done by studying every step of the process that is being evaluated. To site an example that have been tried and tested successfully in a local hospital in North East recently is the process of a patient attending the endoscopy unit. The whole patient experience and journey from arrival to leaving the unit was evaluated at every step i.e. from arrival in the waiting room to nursing documentation, consent and right down to the procedure itself and discharge. The time line for each step is quantified into value added and non-value added (waste) steps. The team will then identify which step adds value to the patient experience and which step incurs unnecessary cost and resources.
In this case (figure 1) the unnecessary nursing documentation of details, which are often irrelevant, could be eliminated. Essential patient details such as drug allergy can be obtained during consent. The patient waiting time could also be minimized to improve patient experience. The additional nursing staff originally used for documentation could be mobilised to the discharge or recovery area. In essence the reduction of 12 minutes per case could essentially accommodate additional procedures for the session hence increasing productivity without compromising patient care.
Figure 1. Flow of patient movement through the endoscopy unit before & after application of Lean principles.
This principle could easily be applied to a typical busy acute medical admission setting. A patient typically goes through repetitive steps right from beginning in accident & emergency only to be repeated again in the medical admission unit. With careful planning much time could be saved and the patient journey could be improved upon.
References:
1. Department of Health. Guidance; The NHS operating framework for England for 2010/11. 16th December 2009
2. Eric W. Dickson, et al. Application of Lean Manufacturing Techniques in the Emergency Department.
RECENT PUBLICATIONS FROM THE NORTHEAST
1. Raivio T, Sidis Y, Plummer L, Chen H, Ma J, Mukherjee A, Jacobson-Dickman E, Quinton R, Van Vliet G, Lavoie H, Hughes VA, Dwyer AA, Hayes FJ, Xu S, Sparks S, Kaiser UB, Mohammadi M, Pitteloud N. 2009 Impaired fibroblast growth factor receptor 1 signaling as a cause of normosmic idiopathic hypogonadotropic hypogonadism. Journal of Clinical Endocrinology & Metabolism. 94: 4380-4390.
2. Hill S, Arutchelvan V, Quinton R. 2009 Enclomiphene, an estrogen receptor antagonist for the treatment of testosterone deficiency in men. Idrugs. 12: 109-119.
3. Syed AA, Jones NAG, Bliss R, Roberts T, Mallick U, Johnson S, Douglas F, Perros P, Quinton R. 2009 Metachronous testicular teratoma, testicular seminoma and papillary thyroid carcinoma occurring in a single individual: a report of two unrelated cases. European Journal of Cancer Care. Nov 11. [Epub ahead of print].
4. Gan EH, Wahid ST, Quinton R. 2009 Hypercalcaemia: two myths. BMJ. 339: b5649.
5. Quinton R. 2009 The story of Axel Munthe. Clinical Medicine. 9: 504-505.
6. Shakoor SK, Aldibbiat A, Ingoe LE, Campbell SC, Sibal L, Shaw J, et al. Endothelial Progenitor Cells in Subclinical Hypothyroidism: The Effect of Thyroid Hormone Replacement Therapy. J Clin Endocrinol Metab 2009.
7. Ramchurn N, Mashamba C, Leitch E, Arutchelvam V, Narayanan K, Weaver J, et al. Upper limb musculoskeletal abnormalities and poor metabolic control in diabetes. Eur J Intern Med 2009;20(7):718-21.
8. Cooke D, Hurel SJ, Casbard A, Steed L, Walker S, Meredith S, et al. Randomized controlled trial to assess the impact of continuous glucose monitoring on HbA(1c) in insulin-treated diabetes (MITRE Study). Diabet Med 2009;26(5):540-7.
9. Sibal L, Aldibbiat A, Agarwal SC, Mitchell G, Oates C, Razvi S, et al. Circulating endothelial progenitor cells, endothelial function, carotid intima-media thickness and circulating markers of endothelial dysfunction in people with type 1 diabetes without macrovascular disease or microalbuminuria. Diabetologia 2009;52(8):1464-73.
10. V Arutchelvam, T Heise, S Dellweg, B Elbroend, I Minns and PD Home. Plasma glucose and hypoglycaemia following exercise in people with Type 1 diabetes: a comparison of three basal insulins. Diabetic medicine 2009:26; 1027-1032.
RECENT PUBLICATIONS IN DIABETES & ENDOCRINOLOGY THAT HIT THE NEWS OR THAT MAY HAVE A SIGNIFICANT IMPACT ON MANAGEMENT
Hyperkalaemia. Moffat et al. BMJ 2009;339:1019-1024. An excellent practical review. Well worth a read.
Is haemoglobin A1c a step forward for diagnosing diabetes? Eric Kilpatrick et al. BMJ 2009;339:1288-1290. A must read review. My personal answer, NO but it does have a role. Example 75-yr old with 2 fasting glucoses of 7.0 and 6.9 mmol/l AND a HbA1c of 59 mmol/mol probably does have diabetes, hence saving an OGTT.
Aspirin for primary prevention of vascular disease in people with diabetes. Balance of benefits versus risks is unclear. Richard Haynes et al. BMJ 2009;339:1210-1211. A good editorial with the linked meta-analysis worth a read.
Metformin associated lactic acidosis. Emma Fitzgerald et al. BMJ 2009;339:1254-1256. A timely reminder case report that includes a wonderful diagrame explaining the phenomenon biochemically.
Surgery for obesity in adulthood. Daniel Richard Leff and Dugal Heath. BMJ 2009;339:740-746. An excellent review and update.
Sarcoidosis. Owen J Dempsey et al. BMJ 2009;339:620-625. An excellent review that is practical.
Osteoporosis associated with neutralizing autoantibodies against osteoprotegerin. Philip Riches et al. NEJM 2009;361:1459-1465. An interesting case report.
Renal-artery stenosis. Lance Dworkin and Christopher Cooper. NEJM 2009;361:1972-1978. A wonderful review article. Practical and useful for diabetic renal clinic.
Pre-eclampsia, soluble fms-like tyrosine kinase 1, and the risk of reduced thyroid function: nested case-control and population based study. Levine RJ, et al. BMJ. 2009 Nov 17;339:b4336. This Nested case-control study during pregnancy and population based follow-up study after pregnancy as part of the Calcium for Pre-eclampsia Prevention trial of healthy pregnant nulliparous women in the United States during 1992-5 and a Norwegian population based study(Nord-Trondelag Health Study or HUNT-2) during 1995-7 with linkage to the medical birth registry of Norway, studied serum measurements of in 141 women before 21 weeks' gestation(baseline) and after onset of pre-eclampsia (before delivery); 141 normotensive controls with serum measurements at similar gestational ages, and 7121 women in the Nord-Trondelag Health Study whose first birth had occurred in 1967 or later and in whom serum levels of TSH had been subsequently measured. The main outcome measures were: thyroid function tests and human chorionic gonadotrophin and soluble fms-like tyrosine kinase 1 concentrations in the Calcium for Pre-eclampsia Prevention cohort and odds ratios for levels of TSH above the reference range, according to pre-eclampsia status in singleton pregnancies before the Nord-Trondelag Health Study. In predelivery specimens of the Calcium for Pre-eclampsia Prevention cohort after the onset of pre-eclampsia, TSH levels increased 2.42 times above baseline compared with a 1.48 times increase in controls. The ratio of the predelivery to baseline ratio of cases to that of the controls was 1.64 [95%CI 1.29-2.08]. Free T3 decreased more in the women with pre-eclampsia than in the controls (case ratio to control ratio 0.96[0.92-0.99]. The predelivery specimens but not baseline samples from women with pre-eclampsia were more likely than those from controls to have TSH levels above the reference range (adjusted odds ratio 2.2[1.1-4.4]. Both in women who developed pre-eclampsia and in normotensive controls the increase in TSH concentration between baseline and predelivery specimens was strongly associated with increasing quarters of predelivery soluble fms-like tyrosine kinase 1 (P for trend 0.002 and <0.001, respectively). In the Nord-Trondelag Health Study, women with a history of pre-eclampsia in their first pregnancy were more likely than other women(adjusted odds ratio 1.7[1.1-2.2] to have TSH levels above the reference range. In particular, they were more likely to have high concentrations of TSH without thyroid peroxidase antibodies (adjusted odds ratio 2.6[1.3-5.0], suggesting hypothyroidism in the absence of an autoimmune process. This association was especially strong (5.8[1.3-25.5] if pre-eclampsia had occurred in both the first and the secondpregnancies. This study suggests that increased serum concentration of soluble fms-like tyrosine kinase 1 during pre-eclampsia is associated with subclinical hypothyroidism during pregnancy. Pre-eclampsia may also predispose to reduced thyroid function in later years. Should we screen all women with pre-eclampsia for hypothyroidism?
Three-year efficacy of complex insulin regimens in type 2 diabetes. Holman RR, et al. N Engl J Med. 2009 Oct 29;361(18):1736-47. In this 3-year open-label, multicentre trial 708 patients who had suboptimal glycaemic control while taking metformin and sulfonylurea therapy were randomly assigned to receive biphasic insulin aspart twice daily, prandial insulin aspart three times daily, or basal insulin detemir once daily (twice if required). Sulfonylurea therapy was replaced by a second type of insulin if hyperglycaemia became unacceptable during the first year of the study or subsequently if HbA1c more than 6.5%. The median HbA1c levels were similar for patients receiving biphasic (7.1%), prandial (6.8%), and basal (6.9%) insulin-based regimens (P=0.28). However, fewer patients had a level of 6.5% or less in the biphasic group (31.9%) than in the prandial group (44.7%, P=0.006) or in the basal group (43.2%, P=0.03), with 67.7%, 73.6%, and 81.6%, respectively, taking a second type of insulin (P=0.002). Median rates of hypoglycemia per patient per year were lowest in the basal group (1.7), higher in the biphasic group (3.0), and highest in the prandial group (5.7) (P<0.001 for the overall comparison). The mean weight gain was higher in the prandial group than in either the biphasic group or the basal group. Other adverse event rates were similar in the three groups. In conclusion it can be said that patients who added a basal or prandial insulin-based regimen to oral therapy had better glycaemic control than patients who added a biphasic insulin-based regimen. Fewer hypoglycemic episodes and less weight gain occurred in patients adding basal insulin. However, 68-82% of patients in the trial received an additional type of insulin to achieve a median HbA1c < 6.9%. Hence, in effect most patients were on “complex” insulin regimens regardless of their starting point. Does this study change my practice? No, it simply reaffirms my belief that we should aggressively lower HbA1c in patients with Type 2 diabetes to a target of < 53mmol/mol (7%) using the regimen that best suits the patients lifestyle and individual circumstances. Trying to introduce an algorithm that can be used as a one glove fits all may pamper towards pharmacia and government drive agendas, but ultimately what is required is an experienced MDT that can manage the circumstances of any individual regardless of affiliation.
NEXT NEWSLETTER Due out beginning of June 2010 so keep the gossip coming.
Labels: Diabetes, Endocrinology, North UK
posted by Arutchelvam at 12:12 PM
