Endodiabology May 2011 Issue 2
ENDODIABOLOGY
Endodiabology.blogspot.com
NORTHEAST
NEWSLETTER
FOR SPRs AND BOSSES TRAPPED
IN THE NORTHERN DEANERY
June 2011
Editors: Shaz Wahid, Petros Perros and Arutchelvam Vijayaraman
Associate Editor: Srikanth Mada
StR PLACEMENTS (NTN year of training from 1st October 2010)
• Newcastle- Atif Munir (2), Sajid Ethol Kalathil (2), Catherine Napier (2), Naveen Aggarwal (2), Hamza Ali Khan (2), Agnieska Sawiecicka (1), Vacant
• North Tyneside/Wansbeck- Alison Heggie (1), Vacant
• South Tyneside- Nimanthe De Alwis (2)
• Gateshead- Kathryn Stewart (3)
• Sunderland- Jakob Buckovan (1), vacant
• North Tees/Hartlepool- Sudeep Manohar (4), vacant
• Middlesbrough- Arif Ullah (4), Naveen Siddaramaiha (4), Shunmugam Nellaiappan (1)
• Bishop Auckland/Darlington/Durham- Sathia Raghavan(1), Vacant
• NGH- Srikanth Mada(4),
• Research with numbers (supervisor)- Stuart Little (3-Dr Shaw), Asgar Madathil (4-Dr Weaver), Sarah Steven (3-Prof Taylor), Anna Mitchell (1-Prof Pearce), Earn Gan (1-Prof Pearce)
• Maternity Leave Rohana Wright (3), Anjali SanthaKumar (3)
MEETINGS / LECTURES / ANNOUNCEMENTS
• 4th-7th June 2011 ENDO 2011, Boston, USA. Contact endostaff@endo-societ.org or www.endo-society.org/scimeetings .
• 16th June 2011 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk
• 24th – 28th June 2011 American Diabetes Association 71st Annual Scientific Sessions, San Diego, USA. Contact meetings@diabetes.org .
• 13th July 2011 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk
• 12th - 16th September 2011 47th EASD annual meeting, Lisbon, Portugal. Contact www.easd.org
• 14th September 2011 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk
• 21st September 2011 DUK APC 2012 abstract deadline.
• 11th October 2011 SfE Regional Clinical Cases Meeting. Venue TBC. Contact www.endocrinology.org/meetings/index
• 12th October 2011 Northern Endocrine & Diabetes Autumn CME, Durham. Contact Sarah Steven(sarah.steven@doctors.org.uk ) or Srikanth Mada (srikanth.mada@nhs.net )
• 7th – 9th November 2011 SfE Clinical Update 2011. Venue TBC. Contact www.endocrinology.org/meetings/index
• 16th November 2011 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk
• 23rd November 2011 Northern Endocrine Region Research and Audit Group meeting, Lumley Castle, Chester-le-street. Contact Shahid.wahid@stft.nhs.uk
• 24th-25th November 2011 Middlesbrough insulin pump course. Contact Nicky.Skippon@stees.nhs.uk
• 30th November 2011 RCP Updates in Medicine, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
TRAINING ISSUES
STOP PRESS: NEW Assessment tools Please see www.jrcptb.org.uk; It is the trainee’s responsibility to make sure that the appropriate assessments are available in their portfolio for ARCP purposes. For 2011 there are 3 new work based assessment tools available: Patient Surveys, Audit Assessment and Teaching Observation. It is essential that you review the web site and make arrangements to utilize these new assessment tools as evidence for your ARCP.
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.
Registering with PMETB It is essential that all new StRs (even LATs) register with the PMETB through the Joint Royal Colleges of Physicians Training Board on www.jrcptb.org.uk. Not doing so means your training is not counted.
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.
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 G(I)M PYAs.
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.
The Kelly-Young MRCP Diabetes & Endocrinology Prize This prize is awarded annually at NERRAG to the youngest in terms of training year StR passing the MRCP Diabetes & endocrinology exam. Richard Quinton secures the funding of £800 and it is named after 2 distinguished former Endocrinologists in the region, Bill Kelly and Eric Young.
Faculty training day The next Faculty training day is on 14th June 2011. It kicks off with the STC meeting followed by a trainers training session and the Trainers and Trainees meeting from 1530. For more details see the letters section.
GIM ARCPs This year’s GIM ARCP made for grim reading for our training programme. Out of the 12 trainees assessed 3 achieved an outcome 1 (satisfactory progression), 8 achieved an outcome 2 (targeted training needed with no additional time to CCT date) and 1 achieved an outcome 5 (further information required to make an award). The fall-out of this poor showing is multifactorial and something we will have to address. Before you blame the tensions between balancing GIM and specialty, the reasons relate a lot more to the fundamentals of educational supervision and trainee engagement. Further discussion will occur at the T&T meeting planned for 14th June 2011.
Critical incident/complaint If you are involved in a critical incident or if reporting an incident concerning training issues please inform your supervisor and the TPD. Ensure they are reflected upon in your portfolio
Educational Supervision With revalidation requiring evidence of effectiveness in all of our roles as a Consultant and with the School of Medicine publishing minimum standards for Educational Supervisors (see letters section), this critical role will come under the spotlight in the next 18-24 months. It is no longer acceptable to simply have been to the training courses and undertaken education supervision and other regional activity, such as ARCPs. The Consultant will have to show effectiveness in this role. The effectiveness of this role will be appraised at a Consultant’s appraisal (it should be any appraiser worth their salt!). To help a Consultant gather evidence of their effectiveness as an Educational Supervisor, at this year’s ARCPs the panel has made a note of good practice and areas to improve for each educational supervisor when reviewing their trainee’s e-portfolio using a structured feedback form developed by the School of Medicine. This feedback form will be returned to each educational supervisor for both GIM and DM&ENDO ARCPs so that they can reflect on their performance and develop an action plan for their appraisal to be part of their PDP. There will always need to be a carrot! It is common practice to ask trainees to vote with their feet when choosing a training unit. Following the GIM ARCPs, there has been a ground shift with the first factor to consider when allocating trainees post ARCP rapidly becoming the quality and effectiveness of the Educational Supervision that the training unit can deliver and has delivered.
Training Committee Chair- Nicky Leech nicola.leech@nuth.northy.nhs.uk; Regional Speciality Advisor- Shaz Wahid, shahid.wahid@sthct.nhs.uk; Programme Director- Arutchelvam Vijayaraman Vijayaraman.Arutchelvam@stees.nhs.uk; Consultant member (SAC rep)- Richard Quinton, Richard.Quinton@nuth.nhs.uk; Consultant member-Jean MacLeod, Jean.Macleod@nth.nhs.uk; Consultant member-Dr Peter Carey; Consultant member-Simon Eaton, simon.eaton@northumbria-healthcare.nhs.uk; SpR representative-Srikanth Mada srikanth.mada@nhs.net ; SpR representative-Stuart Little stuartlittle@doctors.org.uk
NEWS FROM THE NORTHEAST
• Congratulations to Mark Walker for being recently selected as an NIHR Senior Investigator, the first for our Region in Endocrinology and Metabolism.
• Some kind words for the region from Preethi Rao “I got the ‘Clinical endocrinology trust clinical practice award’ and ‘ highly commended oral presentation prize’ yesterday at the BES for the study I did with Salman at Gateshead. The title of the study is ‘Thyroid hormones in the euthyroid range predict subsequent body mass composition in women: The OPUS study’. I also got the opportunity to present our data at the young endocrinologist prize session. I am extremely thankful to the northern deanery and in particular to Salman for training me well to achieve these. I hence wanted to share this good news with you as I think the credit of these prizes definitely go to the northern deanery “.
• Congratulations to Sajid Kalathil and co-authors for their Best Poster award at the Pituitary Clinicopathological meeting in London in February 2011, the poster was on 'sellar Haemangiopericytoma'.
LETTERS
Faculty Development Day-Simon Pearce
I have arranged a further 'Training the Trainers' session on the subject of "Recognising and Responding to Underperforming trainees(including Action Planning)" to be delivered by Juliet Graves.
This session will be before the Trainers and Trainees meeting from 11.00 to 15.00 on June 14th, with the T&T meeting being from 15.30 to 18.00, both at the SHA Waterfront Building, Newburn.
Members of the STC will meet 09.30 to 10.45 at the same venue:
Northern Deanery
Waterfront 4
Newburn Riverside
Newcastle upon Tyne
NE15 8NY
Educational Supervisor, Clinical Supervisor and Clinical Trainer standards-Shaz Wahid
The Deanery School of Medicine have produced minimal standards for this varied group of trainers. The standards require that Trainers are selected for their roles, must understand what they are training in and must demonstrate ability as effective trainers. The School states that this is a developmental process and that not all specialties and sites will expect to be able to work to the highest standards immediately.
An Education Supervisor (ES) is defined as a trainer who is selected and appropriately trained to be responsible for the overall supervision and management of a specified trainee’s educational progress during a training placement or series of placements. The ES is responsible for the trainee’s educational agreement.
The Clinical Supervisor (CS) is defined as a trainer who is selected and appropriately trained to be responsible for overseeing a specified trainee’s clinical work and providing constructive feedback during a training placement. Some training schemes appoint an ES for each placement. The roles of clinical and educational supervisor may then be merged.
A Clinical Trainer (CTr) is defined as a trainer who undertakes targeted training in one specific curricular area. This might be, for example, a medic (or non-medic) teaching a medical trainee a specific craft skill.
Furthermore there is a defined group of School Officers, defined as some one holding a School position following formal advertisement and interview. These posts are all remunerated and, at present, consist of Head of School, School Leads for QM, DwDD and Faculty Development and all TPDs. Other STC roles are currently appointed/agreed within individual STC and are not a part of the formal School structure.
The following is suggested as a minimum standard for ESs for implementation across the school in 2010-2011. Previous attendance at a ‘Good practice in educational supervision’ course. Continuing CPD in education: a minimum requirement is an average of ½ day per annum on an educational activity related to the role of supervision with appropriate updates. These educational activities might be generic ones such as, for example, training in teaching, in mentoring, in feedback, in how to manage doctors in difficulty or might be specific to specialty practice such as how to teach craft skills. Suitable activities would include involvement in recruitment, attendance at STCs and ARCPs as long as these were interspersed with other activities of a more obviously educational value A range of courses offered by the Deanery is available at http://mypimd.ncl.ac.uk/training Equality and diversity training every 3 years. This can be provided by Trust or College. Anyone also involved in Recruitment and Selection must undertake training in this and a refresher course every three years. This is available via the Deanery. The ES must be familiar with the relevant eportfolio and maintain familiarity with the relevant curricula. The educational role must be included within the annual trust appraisal process and this documented using whatever format the particular trust wishes to follow.
The School of Medicine states that the time for determining standards for clinical supervisors is not yet arrived. Standards for clinical trainers are likely to arise from the specialty context in which such training is delivered. One of the Scholl of Medicine’s aspirational goals is that there should be a move to greater recognition of the importance of the role of CS and that such people should be encouraged to have training suitable to their role: Eportfolio training, work place based assessments training, training in effective feedback, in identifying DwDN and familiarity with the curricula.
The paper circulated by the School of Medicine discusses aspirational standards & goals such as formal mechanisms of trainer allocation, further definition of standards for a CS and CTr, more formal documentation of Educational roles at appraisal both at Trust and Regional level, the ability to deselect supervisors following appraisal.
The full paper will be circulated and discussed at the T&T meeting on 14th June 2011. My early verdict: a good pragmatic start with good intentions. Training should be seen as a mandatory professional role that needs to be done effectively. With the recent problems in recruitment a number of colleagues in my Trust will be moving towards converting their registrar posts to SAS posts. My comment “it would not be worth coming to work if I was not involved in training the young generation”. With undue bureaucracy in recent years when it comes to training our young generation there has been significant disillusionment amongst Consultants, further compounded by the clinical and performance measures that add to the “lot” of a Consultant. I am encouraged that early indications from this paper suggest that these standards will not be burdensome but add to routine appraisal and the working practice of a NHS Consultant. For those with more advanced roles in Education, they off course will quite rightly have more standards to achieve and require more formal appraisal of their role. There will always be those who will not engage in any way or form using the old adage “it is not in my job plan”! The way around that, well in our Trust with revalidation around the corner we will be moving to a mandatory e-portfolio for all Consultants in our Trust. We will make sure it is not over burdensome.
www.diabetesbible.com Mike Broad
I’ve been working with Dr Jeremy Turner, a consultant in diabetes and endocrinology at the Norfolk and Norwich Hospital, to develop an online guide to diabetes diagnosis and treatment.
The site is designed to help junior doctors to take full histories, and make very thorough assessments, as well as to unify and clarify patient pathways.
Diabetes Bible also includes management overviews on all common diabetes conditions, complications and emergencies. It includes links to latest guidelines (such as NICE and JBDS), and detailed investigation protocols as used by Norwich’s CIU. It’s a free to access site, and should be relevant for consultants, trainees, GPs and specialist nurses. The link to Diabetes Bible is available on the endodiabology website.
Existing links:
Norfolk Diabetes Prevention Study
http://www.norfolkdiabetespreventionstudy.nhs.uk/links
Hospital Dr
http://www.hospitaldr.co.uk/related-websites
Endobible
http://www.endobible.com/page.php?id=10
Young Diabetologists Forum
http://www.youngdiabetologists.org/index.php?option=com_wrapper&Itemid=143
RECENT PUBLICATIONS FROM THE NORTHEAST
1. M. Chetty; E. Sawyer; T. Dew; A. J. Chapman; J. Elson The use of novel biochemical markers in predicting spontaneously resolving 'pregnancies of unknown location' Human Reproduction 2011; doi: 10.1093/humrep/der064
2. A Munir, S Kalathil, S Nag. Pleural effusion caused by pioglitazone. Practical Diabetes International 2011 volume 28 No. 3.
3. Shaw N, Seminara SB, Welt CK, Au M, Plummer L, Hughes VA, Dwyer AA, Martin KA, Quinton R, Mericq V, Merino P, Crowley WF, Jr,, Pitteloud N, Hall JE. 2011 Expanding the phenotype and genotype of female GnRH deficiency. Journal of Clinical Endocrinology & Metabolism. 96: E566-576.
4. Mitchell AL, Dwyer AA, Pitteloud N, Quinton R. 2011 Genetic basis and variable phenotypic expression of Kallmann syndrome: towards a unifying theory. Trends in Endocrinology & Metabolism. Epub 19 April 2011
5. Woods D, Hooper T, Hodkinson P, Ball S, Wakeford R, Peaston B, Bairsto C, Green N, Mellor A. Effects of altitude exposure on brain natriuretic peptide in humans. Eur J Appl Physiol. 2011 Mar 11. [Epub ahead of print]
6. Woods D, Hooper T, Mellor A, Hodkinson P, Wakeford R, Peaston B, Ball S, Green N. Brain natriuretic peptide and acute hypobaric hypoxia in humans. J Physiol Sci. 2011 May;61(3):217-20. Epub 2011 Mar 24.
7. Shashithej K. Narayana, David R. Woods and Christopher J. Boos Management of amiodarone-related thyroid problems. Ther Adv Endocrinol Metab (2011) 0(0) 1_12 DOI: 10.1177/2042018811398516
8. Woods DR, Boos C, Roberts PR.. Cardiac arrhythmias at high altitude. J R Army Med Corps. 2011 Mar;157(1):59-62.
9. Hill NE, Stacey MJ, Woods DR. Energy at high altitude. J R Army Med Corps. 2011 Mar;157(1):43-8.
10. Woods DR, Stacey M, Hill N, de Alwis N. Endocrine aspects of high altitude acclimatization and acute mountain sickness. J R Army Med Corps. 2011 Mar;157(1):33-7.
RECENT PUBLICATIONS IN DIABETES & ENDOCRINOLOGY THAT HIT THE NEWS OR THAT MAY HAVE A SIGNIFICANT IMPACT ON MANAGEMENT
Vertebral Fractures. KE Ensrud & JT Schousboe. NEJM 2011;364:1634-1642. An excellent practical review article for this often encountered issue. Despite the effectiveness of calcitonin in acute vertebral fracture pain, cost prohibits its widespread use. Beside, I have seen pamidronate work!!.
Intensified glucose control in type 2 diabetes-whose agenda? JS Yudkin, B Richter, EAM Gale. Lancet 2011;377:1220-1221. A wonderful down to earth editorial. It certainly provoked controversy, but comes back to underlining the importance of individualised control for our patients. So the next time you get a letter from a GP asking you to get an 80 year old’s HbA1c of 69 mmol/mol (8.5% for those still not attuned!) to their QUoF target send them a copy of this editorial. I did last week!
Osteoporosis: now and the future. TD Rachner, S Khosla, LC Hofbauer. Lancet 2011;377:1276-1287. There is a lot happening in therapies for osteoporosis. This review article is well worth a read.
Myxoma, dyspnoea, tinnitus, scoliosis and alopecia. TK Rajab et al. Lancet 2011;377:1378. A wonderful case report. The next time you see alopecia think myxoma. Intrigued, read it…………………..
Vitamin D and prevention of cancer-Ready for Prime Time? JAE Manson et al. NEJM 2011;364:1385-1387. A very balanced article, well worth reading before we put Vitamin D in the water.
Ciliopathies. F Hildenbrandt et al. NEJM 2011;364:1533-1542. An excellent clinical science review paper. The link to us is the metabolic conditions associated with this syndrome. Well worth a read.
The challenge of managing coexistent diabetes and obesity. Clifford Bailey. BMJ 2011;342:913-918. A good review article with practical advice.
Pituitary apoplexy. BMJ 2011;342:668-669. An excellent editorial reviewing the SfE guidelines on the subject linked with an accompanying case report (BMJ 2011;342:d1221 doi:10.1136/bmj.d1221).
HbA1c: an old friend in new clothes. S Misra et al. Lancet 2011;377:1476-1477. A timely editorial, after which I have forgot about talking in %. Remember aim for an Hba1c of 48-58 mmol/mol!
Cardiovascular safety and diabetes drug development. DJ Drucker, AB Goldfine. Lancet 2011;377:977-979. The fall-out and debate continue……….
Rupture without warning. S Schimmack et al. Lancet 2011;377:966. Beware the ruptured thyroid cyst!
Deep Vein Thrombosis of the Upper Extremities. Nils Kucher. NEJM 2011;364:861-869. I know that this is Acute Medicine, but this review article is an essential read for all.
New Drugs for Hyponatraemia. A Amin and K Meeran. BMJ 2011;342:559-560. A very well balanced editorial worth a read.
Investigating hyponatraemia. A Wakil et al. BMJ 2011;342:594-596. Not bad. Personally what ever Peter Baylis and Steve Ball taught me in the late 90s has stayed with me thus far!
Hidden Harm. M Suzuki et al. Lancet 2011;377:874. Recently a lab manager advised me of the high number of timed overnight urines for normetadrenaline I am undertaking, specifically for EAU. I guess this case report was answer enough and it quickly winged its way over to him!
Glucagon-like peptide-1 analogues for type 2 diabetes. J Wilding and Kevin Hardy. BMJ 2011;342:433-435. A good update worth a read.
Islet transplantation in type 1 diabetes. H de Kort et al. BMJ 2011;342:426-432. An excellent update. Remember to look out for those patients with hypoglycaemic unawareness that may fit the criteria to refer to Jim Shaw.
Telehealthcare for long term conditions. S McLean et al. BMJ 2011;342:374-378. You IT geeks would love this paper. So did I!
Radioiodine therapy for hyperthyroidism. DS Ross. NEJM 2011;364:542-550. A good update well worth a read.
Gout. T Neogi. NEJM 2011;364:443-452. An excellent update.
Selenium and the course of mild Graves' orbitopathy. Marcocci C, Kahaly GJ et al. NEJM 2011;364:1920-1931. In this randomised, double-blind, placebo-controlled trial selenium (an antioxidant agent) or pentoxifylline (an antiinflammatory agent) were administered to 159 patients with mild Graves' orbitopathy. The patients were given selenium (100 μg twice daily), pentoxifylline (600 mg twice daily), or placebo (twice daily) orally for 6 months and were then followed for 6 months after treatment was withdrawn. Primary outcomes at 6 months were evaluated by means of an overall ophthalmic assessment, conducted by an ophthalmologist who was unaware of the treatment assignments, and a Graves' orbitopathy-specific quality-of-life questionnaire, completed by the patient. Secondary outcomes were evaluated with the use of a Clinical Activity Score and a diplopia score. At the 6-month evaluation, treatment with selenium, but not with pentoxifylline, was associated with an improved quality of life (P<0.001) and less eye involvement (P=0.01) and slowed the progression of Graves' orbitopathy (P=0.01), as compared with placebo. The Clinical Activity Score decreased in all groups, but the change was significantly greater in the selenium-treated patients. Exploratory evaluations at 12 months confirmed the results seen at 6 months. Two patients assigned to placebo and one assigned to pentoxifylline required immunosuppressive therapy for deterioration in their condition. No adverse events were evident with selenium, whereas pentoxifylline was associated with frequent gastrointestinal problems. In this study selenium administration significantly improved quality of life, reduced ocular involvement, and slowed progression of the disease in patients with mild Graves' orbitopathy suggesting a that oxygen free radicals do play a part in the pathophysiology behind Graves’ Orbitopathy.
Diabetes mellitus, fasting glucose, and risk of cause-specific death. Seshasai SR, Kaptoge S, et al. NEJM 2011;364:829-41. The authors calculated hazard ratios for cause-specific death, according to baseline diabetes status or fasting glucose level, from individual-participant data on 123,205 deaths among 820,900 people in 97 prospective studies. After adjustment for age, sex, smoking status, and body-mass index, hazard ratios among persons with diabetes as compared with persons without diabetes were as follows: 1.80 (95% confidence interval [CI], 1.71-1.90) for death from any cause, 1.25 (1.19-1.31) for death from cancer, 2.32 (95% 2.11 -2.56) for death from vascular causes, and 1.73 (1.62-1.85) for death from other causes. Diabetes (vs. no diabetes) was moderately associated with death from cancers of the liver, pancreas, ovary, colorectum, lung, bladder, and breast. Aside from cancer and vascular disease, diabetes (vs. no diabetes) was also associated with death from renal disease, liver disease, pneumonia and other infectious diseases, mental disorders, nonhepatic digestive diseases, external causes, intentional self-harm, nervous-system disorders, and chronic obstructive pulmonary disease. Hazard ratios were appreciably reduced after further adjustment for glycaemia measures, but not after adjustment for systolic blood pressure, lipid levels, inflammation or renal markers. Fasting glucose levels exceeding 5.6 mmol/L, but not levels 3.9 to 5.6 mmol/L, were associated with death. A 50-year-old with diabetes died, on average, 6 years earlier than a counterpart without diabetes, with about 40% of the difference in survival attributable to excess nonvascular deaths. This excellent paper demonstrates that in addition to vascular disease, diabetes is associated with substantial premature death from several cancers, infectious diseases, external causes, intentional self-harm, and degenerative disorders, independent of several major risk factors.
Insulin degludec, an ultra-long-acting basal insulin, once a day or three times a week versus insulin glargine once a day in patients with type 2 diabetes: a 16-week, randomised, open-label, phase 2 trial. Zinman B, Fulcher G, et al. Lancet. 2011;377:880-1. In this 16-week, randomised, open-label, parallel-group phase 2 trial, participants aged 18–75 years with type 2 diabetes and HbA1c of 7·0–11·0% were randomly allocated in a 1:1:1:1 ratio randomisation to receive insulin degludec either once a day or three times a week or insulin glargine once a day, all in combination with metformin. 62 participants were randomly allocated to receive insulin degludec three times a week (starting dose 20 U per injection [1 U=9 nmol]), 60 to receive insulin degludec once a day (starting dose 10 U [1 U=6 nmol]; group A), 61 to receive insulin degludec once a day (starting dose 10 U [1 U=9 nmol]; group B), and 62 to receive insulin glargine (starting dose 10 U [1 U=6 nmol]) once a day. At study end, mean HbA1c levels were much the same across treatment groups, at 7·3% (SD 1·1), 7·4% (1·0), 7·5% (1·1), and 7·2% (0·9), respectively. Estimated mean HbA1c treatment differences from insulin degludec by comparison with insulin glargine were 0·08% (95% CI –0·23 to 0·40) for the three dose per week schedule, 0·17% (–0·15 to 0·48) for group A, and 0·28% (–0·04 to 0·59) for group B. Few participants had hypoglycaemia and the number of adverse events was much the same across groups, with no apparent treatment-specific pattern. In this trial insulin degludec provides comparable glycaemic control to insulin glargine without additional adverse events and might reduce dosing frequency due to its ultra-long action profile. An interesting insulin to add to our therapies. It is worth checking out the 2 trials in the March Diabetes Care edition on insulin degludec as well.
Levothyroxine dose and risk of fractures in older adults: nested case-control study. Turner MR, Camacho X, et al. BMJ. 2011 Apr 28;342:d2238. In this nested case-control study adults aged 70 or more who were prescribed levothyroxine between 1 April 2002 and 31 March 2007 and followed for fractures until 31 March 2008 were studied. Cases were cohort members admitted to hospital for any fracture, matched with up to five controls from within the cohort who had not yet had a fracture. The primary outcome was fracture (wrist or forearm, shoulder or upper arm, thoracic spine, lumbar spine and pelvis, hip or femur, or lower leg or ankle) in relation to levothyroxine use (current, recent past, remote). Risk among current users was compared between those prescribed high, medium, and low cumulative levothyroxine doses in the year before fracture. Of 213 511 prevalent levothyroxine users identified, 22 236 (10.4%) experienced a fracture over a mean 3.8 years of follow-up, 18 108 (88%) of whom were women. Compared with remote levothyroxine use, current use was associated with a significantly higher risk of fracture (adjusted odds ratio 1.88, 95% confidence interval 1.71-2.05), despite adjustment for numerous risk factors. Among current users, high and medium cumulative doses (>0.093 mg/day and 0.044-0.093 mg/day) were associated with a significantly increased risk of fracture compared with low cumulative doses (<0.044 mg/day): 3.45 (3.27-3.65) and 2.62 (2.50-2.76), respectively. This study has shown that among adults aged 70 or more, current levothyroxine treatment was associated with a significantly increased risk of fracture, with a strong dose-response relation, hence outlining the importance to avoid overtreatment in this population.
Effects of low-dose, controlled-release, phentermine plus topiramate combination on weight and associated comorbidities in overweight and obese adults (CONQUER): a randomised, placebo-controlled, phase 3 trial. Gadde KM, Allison DB, et al. In this 56-week phase 3 trial, the authors randomly assigned 2487 overweight or obese adults (aged 18-70 years), with a body-mass index of 27-45 kg/m2 and two or
more of hypertension, dyslipidaemia, diabetes or prediabetes, or abdominal obesity to placebo, once-daily phentermine 7·5 mg plus topiramate 46 mg, or once-daily phentermine 15·0 mg plus topiramate 92 mg in a 2:1:2 ratio Primary endpoints were the percentage change in bodyweight and the proportion of patients achieving at least 5% weight loss. Analysis was by intention to treat. At 56 weeks, change in bodyweight was -1·4 kg (least-squares mean -1·2%, 95% CI -1·8 to -0·7), -8·1kg (-7·8%, -8·5 to -7·1; p<0·0001), and -10·2 kg (-9·8%, -10·4 to -9·3; p<0·0001)in the patients assigned to placebo, phentermine 7·5 mg plus topiramate 46 mg, and phentermine 15·0 mg plus topiramate 92 mg, respectively. 204 (21%) patients achieved at least 5% weight loss with placebo, 303 (62%; odds ratio 6·3, 95% CI 4·9 to 8·0; p<0·0001) with phentermine 7·5 mg plus topiramate 46 mg, and 687 (70%; 9·0, 7·3 to 11·1; p<0·0001) with phentermine 15·0 mg plus topiramate 92 mg; for ≥10% weight loss, the corresponding numbers were 72 (7%), 182 (37%; 7·6, 5·6 to 10·2; p<0·0001), and 467 (48%; 11·7, 8·9 to 15·4; p<0·0001). The most common adverse events were dry mouth (24 [2%], 67 [13%], and 207 [21%] in the groups assigned to placebo, phentermine 7·5 mg plus topiramate 46 mg, and phentermine 15·0 mg plus topiramate 92 mg, respectively), paraesthesia (20 [2%], 68 [14%], and 204 [21%], respectively), constipation (59 [6%], 75 [15%], and 173 [17%], respectively), insomnia (47 [5%], 29 [6%], and 102 [10%], respectively), dizziness (31 [3%], 36 [7%], 99 [10%], respectively), and dysgeusia (11 [1%], 37 [7%], and 103 [10%], respectively). 38 (4%) patients assigned to placebo, 19 (4%) to phentermine 7·5 mg plus topiramate 46·0 mg, and 73 (7%) to phentermine 15·0 mg plus topiramate 92·0 mg had depression-related adverse events; and 28 (3%), 24 (5%), and 77 (8%), respectively, had anxiety-related adverse events. This trial suggests that the combination of phentermine and topiramate, with lifestyle interventions, might be a valuable treatment for obesity.
NEXT NEWSLETTER Due out beginning of October 2011 so keep the gossip coming.
Endodiabology.blogspot.com
NORTHEAST
NEWSLETTER
FOR SPRs AND BOSSES TRAPPED
IN THE NORTHERN DEANERY
June 2011
Editors: Shaz Wahid, Petros Perros and Arutchelvam Vijayaraman
Associate Editor: Srikanth Mada
StR PLACEMENTS (NTN year of training from 1st October 2010)
• Newcastle- Atif Munir (2), Sajid Ethol Kalathil (2), Catherine Napier (2), Naveen Aggarwal (2), Hamza Ali Khan (2), Agnieska Sawiecicka (1), Vacant
• North Tyneside/Wansbeck- Alison Heggie (1), Vacant
• South Tyneside- Nimanthe De Alwis (2)
• Gateshead- Kathryn Stewart (3)
• Sunderland- Jakob Buckovan (1), vacant
• North Tees/Hartlepool- Sudeep Manohar (4), vacant
• Middlesbrough- Arif Ullah (4), Naveen Siddaramaiha (4), Shunmugam Nellaiappan (1)
• Bishop Auckland/Darlington/Durham- Sathia Raghavan(1), Vacant
• NGH- Srikanth Mada(4),
• Research with numbers (supervisor)- Stuart Little (3-Dr Shaw), Asgar Madathil (4-Dr Weaver), Sarah Steven (3-Prof Taylor), Anna Mitchell (1-Prof Pearce), Earn Gan (1-Prof Pearce)
• Maternity Leave Rohana Wright (3), Anjali SanthaKumar (3)
MEETINGS / LECTURES / ANNOUNCEMENTS
• 4th-7th June 2011 ENDO 2011, Boston, USA. Contact endostaff@endo-societ.org or www.endo-society.org/scimeetings .
• 16th June 2011 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk
• 24th – 28th June 2011 American Diabetes Association 71st Annual Scientific Sessions, San Diego, USA. Contact meetings@diabetes.org .
• 13th July 2011 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk
• 12th - 16th September 2011 47th EASD annual meeting, Lisbon, Portugal. Contact www.easd.org
• 14th September 2011 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk
• 21st September 2011 DUK APC 2012 abstract deadline.
• 11th October 2011 SfE Regional Clinical Cases Meeting. Venue TBC. Contact www.endocrinology.org/meetings/index
• 12th October 2011 Northern Endocrine & Diabetes Autumn CME, Durham. Contact Sarah Steven(sarah.steven@doctors.org.uk ) or Srikanth Mada (srikanth.mada@nhs.net )
• 7th – 9th November 2011 SfE Clinical Update 2011. Venue TBC. Contact www.endocrinology.org/meetings/index
• 16th November 2011 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk
• 23rd November 2011 Northern Endocrine Region Research and Audit Group meeting, Lumley Castle, Chester-le-street. Contact Shahid.wahid@stft.nhs.uk
• 24th-25th November 2011 Middlesbrough insulin pump course. Contact Nicky.Skippon@stees.nhs.uk
• 30th November 2011 RCP Updates in Medicine, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
TRAINING ISSUES
STOP PRESS: NEW Assessment tools Please see www.jrcptb.org.uk; It is the trainee’s responsibility to make sure that the appropriate assessments are available in their portfolio for ARCP purposes. For 2011 there are 3 new work based assessment tools available: Patient Surveys, Audit Assessment and Teaching Observation. It is essential that you review the web site and make arrangements to utilize these new assessment tools as evidence for your ARCP.
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.
Registering with PMETB It is essential that all new StRs (even LATs) register with the PMETB through the Joint Royal Colleges of Physicians Training Board on www.jrcptb.org.uk. Not doing so means your training is not counted.
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.
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 G(I)M PYAs.
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.
The Kelly-Young MRCP Diabetes & Endocrinology Prize This prize is awarded annually at NERRAG to the youngest in terms of training year StR passing the MRCP Diabetes & endocrinology exam. Richard Quinton secures the funding of £800 and it is named after 2 distinguished former Endocrinologists in the region, Bill Kelly and Eric Young.
Faculty training day The next Faculty training day is on 14th June 2011. It kicks off with the STC meeting followed by a trainers training session and the Trainers and Trainees meeting from 1530. For more details see the letters section.
GIM ARCPs This year’s GIM ARCP made for grim reading for our training programme. Out of the 12 trainees assessed 3 achieved an outcome 1 (satisfactory progression), 8 achieved an outcome 2 (targeted training needed with no additional time to CCT date) and 1 achieved an outcome 5 (further information required to make an award). The fall-out of this poor showing is multifactorial and something we will have to address. Before you blame the tensions between balancing GIM and specialty, the reasons relate a lot more to the fundamentals of educational supervision and trainee engagement. Further discussion will occur at the T&T meeting planned for 14th June 2011.
Critical incident/complaint If you are involved in a critical incident or if reporting an incident concerning training issues please inform your supervisor and the TPD. Ensure they are reflected upon in your portfolio
Educational Supervision With revalidation requiring evidence of effectiveness in all of our roles as a Consultant and with the School of Medicine publishing minimum standards for Educational Supervisors (see letters section), this critical role will come under the spotlight in the next 18-24 months. It is no longer acceptable to simply have been to the training courses and undertaken education supervision and other regional activity, such as ARCPs. The Consultant will have to show effectiveness in this role. The effectiveness of this role will be appraised at a Consultant’s appraisal (it should be any appraiser worth their salt!). To help a Consultant gather evidence of their effectiveness as an Educational Supervisor, at this year’s ARCPs the panel has made a note of good practice and areas to improve for each educational supervisor when reviewing their trainee’s e-portfolio using a structured feedback form developed by the School of Medicine. This feedback form will be returned to each educational supervisor for both GIM and DM&ENDO ARCPs so that they can reflect on their performance and develop an action plan for their appraisal to be part of their PDP. There will always need to be a carrot! It is common practice to ask trainees to vote with their feet when choosing a training unit. Following the GIM ARCPs, there has been a ground shift with the first factor to consider when allocating trainees post ARCP rapidly becoming the quality and effectiveness of the Educational Supervision that the training unit can deliver and has delivered.
Training Committee Chair- Nicky Leech nicola.leech@nuth.northy.nhs.uk; Regional Speciality Advisor- Shaz Wahid, shahid.wahid@sthct.nhs.uk; Programme Director- Arutchelvam Vijayaraman Vijayaraman.Arutchelvam@stees.nhs.uk; Consultant member (SAC rep)- Richard Quinton, Richard.Quinton@nuth.nhs.uk; Consultant member-Jean MacLeod, Jean.Macleod@nth.nhs.uk; Consultant member-Dr Peter Carey; Consultant member-Simon Eaton, simon.eaton@northumbria-healthcare.nhs.uk; SpR representative-Srikanth Mada srikanth.mada@nhs.net ; SpR representative-Stuart Little stuartlittle@doctors.org.uk
NEWS FROM THE NORTHEAST
• Congratulations to Mark Walker for being recently selected as an NIHR Senior Investigator, the first for our Region in Endocrinology and Metabolism.
• Some kind words for the region from Preethi Rao “I got the ‘Clinical endocrinology trust clinical practice award’ and ‘ highly commended oral presentation prize’ yesterday at the BES for the study I did with Salman at Gateshead. The title of the study is ‘Thyroid hormones in the euthyroid range predict subsequent body mass composition in women: The OPUS study’. I also got the opportunity to present our data at the young endocrinologist prize session. I am extremely thankful to the northern deanery and in particular to Salman for training me well to achieve these. I hence wanted to share this good news with you as I think the credit of these prizes definitely go to the northern deanery “.
• Congratulations to Sajid Kalathil and co-authors for their Best Poster award at the Pituitary Clinicopathological meeting in London in February 2011, the poster was on 'sellar Haemangiopericytoma'.
LETTERS
Faculty Development Day-Simon Pearce
I have arranged a further 'Training the Trainers' session on the subject of "Recognising and Responding to Underperforming trainees(including Action Planning)" to be delivered by Juliet Graves.
This session will be before the Trainers and Trainees meeting from 11.00 to 15.00 on June 14th, with the T&T meeting being from 15.30 to 18.00, both at the SHA Waterfront Building, Newburn.
Members of the STC will meet 09.30 to 10.45 at the same venue:
Northern Deanery
Waterfront 4
Newburn Riverside
Newcastle upon Tyne
NE15 8NY
Educational Supervisor, Clinical Supervisor and Clinical Trainer standards-Shaz Wahid
The Deanery School of Medicine have produced minimal standards for this varied group of trainers. The standards require that Trainers are selected for their roles, must understand what they are training in and must demonstrate ability as effective trainers. The School states that this is a developmental process and that not all specialties and sites will expect to be able to work to the highest standards immediately.
An Education Supervisor (ES) is defined as a trainer who is selected and appropriately trained to be responsible for the overall supervision and management of a specified trainee’s educational progress during a training placement or series of placements. The ES is responsible for the trainee’s educational agreement.
The Clinical Supervisor (CS) is defined as a trainer who is selected and appropriately trained to be responsible for overseeing a specified trainee’s clinical work and providing constructive feedback during a training placement. Some training schemes appoint an ES for each placement. The roles of clinical and educational supervisor may then be merged.
A Clinical Trainer (CTr) is defined as a trainer who undertakes targeted training in one specific curricular area. This might be, for example, a medic (or non-medic) teaching a medical trainee a specific craft skill.
Furthermore there is a defined group of School Officers, defined as some one holding a School position following formal advertisement and interview. These posts are all remunerated and, at present, consist of Head of School, School Leads for QM, DwDD and Faculty Development and all TPDs. Other STC roles are currently appointed/agreed within individual STC and are not a part of the formal School structure.
The following is suggested as a minimum standard for ESs for implementation across the school in 2010-2011. Previous attendance at a ‘Good practice in educational supervision’ course. Continuing CPD in education: a minimum requirement is an average of ½ day per annum on an educational activity related to the role of supervision with appropriate updates. These educational activities might be generic ones such as, for example, training in teaching, in mentoring, in feedback, in how to manage doctors in difficulty or might be specific to specialty practice such as how to teach craft skills. Suitable activities would include involvement in recruitment, attendance at STCs and ARCPs as long as these were interspersed with other activities of a more obviously educational value A range of courses offered by the Deanery is available at http://mypimd.ncl.ac.uk/training Equality and diversity training every 3 years. This can be provided by Trust or College. Anyone also involved in Recruitment and Selection must undertake training in this and a refresher course every three years. This is available via the Deanery. The ES must be familiar with the relevant eportfolio and maintain familiarity with the relevant curricula. The educational role must be included within the annual trust appraisal process and this documented using whatever format the particular trust wishes to follow.
The School of Medicine states that the time for determining standards for clinical supervisors is not yet arrived. Standards for clinical trainers are likely to arise from the specialty context in which such training is delivered. One of the Scholl of Medicine’s aspirational goals is that there should be a move to greater recognition of the importance of the role of CS and that such people should be encouraged to have training suitable to their role: Eportfolio training, work place based assessments training, training in effective feedback, in identifying DwDN and familiarity with the curricula.
The paper circulated by the School of Medicine discusses aspirational standards & goals such as formal mechanisms of trainer allocation, further definition of standards for a CS and CTr, more formal documentation of Educational roles at appraisal both at Trust and Regional level, the ability to deselect supervisors following appraisal.
The full paper will be circulated and discussed at the T&T meeting on 14th June 2011. My early verdict: a good pragmatic start with good intentions. Training should be seen as a mandatory professional role that needs to be done effectively. With the recent problems in recruitment a number of colleagues in my Trust will be moving towards converting their registrar posts to SAS posts. My comment “it would not be worth coming to work if I was not involved in training the young generation”. With undue bureaucracy in recent years when it comes to training our young generation there has been significant disillusionment amongst Consultants, further compounded by the clinical and performance measures that add to the “lot” of a Consultant. I am encouraged that early indications from this paper suggest that these standards will not be burdensome but add to routine appraisal and the working practice of a NHS Consultant. For those with more advanced roles in Education, they off course will quite rightly have more standards to achieve and require more formal appraisal of their role. There will always be those who will not engage in any way or form using the old adage “it is not in my job plan”! The way around that, well in our Trust with revalidation around the corner we will be moving to a mandatory e-portfolio for all Consultants in our Trust. We will make sure it is not over burdensome.
www.diabetesbible.com Mike Broad
I’ve been working with Dr Jeremy Turner, a consultant in diabetes and endocrinology at the Norfolk and Norwich Hospital, to develop an online guide to diabetes diagnosis and treatment.
The site is designed to help junior doctors to take full histories, and make very thorough assessments, as well as to unify and clarify patient pathways.
Diabetes Bible also includes management overviews on all common diabetes conditions, complications and emergencies. It includes links to latest guidelines (such as NICE and JBDS), and detailed investigation protocols as used by Norwich’s CIU. It’s a free to access site, and should be relevant for consultants, trainees, GPs and specialist nurses. The link to Diabetes Bible is available on the endodiabology website.
Existing links:
Norfolk Diabetes Prevention Study
http://www.norfolkdiabetespreventionstudy.nhs.uk/links
Hospital Dr
http://www.hospitaldr.co.uk/related-websites
Endobible
http://www.endobible.com/page.php?id=10
Young Diabetologists Forum
http://www.youngdiabetologists.org/index.php?option=com_wrapper&Itemid=143
RECENT PUBLICATIONS FROM THE NORTHEAST
1. M. Chetty; E. Sawyer; T. Dew; A. J. Chapman; J. Elson The use of novel biochemical markers in predicting spontaneously resolving 'pregnancies of unknown location' Human Reproduction 2011; doi: 10.1093/humrep/der064
2. A Munir, S Kalathil, S Nag. Pleural effusion caused by pioglitazone. Practical Diabetes International 2011 volume 28 No. 3.
3. Shaw N, Seminara SB, Welt CK, Au M, Plummer L, Hughes VA, Dwyer AA, Martin KA, Quinton R, Mericq V, Merino P, Crowley WF, Jr,, Pitteloud N, Hall JE. 2011 Expanding the phenotype and genotype of female GnRH deficiency. Journal of Clinical Endocrinology & Metabolism. 96: E566-576.
4. Mitchell AL, Dwyer AA, Pitteloud N, Quinton R. 2011 Genetic basis and variable phenotypic expression of Kallmann syndrome: towards a unifying theory. Trends in Endocrinology & Metabolism. Epub 19 April 2011
5. Woods D, Hooper T, Hodkinson P, Ball S, Wakeford R, Peaston B, Bairsto C, Green N, Mellor A. Effects of altitude exposure on brain natriuretic peptide in humans. Eur J Appl Physiol. 2011 Mar 11. [Epub ahead of print]
6. Woods D, Hooper T, Mellor A, Hodkinson P, Wakeford R, Peaston B, Ball S, Green N. Brain natriuretic peptide and acute hypobaric hypoxia in humans. J Physiol Sci. 2011 May;61(3):217-20. Epub 2011 Mar 24.
7. Shashithej K. Narayana, David R. Woods and Christopher J. Boos Management of amiodarone-related thyroid problems. Ther Adv Endocrinol Metab (2011) 0(0) 1_12 DOI: 10.1177/2042018811398516
8. Woods DR, Boos C, Roberts PR.. Cardiac arrhythmias at high altitude. J R Army Med Corps. 2011 Mar;157(1):59-62.
9. Hill NE, Stacey MJ, Woods DR. Energy at high altitude. J R Army Med Corps. 2011 Mar;157(1):43-8.
10. Woods DR, Stacey M, Hill N, de Alwis N. Endocrine aspects of high altitude acclimatization and acute mountain sickness. J R Army Med Corps. 2011 Mar;157(1):33-7.
RECENT PUBLICATIONS IN DIABETES & ENDOCRINOLOGY THAT HIT THE NEWS OR THAT MAY HAVE A SIGNIFICANT IMPACT ON MANAGEMENT
Vertebral Fractures. KE Ensrud & JT Schousboe. NEJM 2011;364:1634-1642. An excellent practical review article for this often encountered issue. Despite the effectiveness of calcitonin in acute vertebral fracture pain, cost prohibits its widespread use. Beside, I have seen pamidronate work!!.
Intensified glucose control in type 2 diabetes-whose agenda? JS Yudkin, B Richter, EAM Gale. Lancet 2011;377:1220-1221. A wonderful down to earth editorial. It certainly provoked controversy, but comes back to underlining the importance of individualised control for our patients. So the next time you get a letter from a GP asking you to get an 80 year old’s HbA1c of 69 mmol/mol (8.5% for those still not attuned!) to their QUoF target send them a copy of this editorial. I did last week!
Osteoporosis: now and the future. TD Rachner, S Khosla, LC Hofbauer. Lancet 2011;377:1276-1287. There is a lot happening in therapies for osteoporosis. This review article is well worth a read.
Myxoma, dyspnoea, tinnitus, scoliosis and alopecia. TK Rajab et al. Lancet 2011;377:1378. A wonderful case report. The next time you see alopecia think myxoma. Intrigued, read it…………………..
Vitamin D and prevention of cancer-Ready for Prime Time? JAE Manson et al. NEJM 2011;364:1385-1387. A very balanced article, well worth reading before we put Vitamin D in the water.
Ciliopathies. F Hildenbrandt et al. NEJM 2011;364:1533-1542. An excellent clinical science review paper. The link to us is the metabolic conditions associated with this syndrome. Well worth a read.
The challenge of managing coexistent diabetes and obesity. Clifford Bailey. BMJ 2011;342:913-918. A good review article with practical advice.
Pituitary apoplexy. BMJ 2011;342:668-669. An excellent editorial reviewing the SfE guidelines on the subject linked with an accompanying case report (BMJ 2011;342:d1221 doi:10.1136/bmj.d1221).
HbA1c: an old friend in new clothes. S Misra et al. Lancet 2011;377:1476-1477. A timely editorial, after which I have forgot about talking in %. Remember aim for an Hba1c of 48-58 mmol/mol!
Cardiovascular safety and diabetes drug development. DJ Drucker, AB Goldfine. Lancet 2011;377:977-979. The fall-out and debate continue……….
Rupture without warning. S Schimmack et al. Lancet 2011;377:966. Beware the ruptured thyroid cyst!
Deep Vein Thrombosis of the Upper Extremities. Nils Kucher. NEJM 2011;364:861-869. I know that this is Acute Medicine, but this review article is an essential read for all.
New Drugs for Hyponatraemia. A Amin and K Meeran. BMJ 2011;342:559-560. A very well balanced editorial worth a read.
Investigating hyponatraemia. A Wakil et al. BMJ 2011;342:594-596. Not bad. Personally what ever Peter Baylis and Steve Ball taught me in the late 90s has stayed with me thus far!
Hidden Harm. M Suzuki et al. Lancet 2011;377:874. Recently a lab manager advised me of the high number of timed overnight urines for normetadrenaline I am undertaking, specifically for EAU. I guess this case report was answer enough and it quickly winged its way over to him!
Glucagon-like peptide-1 analogues for type 2 diabetes. J Wilding and Kevin Hardy. BMJ 2011;342:433-435. A good update worth a read.
Islet transplantation in type 1 diabetes. H de Kort et al. BMJ 2011;342:426-432. An excellent update. Remember to look out for those patients with hypoglycaemic unawareness that may fit the criteria to refer to Jim Shaw.
Telehealthcare for long term conditions. S McLean et al. BMJ 2011;342:374-378. You IT geeks would love this paper. So did I!
Radioiodine therapy for hyperthyroidism. DS Ross. NEJM 2011;364:542-550. A good update well worth a read.
Gout. T Neogi. NEJM 2011;364:443-452. An excellent update.
Selenium and the course of mild Graves' orbitopathy. Marcocci C, Kahaly GJ et al. NEJM 2011;364:1920-1931. In this randomised, double-blind, placebo-controlled trial selenium (an antioxidant agent) or pentoxifylline (an antiinflammatory agent) were administered to 159 patients with mild Graves' orbitopathy. The patients were given selenium (100 μg twice daily), pentoxifylline (600 mg twice daily), or placebo (twice daily) orally for 6 months and were then followed for 6 months after treatment was withdrawn. Primary outcomes at 6 months were evaluated by means of an overall ophthalmic assessment, conducted by an ophthalmologist who was unaware of the treatment assignments, and a Graves' orbitopathy-specific quality-of-life questionnaire, completed by the patient. Secondary outcomes were evaluated with the use of a Clinical Activity Score and a diplopia score. At the 6-month evaluation, treatment with selenium, but not with pentoxifylline, was associated with an improved quality of life (P<0.001) and less eye involvement (P=0.01) and slowed the progression of Graves' orbitopathy (P=0.01), as compared with placebo. The Clinical Activity Score decreased in all groups, but the change was significantly greater in the selenium-treated patients. Exploratory evaluations at 12 months confirmed the results seen at 6 months. Two patients assigned to placebo and one assigned to pentoxifylline required immunosuppressive therapy for deterioration in their condition. No adverse events were evident with selenium, whereas pentoxifylline was associated with frequent gastrointestinal problems. In this study selenium administration significantly improved quality of life, reduced ocular involvement, and slowed progression of the disease in patients with mild Graves' orbitopathy suggesting a that oxygen free radicals do play a part in the pathophysiology behind Graves’ Orbitopathy.
Diabetes mellitus, fasting glucose, and risk of cause-specific death. Seshasai SR, Kaptoge S, et al. NEJM 2011;364:829-41. The authors calculated hazard ratios for cause-specific death, according to baseline diabetes status or fasting glucose level, from individual-participant data on 123,205 deaths among 820,900 people in 97 prospective studies. After adjustment for age, sex, smoking status, and body-mass index, hazard ratios among persons with diabetes as compared with persons without diabetes were as follows: 1.80 (95% confidence interval [CI], 1.71-1.90) for death from any cause, 1.25 (1.19-1.31) for death from cancer, 2.32 (95% 2.11 -2.56) for death from vascular causes, and 1.73 (1.62-1.85) for death from other causes. Diabetes (vs. no diabetes) was moderately associated with death from cancers of the liver, pancreas, ovary, colorectum, lung, bladder, and breast. Aside from cancer and vascular disease, diabetes (vs. no diabetes) was also associated with death from renal disease, liver disease, pneumonia and other infectious diseases, mental disorders, nonhepatic digestive diseases, external causes, intentional self-harm, nervous-system disorders, and chronic obstructive pulmonary disease. Hazard ratios were appreciably reduced after further adjustment for glycaemia measures, but not after adjustment for systolic blood pressure, lipid levels, inflammation or renal markers. Fasting glucose levels exceeding 5.6 mmol/L, but not levels 3.9 to 5.6 mmol/L, were associated with death. A 50-year-old with diabetes died, on average, 6 years earlier than a counterpart without diabetes, with about 40% of the difference in survival attributable to excess nonvascular deaths. This excellent paper demonstrates that in addition to vascular disease, diabetes is associated with substantial premature death from several cancers, infectious diseases, external causes, intentional self-harm, and degenerative disorders, independent of several major risk factors.
Insulin degludec, an ultra-long-acting basal insulin, once a day or three times a week versus insulin glargine once a day in patients with type 2 diabetes: a 16-week, randomised, open-label, phase 2 trial. Zinman B, Fulcher G, et al. Lancet. 2011;377:880-1. In this 16-week, randomised, open-label, parallel-group phase 2 trial, participants aged 18–75 years with type 2 diabetes and HbA1c of 7·0–11·0% were randomly allocated in a 1:1:1:1 ratio randomisation to receive insulin degludec either once a day or three times a week or insulin glargine once a day, all in combination with metformin. 62 participants were randomly allocated to receive insulin degludec three times a week (starting dose 20 U per injection [1 U=9 nmol]), 60 to receive insulin degludec once a day (starting dose 10 U [1 U=6 nmol]; group A), 61 to receive insulin degludec once a day (starting dose 10 U [1 U=9 nmol]; group B), and 62 to receive insulin glargine (starting dose 10 U [1 U=6 nmol]) once a day. At study end, mean HbA1c levels were much the same across treatment groups, at 7·3% (SD 1·1), 7·4% (1·0), 7·5% (1·1), and 7·2% (0·9), respectively. Estimated mean HbA1c treatment differences from insulin degludec by comparison with insulin glargine were 0·08% (95% CI –0·23 to 0·40) for the three dose per week schedule, 0·17% (–0·15 to 0·48) for group A, and 0·28% (–0·04 to 0·59) for group B. Few participants had hypoglycaemia and the number of adverse events was much the same across groups, with no apparent treatment-specific pattern. In this trial insulin degludec provides comparable glycaemic control to insulin glargine without additional adverse events and might reduce dosing frequency due to its ultra-long action profile. An interesting insulin to add to our therapies. It is worth checking out the 2 trials in the March Diabetes Care edition on insulin degludec as well.
Levothyroxine dose and risk of fractures in older adults: nested case-control study. Turner MR, Camacho X, et al. BMJ. 2011 Apr 28;342:d2238. In this nested case-control study adults aged 70 or more who were prescribed levothyroxine between 1 April 2002 and 31 March 2007 and followed for fractures until 31 March 2008 were studied. Cases were cohort members admitted to hospital for any fracture, matched with up to five controls from within the cohort who had not yet had a fracture. The primary outcome was fracture (wrist or forearm, shoulder or upper arm, thoracic spine, lumbar spine and pelvis, hip or femur, or lower leg or ankle) in relation to levothyroxine use (current, recent past, remote). Risk among current users was compared between those prescribed high, medium, and low cumulative levothyroxine doses in the year before fracture. Of 213 511 prevalent levothyroxine users identified, 22 236 (10.4%) experienced a fracture over a mean 3.8 years of follow-up, 18 108 (88%) of whom were women. Compared with remote levothyroxine use, current use was associated with a significantly higher risk of fracture (adjusted odds ratio 1.88, 95% confidence interval 1.71-2.05), despite adjustment for numerous risk factors. Among current users, high and medium cumulative doses (>0.093 mg/day and 0.044-0.093 mg/day) were associated with a significantly increased risk of fracture compared with low cumulative doses (<0.044 mg/day): 3.45 (3.27-3.65) and 2.62 (2.50-2.76), respectively. This study has shown that among adults aged 70 or more, current levothyroxine treatment was associated with a significantly increased risk of fracture, with a strong dose-response relation, hence outlining the importance to avoid overtreatment in this population.
Effects of low-dose, controlled-release, phentermine plus topiramate combination on weight and associated comorbidities in overweight and obese adults (CONQUER): a randomised, placebo-controlled, phase 3 trial. Gadde KM, Allison DB, et al. In this 56-week phase 3 trial, the authors randomly assigned 2487 overweight or obese adults (aged 18-70 years), with a body-mass index of 27-45 kg/m2 and two or
more of hypertension, dyslipidaemia, diabetes or prediabetes, or abdominal obesity to placebo, once-daily phentermine 7·5 mg plus topiramate 46 mg, or once-daily phentermine 15·0 mg plus topiramate 92 mg in a 2:1:2 ratio Primary endpoints were the percentage change in bodyweight and the proportion of patients achieving at least 5% weight loss. Analysis was by intention to treat. At 56 weeks, change in bodyweight was -1·4 kg (least-squares mean -1·2%, 95% CI -1·8 to -0·7), -8·1kg (-7·8%, -8·5 to -7·1; p<0·0001), and -10·2 kg (-9·8%, -10·4 to -9·3; p<0·0001)in the patients assigned to placebo, phentermine 7·5 mg plus topiramate 46 mg, and phentermine 15·0 mg plus topiramate 92 mg, respectively. 204 (21%) patients achieved at least 5% weight loss with placebo, 303 (62%; odds ratio 6·3, 95% CI 4·9 to 8·0; p<0·0001) with phentermine 7·5 mg plus topiramate 46 mg, and 687 (70%; 9·0, 7·3 to 11·1; p<0·0001) with phentermine 15·0 mg plus topiramate 92 mg; for ≥10% weight loss, the corresponding numbers were 72 (7%), 182 (37%; 7·6, 5·6 to 10·2; p<0·0001), and 467 (48%; 11·7, 8·9 to 15·4; p<0·0001). The most common adverse events were dry mouth (24 [2%], 67 [13%], and 207 [21%] in the groups assigned to placebo, phentermine 7·5 mg plus topiramate 46 mg, and phentermine 15·0 mg plus topiramate 92 mg, respectively), paraesthesia (20 [2%], 68 [14%], and 204 [21%], respectively), constipation (59 [6%], 75 [15%], and 173 [17%], respectively), insomnia (47 [5%], 29 [6%], and 102 [10%], respectively), dizziness (31 [3%], 36 [7%], 99 [10%], respectively), and dysgeusia (11 [1%], 37 [7%], and 103 [10%], respectively). 38 (4%) patients assigned to placebo, 19 (4%) to phentermine 7·5 mg plus topiramate 46·0 mg, and 73 (7%) to phentermine 15·0 mg plus topiramate 92·0 mg had depression-related adverse events; and 28 (3%), 24 (5%), and 77 (8%), respectively, had anxiety-related adverse events. This trial suggests that the combination of phentermine and topiramate, with lifestyle interventions, might be a valuable treatment for obesity.
NEXT NEWSLETTER Due out beginning of October 2011 so keep the gossip coming.
posted by Arutchelvam at 9:25 PM
