Endodiabology: October 2012

ENDODIABOLOGY

Endodiabology.blogspot.com

NORTHEAST

FOR SPECIALTY TRAINEES AND BOSSES TRAPPED

IN THE NORTHERN DEANERY

October 2012

Editors:

Shahid Wahid, Petros Perros, Arutchelvam Vijayaraman

Associate Editor: Atif Munir

StR PLACEMENTS (NTN year of training from 1^st August 2012)

Newcastle Hospitals

Sudeeep Manohar (5) till October 2(CCT)

Anjali Shanthakumar (4) (LTFT)

Stuart Little (4)

Hamza Ali Khan(4)

Catherine Napier (4)

Atif Munir(5)

Anna Mitchell ( to start in April)

James Cook University Hospital

Jehangir Abbas (2)

Sviatlana Zhyzhneuskaya (2)

NorthTyneside/ Wansbeck

Kathryn Stewart (4)(LTFT)

Nimantha DeAlwis (5) job share with NGH community diabetes post

NGH community diabetes post

Arif Ullah (CCT)

South Tyneside Hospital

Sajid Ethol Kalathil (5)

Shun Nellaiappan (2)

Gateshead

Naveen Aggarwal (3)

Sunderland

Agnieska Swiecieka (3)

Alison Heggie (till October)

NorthTees/ Hartlepool

Muhammad Asam (3)

Darlington memorial Hospital

David Bishop(1)

Durham

Asgar Madathil (till October)( CCT)

Maternity Leave

Rohana Wright

Research with numbers

Anna Mitchell (Simon Pearce)

Earn Gan (Simon Pearce)

Alison Heggie (Mark Walker)

Sarah Steven (Prof Taylor)

Jakob Buckowzan (Prof Bilous)

Naveen Siddaramaiah (Prof Bilous)

Ali Aldibiati (JamesShaw)

MEETINGS / LECTURES / ANNOUNCEMENTS

· 11^th October 2012 Northern Endocrine & Diabetes Autumn CME, JCUH. Contact Sarah Steven(sarah.steven@doctors.org.uk ) or Rohana Wright rohanawright@doctors.org.uk

· 5^th-7^th November 2012 SfE Clinical Update 2011. Stratford-Upon-Avon. Contact www.endocrinology.org/meetings/index

· 8^th-9^th November 2012 ABCD autumn meeting, London. Contact www.diabetologists.org.uk followed by SpRs meeting.

· 21^st November 2012 Northern Endocrine Region Research and Audit Group meeting, Lumley Castle, Chester-le-street. Contact Shahid.wahid@stft.nhs.uk

· 27^th November 2012 RCP Updates in Medicine, Freeman Hospital. Contact Sue Archibald 0191 223 1247 sue.archibald@nuth.nhs.uk .

· 28^th November 2012 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Sue Archibald 0191 223 1247 sue.archibald@nuth.nhs.uk .

· 29^th & 30^th November 2012 Insulin Infusion Pump Course, Middlesbrough, JCUH. Contact nicky.scippon@stees.nhs.uk

· 3^rd & 4^th December 2012 61^st British Thyroid Association Annual meeting, London, www.british-thyroid-association.org .

· 16^th January 2013 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Sue Archibald 0191 223 1247 sue.archibald@nuth.nhs.uk .

· 26^th February 2013 SfE Clinical Cases. London. Contact www.endocrinology.org/meetings

· 13^th March 2013 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Sue Archibald 0191 223 1247 sue.archibald@nuth.nhs.uk .

· 13^th-15^th March 2013 Diabetes UK APC. Manchester. Contact www.diabetes.org.uk/conference

· 18^th-21st March 2013 BES 2013. Harrogate. Contact www.endocrinology.org/meetings

· 24^th April 2013 Acute Medicine Conference, Freeman Hospital. Contact Sue Archibald 0191 223 1247 sue.archibald@nuth.nhs.uk .

· 15^th May 2013 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Sue Archibald 0191 223 1247 sue.archibald@nuth.nhs.uk .

· 15^th-18^th June 2013 ENDO 2013, San Francisco, USA. Contact endostaff@endo-societ.org or www.endo-society.org/scimeetings .

· 21^st – 25^th June 2013 American Diabetes Association 73^rd Annual Scientific Sessions, Chicago, USA. Contact meetings@diabetes.org .

· 3^rd July 2013 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Sue Archibald 0191 223 1247 sue.archibald@nuth.nhs.uk .

· 18^th September 2013 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Sue Archibald 0191 223 1247 sue.archibald@nuth.nhs.uk .

· 13^th November 2013 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Sue Archibald 0191 223 1247 sue.archibald@nuth.nhs.uk .

· 26^th November 2013 RCP Updates in Medicine, Freeman Hospital. Contact Sue Archibald 0191 223 1247 sue.archibald@nuth.nhs.uk .

TRAINING ISSUES

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 £400 and it is named after 2 distinguished former Endocrinologists in the region, Bill Kelly and Eric Young.

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

Portfolio Completion It is essential for trainees to engage with their portfolio on a regular basis and record learning. It is also essential to record the numbers of patients seen as news or reviews for clinics, on-call, ambulatory care. It is essential to record the number of specialty clinics undertaken. Undertaking this activity means that your Educational Supervisor should be able to engage with the portfolio so as to provide you that assessment for ARCP purposes.

Management Training A regional management programme is in place for StRs. Contact Nimantha De Alwis nimdeal@googlemail.com for more information. The next meeting is on 10^th October 2012, Lumley Castle, 6pm “7-habits”.

Kings Fund Please read the excellent article by Arif Ullah in the BMJ careers section http://careers.bmj.com/careers/advice/view-article.html?id=20008282

From the TPD
We were pleased to find that all our trainees have done very well in this years ARCP, 95% achieving outcome 1 both in the speciality and the GIM. Both the trainees and trainers are well engaged with the training and the e-portfolio. This received a complementary comment from the medical school. We need to continue to keep our standards high. I am also pleased to note that quite a few trainees have started high quality research jobs this year and I am keen to see this trend to continue.

I am aware of the difficulties with the GIM service having an impact on the speciality training. Though it is no consolation, this issue appears to be national as I found it being discussed widely in the JRCPTB plenary meeting and in our national SAC meeting. No easy solution was offered. The problem is confounded by the fact that recruitment remains a problem and many units are left with gaps in our region . We need to keep a close watch on this and need to find our way around to make sure service provision is taken care of, patient safety is ensured and the standards of training maintained. If there are any unusual problem found in any unit, please inform me, our STC will do the best to resolve it.

When I am writing this, I am on my way to Bristol for the 2nd round interview for our ST posts and I hope I will bring some good candidates and fill the gaps. Fingers crossed.

I wish to meet up with the registrars regularly and with help from the trainee representatives , we will organise an informal meeting with all the trainees at least once a year, where we can share good practices and address any problems. I am looking forward to the future and will keep in regular touch

Training Committee

Chair- Nicky Leech
Programme Director- Arutchelvam Vijayaraman Vijayaraman.Arutchelvam@stees.nhs.uk

Consultant member-Shaz Wahid ;Consultant member- Richard Quinton, ; Consultant member-Jean MacLeod, ; Consultant member-Dr Peter Carey ; Consultant member-Simon Eaton, Consultant member-Salman Razvi salman.razvi@ghnt.nhs.uk ; Consultant member-Paul Peter ;Consultant member-Jeevan Mettayil Consultant Member Sath Nag: StR representative-Sajid Ethol Kalthil ; StR representative-Stuart Little

NEWS FROM THE NORTHEAST

· June 2012, baby girl Lakshana born to Muthu Jayapaul, whose new place of practice is: Dr. Muthu Kumaran Jayapaul MD MRCP(UK) Managing Director & Consultant Physician in Endocrinology & Diabetes Arka Center for Hormonal Health (Specialty Center for Thyroid, Diabetes & Obesity) 5/2 First Avenue, Sastri Nagar, Adayar Chennai -600020. Ph: 04424900050/51Web:www.arkahospital.com Mobile - 090031 93839.

· Richard Quinton Our Testosterone Guru has requested I mention the following papers: Abrupt Decrease in Serum Testosterone Levels After an Oral Glucose Load in Men: Implications for Screening for Hypogonadism. Caronia LM, Dwyer AA, Hayden D, Amati F, Pitteloud N, Hayes FJ. Clin Endocrinol (Oxf). 2012 Jul 17. doi: 10.1111/j.1365-2265.2012.04486.x. [Epub ahead of print]. The implication is that if one is screening somebody for possible male Hypogonadism then the sample should ideally be fasted as well as 9am so as to avoid getting false positives; Dwyer AA, et al in Clin Endo showing that serum Testo in males falls acutely during OGTT. ie. if you’re screening for male hypogonadism, always ask for a 9am FASTING sample to avoid false positives; Recent paper showing that Pioglitazone lowers serum testosterone & increases SHBG (so correspondingly steeper fall in free testosterone) in men with T2DM.

· Congratulations to Sudeep Manohar for his Locum Consultant at NUTH (Diabetes & General Medicine), with specific remit to improve inpatient diabetes care.

· Congratulations to Richard Quinton on his election as Vice-Chair of an EU-funded (Co-operation in Scientific & Technical Research) network into human GnRH (Gonadotropin releasing-hormone) deficiency (www.cost.eu/domains_actions/bmbs/Actions/BM1105).

· Congratulations to Simon Ashwell and his wife Amelia on their baby boy born on 16^th July 2012. Auden David is doing well and was 8lb 50z at birth.

LETTERS

Endocrine emergencies on take-Reflective practice by Atif Munir

Yes Addisonian crisis is perhaps the commonest but having managed Myxedoema Coma and Thyrotoxic Periodic Paralysis over the last few months made me realise that these conditions do exist outside the context of Endocrine textbooks and membership questions. Will I come across these conditions ever again? Having searched the literature about their incidence, perhaps not, hence sharing the cases with the local Endocrine fraternity sounded like a fair thought.

This is not a case report hence would only very briefly describe the cases, aiming to highlight that these conditions can be encountered in clinical practice, hence beware.

74 year old fit and well female few hours after presenting with acute delirium secondary to presumed urinary tract infection dropped her GCS requiring ventilatory support and ITU transfer after being given midazolam for agitation. Being clinically and biochemically profoundly hypothyroid with previously unknown thyroid status we treated her with IV T3 and corticosteroid cover. Made a gradual recovery over the next ten days and managed to come out of ITU when was switched to T4 administered through NG tube but unfortunately succumbed to hospital acquired pneumonia hence adding to the tally of mortality statistics of Myxoedema Coma quoted in literature (about 40%).

36 year old male of Asian origin with history of Grave’s disease treated medically and in remission presented with a 2-3 day history of progressive paraplegia to the extent of being bedridden for last 24 hours. Neuromuscular examination revealed proximal muscle weakness with preserved reflexes. Clinically euthyroid but biochemically thyrotoxic and profoundly hypokalaemic. IV potassium replacement rendered him eukalaemic within few hours; patient was independently mobile next morning. Was discharged home on propylthiouracil and propranolol and remains euthyroid with no further episodes of periodic paralysis.

Palliative Care Guidance for Diabetes-Shaz Wahid

The first thing I was “asked” to do on my first day as a Consultant was produce some palliative care guidelines for hyperglycaemia by Jimmy Youll our Lead Cancer Nurse Specialist. In fact he approached John Parr whilst we were both in Obs Med clinic. It was the first thing John delegated across to me, so I am sure you new boys will find this familiar. Since 2003 there have not been any consistent guidelines for this issue and our local guidelines stood the test of time. The team are currently reviewing 2 sets of guidance. The North of England Cancer Network guidance is a simple flow chart on 1 side that our local guidance fit in with easily. There are the comprehensive guidelines from Diabetes UK (End of Life Diabetes Care Clinical Recommendations on the website) that involved input from Jean MacLeod. These guidelines are relevant to the regional moves on Deciding Right, Care planning and use of the Liverpool Care Pathway. I am currently running them past our Palliative Care Consultant.

RECENT PUBLICATIONS FROM THE NORTHEAST

1. Avbelj M, Jeanpierre M, Sykiotis GP, Young J, Quinton R, Abreu AP, Plummer P, Au MG, Balasubramanian R, Dwyer AA, Florez JC, Cheetham T, Pearce SH, Purushothaman R, Schinzel A, Pugeat M, Jacobson‑Dickman EE, Ten S, Latronico AC, Gusella JF, Catherine Dode C, Crowley WF, Jr., Pitteloud N. An ancient founder mutation in PROKR2 impairs human reproduction. Human Molecular Genetics. 2012 Jul 17. [Epub ahead of print]

2. Gianetti E, Hall JE, Au MG, Kaiser UB, Quinton R, Stewart JA, Metzger DL, Pitteloud N, Mericq V, Merino PM, Levitsky LL, Izatt L, Muritano ML, Fujimoto VY, Dluhy RG, Chase ML, Crowley WF, Jr, Plummer L, Seminara SB. When genetic load does not correlate with phenotypic spectrum: lessons from the GnRH receptor (GNRHR). Journal of Clinical Endocrinology & Metabolism. 2012 Jun 28. [Epub ahead of print]

3. Munir A, Leech N, Windebank KP, McLelland J, Jones GL, Mitra D, Jenkins A, Quinton R. 2012 Langerhans cell histiocytosis: a multisystem disorder. Journal of the Royal College of Physicians of Edinburgh. 42: 225-227.

4. Pattman S, Quinton R, Pearce SHS, Datta H. 2012. Quantification of 25‑hydroxyvitamin D ‑serving a clinically important role. Lancet. 379: 1699-1700.

5. Quinton R. 2012 Communication skills & overseas medical graduates. JRSM. 105: 232.

6. Quinton R. 2012 Where specialist diabetes teams can be found. BMJ. 344: e3854.

7. Gan EH, Pattman S, Pearce SH, Quinton R. 2012. Many men are receiving unnecessary testosterone prescriptions. BMJ. 345: 31-32 (e5469).

RECENT PUBLICATIONS IN DIABETES & ENDOCRINOLOGY THAT HIT THE NEWS OR THAT MAY HAVE A SIGNIFICANT IMPACT ON MANAGEMENT

Familial hypercholesterolaemia. PJ Gill et al. BMJ 2012;344:e3228. Well worth a read for an update and a reminder to be ever vigilant.

Effectiveness of a diabetes education and self management programme (DESMOND) for people with newly diagnosed type 2 diabetes mellitus: three year follow-up of a cluster randomised trial in primary care. The 1 year changes in biomedical data were not sustained at 3 years although QOL was improved. My take home message is in relation to our service bidding to run the DESMOND programme for our district. Once set up we need to tackle the thorny issue of on-going education to sustain the changes. Also, it has galvanised me to put in a proposal to our local Health and Wellbeing Board for funding for a group education programme specifically for “pre-diabetes”. The linked editorial by Frank Snoek (BMJ 2012;344:e2673) is well worth a read.

Bisphosphonates for osteoporoses-where do we go from here ? M Whitaker et al. NEJM 2012;366:2048-2051. Continuing bisphosphonate treatment for osteoporoses-for whom and for how long? DM Black et al. NEJM 2012;366:2051-2053. 2 thought provoking articles discussing the issues of risk and effectiveness of bisphosphonates in the long term. The message not all bisphosphonates are alike and to be mind full if the risks is a good one to bear in mind as we await further studies.

The new NHS information strategy. JC Wyatt. BMJ 2012;344:e3807. A relatively provocative editorial on the important issue of medical records.

The June 16-22 2012 Lancet Edition. Is devoted to diabetes with excellent primary research articles on Type 2 diabetes therapies, self-management and prediabetes and seminars on pre-diabetes, diabetes and cognitive dysfunction and bariatric surgery for type 2 diabetes.

The use of pioglitazone and the risk of bladder cancer in people with type 2 diabetes: nested case-control study. L Azoulay et al. BMJ 2012;344:e3645. A useful read confirming that there is an increased risk of bladder cancer with the greatest risk in the first 24 months and at a cumulative dose above 28 000 mg. The accompanying editorial (BMJ 2012;344:e3500) is well worth a read.

Serum glucose levels for predicting death in patients admitted to hospital for community acquired pneumonia: prospective cohort study. PM Lepper et al. A good study confirming the importance of managing hyperglycaemia in this group of patients presenting to the acute take. The glucose levels predict death in patients without pre-existing diabetes and those with diabetes have an increase risk of death independent of glucose levels.

Effect of pre-diabetes on future risk of stroke: meta-analysis. M Lee et al. BMJ 2012;344:e3564. The overall message from this meta-analysis of 15 studies and 700 000 participants is that there is an increased risk. The accompanying editorial (BMJ 2012;344:e3285) is well worth a read. As a specialty service I think we all need to get our claws into pre-diabetes service delivery models.

Is surgery a magic bullet against diabetes? SG Thrumurthy et al. BMJ 2012;345:e4552. A balanced editorial given the recent seminal trials on this subject.

Thrombotic Stroke and Myocardial Infarction with Hormonal Contraception. O Lidegaard et al. NEJM 2012;366:2257-2266. This cohort study demonstrates an increased risk of stroke or MI by a factor of 0.9-1.7 for an ethinyl oestradiol dose of 20mcg and by a factor of 1.3-2.3 for a dose of 30-40 mcg with no real impact from the progestin type. We must remember that the absolute risks are low. The accompanying editorial by Diana B Petittiti (NEJM 2012;366:2316-2318) is an essential read.

TODAY-A stark glimpse of tomorrow. David B Allen. NEJM 2012;366:2315-2316. The author provides a very telling editorial on the accompanying TODAY trial (NEJM 2012;366:2247-2256) that demonstrates in 10 to 17 year olds with type 2 diabetes metformin alone can get 48% of them to glycaemic control targets adding in rosiglitazone increases this to 61% BUT adding intensive lifestyle intervention to the metformin only increased this to 53%.

Hormone replacement therapy. M Hickey et al. BMJ 2012;344:e763. An excellent update and overview on this important area.

Should we screen for type 2 diabetes? Yes K Khunti and M Davies BMJ 2012;345:e4514 No E Goyder et al BMJ 2012;345:e4516 An excellent read. My practice of targeted screening shall continue.

Vitamin D-baseline status and effective dose. RP Heaney. NEJM 2012;367:77-78. This excellent article linked to the trial (NEJM 2012;367:40-49) says it all the first sentence “There has been more ink spilled over the efficacy of vitamin D than over that of most nutrients, with the possible exception of sodium”.

n-3 fatty acids and cardiovascular outcomes in patients with dysglycemia. The ORIGIN trial investigators. NEJM 2012;367:309-318. Basal insulin and cardiovascular and other outcomes in dysglycemia. The ORIGIN Trial investigators. NEJM 2012;367:319-328. Both negative trials but worth a read to review ones practice.

Risk identification and interventions to prevent type 2 diabetes in adults at high risk: summary of NICE guidance. H Chatterton et al. BMJ 2012;345:e4624. Essential reading for a summary. Our Diabetes Clinical Network is reviewing this as we see it as more bangs for our bucks compared to the DESMOND programme that we have in the long run.

Vitamin D: some perspective please. NC Harvey, C Cooper. BMJ 2012;345:e4695. I can see RQ steaming and banging off a response?

Risk assessment of fragility fractures: summary of NICE guidance. S Rabar et al. BMJ 2012;344:e4082. An essential read for a summary.

Diagnosis of Diabetes. SE Inzucchi. NEJM 2012;367:542-550. A real American flavour to this. It has not changed our pathway.

A dual hyperthyroidism. GR Pishdad et al. Lancet 2012;380:306. A timely case report reminding us that thyroid cancer can occur in Graves’ at the same time.

New drugs, procedures and devices for hypertension. S Laurent et al. Lancet 2012;380:591-610. An excellent update on what is just here, about to come and a little bit further away.

Gliptin versus a sulphonylurea as add-on to metformin. AJ Scheen, Nicolas Paquot. Lancet 2012;380:450-451. A balanced editorial that is linked to the trial by B Gallwitz et al (Lancet 2012;380:475-483).

Minimizing unnecessary surgery for thyroid nodules. JL Jameson. NEJM 2012;367:765-767. An essential read along with the linked trial by EK Alexander et al. (NEJM 2012;367;705-715). The flow chart is very practical.

Bariatric surgery and prevention of Type 2 diabetes in Swedish obese subjects. LMS Carlsson et al. NEJM 2012;367:695-704. For those undergoing bariatric surgery vs those with usual care the risk of developing type 2 diabetes was reduced by 79 to 87 %. The accompanying editorial by Danny Jacobs )NEJM 2012;367:764-765) is well worth a read.

Risk of coronary events in people with chronic kidney disease compared with those with diabetes: a population-level cohort study. M Tonelli et al. Lancet 2012;380:807-814. Hmm Steve Haffner’s seminal study (now disproved??) comes to CKD, in that it seems to be a coronary risk equivalent and more so than diabetes. I would also read the accompanying editorial by Tamar Polansky and Goerge Bakris (Lancet 2012;380:783-785).

Spray-applied cell therapy with human allogeneic fibroblasts and keratinocytes for the treatment of chronic venous leg ulcers: a phase 2, multicentre, double-blind, randomised, placebo-controlled trial. RS Krisner et al. Lancet 2012;380:977-985. We see a fair bit of this in our foot clinics (and on-call!). I think that this trial will turn out to be a seminal moment and is put into context by the editorial Lancet 2012;380:953-955.

PTEN-linkin g metabolism, cell growth and cancer. Ulf Smith. NEJM 2012;367:1061-1063. See the linked trial: Aparna Pal et al. NEJM 2012;367:1002-1011. An excellent editorial linked to the trial describing the role of the tumour-suppressor phosphatase and tensin homologue (PTEN) reduced activity and its impact on cancer through metabolic pathways. Effectively, increasing PTEN will lead to reduced insulin sensitivity and increased risk of type 2 diabetes.

Understanding low sugar from NICE sugar. IB Hirsch. NEJM 2012;367:1150-1151. Linked article NEJM 2012;367:1108-1118 An excellent read that really does support the ADA guidance on this. Just need to get my intensivists to accept it……………………..

Newer insulins in type 2 diabetes. Edwin AM Gale. BMJ 2012;345:e4611. A very timely article. Make your own mind up. When I started at STFT in 2003 the use of analogue insulin rocketed. John Parr audit the patients we (mainly me!) switched from Mixtard 30/Humulin M3 to Novomix 30 and demonstrated that control improved in the majority. The pressure is on to switch all of our Type 2 patients from Novomix 30 analogue to human insulin. I point to the Yorkshire and Humberside Public Health Observatory data that demonstrates South Tyneside as delivering good quality care at a low cost in terms of HbA1c. Failing this I point to the fact that I give patients the “choice” and let them make their own minds up.

Drug eluting stents for patients with diabetes. KH Mak. BMJ 2012;345:e5828. An excellent overview in this editorial linked to the article BMJ 2012;345:e5170.

The relative clinical effectiveness of ranibizumab and bevacizumab in diabetic macular oedema: an indirect comparison. JA Ford et al. BMJ 2012;345:e5182. Well worth a read in this topical area. In summary no difference between the two but there are methodological issues.

Contribution of modifiable risk factors to social inequalities in type 2 diabetes: prospective Whitehall II cohort study. S Stringhini et al. BMJ 2012;345:e5452. Not surprising this one, in that what I teach on the CIDR course is that it is behavioural attitudes that contribute to morbidity and mortality in long term conditions. This study demonstrates that it is obesity and health behaviour contributing to social inequalities in terms of type 2 diabetes incidence.

Prediction models for risk of developing type 2 diabetes: systematic literature search and independent external validation study. A Ababasi et al. BMJ 2012;345:e5900. I have been asked umpteenth times by community colleagues what risk prediction model we can use for type 2 diabetes. With the development of the Health and Wellbeing Board I shall soon be approached again. A timely article that shows all tools are good at picking up those at high risk of diabetes but are unable to quantify future risk effectively.

Association of systolic and diastolic blood pressure and all cause mortality in people with newly diagnosed type 2 diabetes: retrospective cohort study. AP Vamos et al. BMJ 2012;345:e5567. I like to keep things simple, probably because of my “maturity”, so my old adage of keep Trigs less than 5, HbA1c < 58, LDL < 2 or TC < 4 and BP < 140/80 for all pts is backed up by this article on BP.

Low glycaemic index diet in pregnancy to prevent macrosomia (ROLO study): randomised control trial. JM Walsh et al. BMJ 2012;345:e5605. This diet has no effect on reducing fetal birth weight but does help improve maternal gestational weight gain and reduce risk of glucose intolerance. A good article for discussion at my next Maternal Medicine Clinic.

Tight glycemic control versus standard care after pediatric surgery. MSD Agus et al. NEJM 2012;367:1208-1219. Another negative trial for tight control in an ICU setting. So, only treat hyperglycaemia in ITU if blood sugar greater than 10 mmol/l and if treatment needed maintain control between 6 and 10 mmol/l makes absolute sense.

What’s preventing us from preventing Type 2 diabetes? JE Fradkin et al. NEJM 2012;367:1177-1179. More pertinent to the USA but there are some salutary lessons for us.

NEXT NEWSLETTER Due out beginning of February 2013 so keep the gossip coming.

Endodiabology

Wednesday, October 03, 2012