Endodiabology February 2012
ENDODIABOLOGY
Endodiabology.blogspot.com
NORTHEAST
NEWSLETTER
FOR SPRs AND BOSSES TRAPPED
IN THE NORTHERN DEANERY
February 2012
Editors: Shaz Wahid
Petros Perros ( and Arutchelvam Vijayaraman
StR PLACEMENTS (NTN year of training from
1st October 2011)
· Newcastle- Alison Heggie (2), Sudeep Manohar (5), Nimanthe De Alwis
(3), Rohana Wright (3), Anjali SanthaKumar (3), Naveen Siddaramaiha (5), Stuart
Little (3), Vacant
·
North Tyneside/Wansbeck- Asgar Madathil (4), Arif Ullah (3)/ Sajid Ethol
Kalathil (3) job share with NGH community diabetes post
·
South Tyneside- Catherine
Napier (3)
·
Gateshead- Kathryn Stewart (3)
·
Sunderland- Sviatlana Zhyzhneuskaya (1), Shunmugam
Nellaiappan (1) Jehangir Abbas(1)
· North
Tees/Hartlepool- Naveen Aggarwal (3), Atif
Munir (4)
·
Middlesbrough-
Jacog Buckovan (2), Agnieska Sawiecicka (2), Muhammed
Asam(1)
·
Bishop
Auckland/Darlington/Durham- Humza Ali Khan (3)
· NGH-
Arif Ullah (3)/ Sajid Ethol
Kalathil (3) job share
·
Research with numbers (supervisor)- Sarah Steven (3-Prof Taylor), Anna
Mitchell (1-Prof Pearce), Earn Gan (1-Prof Pearce)
MEETINGS / LECTURES / ANNOUNCEMENTS
·
7th March 2012 SFE Visiting Professor-see programme in
letters section.
·
14th March 2012 ½ day SpR G(I)M teaching, Freeman
Hospital. Contact Sue Archibald 0191 223 1247 sue.archibald@nuth.nhs.uk
.
·
18th April 2012 Acute Medicine Conference, Freeman
Hospital. Contact Sue Archibald 0191 223 1247 sue.archibald@nuth.nhs.uk
.
·
19th & 20th
April 2012 Insulin
Infusion Pump Course, JCUH, Middlesbrough. Contact nicky.skippon@stees.nhs.uk
·
8th May 2012 Northern
Endocrine & Diabetes Summer CME, Sunderland. Contact Sarah Steven(sarah.steven@doctors.org.uk
) or Rohana Wright rohanawright@doctors.org.uk
·
16th May 2012 ½ day SpR G(I)M teaching, Freeman
Hospital. Contact Sue Archibald 0191 223 1247 sue.archibald@nuth.nhs.uk
.
·
8th-12th June 2012 American
Diabetes Association 72nd Annual Scientific Sessions, Philadelphia,
USA. Contact meetings@diabetes.org .
·
23rd-26th June 2012 ENDO 2012,
Houston, USA. Contact endostaff@endo-societ.org
or www.endo-society.org/scimeetings
.
·
4th July 2012 ½ day SpR G(I)M teaching, Freeman
Hospital. Contact Sue Archibald 0191 223 1247 sue.archibald@nuth.nhs.uk
.
·
19th September 2012 ½ day SpR G(I)M teaching, Freeman Hospital.
Contact Sue Archibald 0191 223 1247 sue.archibald@nuth.nhs.uk
.
·
11th October 2012 Northern
Endocrine & Diabetes Autumn CME, JCUH. Contact Sarah Steven(sarah.steven@doctors.org.uk
) or Rohana Wright rohanawright@doctors.org.uk
·
21st November 2012 Northern Endocrine Region Research and
Audit Group meeting, Lumley Castle, Chester-le-street. Contact Shahid.wahid@stft.nhs.uk
·
27th November 2012 RCP Updates in Medicine, Freeman Hospital.
Contact Sue Archibald 0191
223 1247 sue.archibald@nuth.nhs.uk .
·
28th November 2012 ½ day SpR G(I)M teaching, 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 £800 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.
Quality Improvement
activity Audit,
audit, audit, audit, audit. The more you say it does not make it any more
interesting, but just another hurdle to get over at ARCP. Thankfully for
Consultant appraisal audit is not the be all and end all, but what matters is a
quality improvement activity. There are numerous examples of such activity a
Consultant undertakes and can utilise in their appraisal. Moves are afoot to
bring quality improvement activity into training curricula. See the letters
section for more information.
Maternity
Medicine Is fun and
opportunities are available to formalise ones training in this field. See the
letters section below.
ARCPs will this year be 22nd to
24th May 2012. Please keep these dates free.
Trainers and
Trainees meeting Weds
30th May 2012 4-6 pm (preceded by the STC meeting 2-4pm).
Training Committee Chair- Nicky Leech nicola.leech@nuth.northy.nhs.uk; Programme
Director- Arutchelvam Vijayaraman Vijayaraman.Arutchelvam@stees.nhs.uk;
Consultant member-Shaz Wahid Shahid.wahid@stft.nhs.uk
;Consultant member- Richard Quinton, Richard.Quinton@nuth.nhs.uk; Consultant member-Jean MacLeod, Jean.Macleod@nth.nhs.uk; Consultant member-Dr Peter Carey Peter.Carey2@chs.northy.nhs.uk ; Consultant
member-Simon Eaton, simon.eaton@northumbria-healthcare.nhs.uk; Consultant member-Salman Razvi salman.razvi@ghnt.nhs.uk ; Consultant
member-Paul Peter paul.peter@cddah.nhs.uk
;Consultant member-Jeevan Mettayil jeevan.mettayil@stft.nhs.uk
; StR representative-Sajid Ethol Kalthil sajidek@hotmail.com
; StR representative-Stuart Little stuartlittle@doctors.org.uk
NEWS FROM THE NORTHEAST
·
Welcome to Ashwin Joshi, who has joined Peter and
Raz at Sunderland as a Consultant Endocrinologist. He trained in
Diabetes/Endocrinology in the Northwest (Manchester) rotation, with an interim
research fellowship at Liverpool. His interests are General Diabetes &
Endocrinology and he has taken over the Metabolic Bone clinic from Terry Aspray
at Sunderland.
·
Welcome to Giridhar Tarigopula, who has us
joined as a Consultant Endocrinologist at Darlington.
·
Congratulations to Sajid Kalathil as the
new trainee rep on the STC.
·
Jeevan Meetayil has joined the STC as a
Consultant member.
·
An opportunity to join the ENDODIABOLOGY
editorial team has arisen. See the letters section.
·
Many of you will remember Beas Bhattacharya as a trainee in the region.
She has been appointed as a Consultant at Swindon.
·
Simon Pearce and Anna Mitchell have a review in press- Anna L. Mitchell and Simon H. S. Pearce. Autoimmune
Addisondisease: pathophysiology and genetic complexity. Nature Reviews
Endocrinology.
·
Many of you will remember Muthu Jayapaul, a former trainee in the
region. He has opened a specialist centre for
Endocrinology in Chennai (Arka centre for Hormonal Health), affiliated to
Chennai University www.arkahospital.com
LETTERS
Associate Editor for
ENDODIABOLOGY-Shaz Wahid
Do you wish to build your CV? Do you wish to gain some Educational
Management experience? ENDODIABOLOGY will allow you to do this. Options include
simply contributing articles on training, paper reviews, book reviews or what
ever takes your fancy! The Editorial team are open to new suggestions and if
have a flair for IT the blog site will allow you to achieve many things. There
is more than one opening to join as an Associate Editor and if you are
interested please contact shahid.wahid@stft.nhs.uk
.
‘Beyond
Audit’: Time to change requirements for doctors in postgraduate training
programmes-Shaz Wahid
Moves are afoot to move away from doing audit for
audits sake as a trainee, about time! Currently, all doctors in postgraduate training programmes are expected
to undertake ‘clinical audit’ as part of their training. This is reflected in
College and Foundation curricula, the Annual Review of Competence Progression
(ARCP) requirements for all specialties and person specifications for entry
into specialty training programmes. The requirement is further bolstered by the
current General Medical Council’s (GMC) Generic Standards for Training which
states that ‘Trainees must regularly be involved in the clinical audit process,
including personally participating in planning, data collection and analysis’.
However,
the GMC have recently demonstrated a shift in emphasis from ‘clinical audit’ to
the broader and more inclusive concept of ‘quality improvement’. The GMC’s Good Medical Practice Framework requires all doctors to ‘take part in
systems of quality assurance and quality improvement’. Furthermore, within the
accompanying document, Supporting Information for Appraisal and
Revalidation it is
proposed that a doctor demonstrates that they regularly participate in ‘quality
improvement activity’ – not just clinical audit, which is simply listed as an
example.
The current
audit requirements for doctors in postgraduate training programmes are
insufficient to meet audit’s primary objective; that is to improve the quality
and safety of patient care. There is increasing evidence that junior doctor-led
clinical audit is failing to deliver [6-8]. Junior doctors perceive their
involvement to be ‘tedious’ and a ‘tick-box exercise’. And crucially, audits
undertaken by doctors in training are failing to change practice.
It is
difficult to argue that there is much educational benefit in this process and
yet trainees are unable to progress in their training if they cannot demonstrate
their participation in the clinical audit process. Apart from the time that
incomplete audit cycles consume in training programmes, the huge numbers of
such audits undertaken each year accrue only a limited benefit to patients or
the organisations who care for them. Audit is simply a vehicle for quality
improvement. There are many other highly effective quality improvement
methodologies e.g. PDSA cycles, process mapping, root cause analysis. It is
important that doctors in postgraduate training are encouraged to focus on
identifying problems in the healthcare system and then seek ways to improve
them. Whilst clinical audit may be one method, there are many other approaches
that can be taken that may be more relevant to doctors in training grades and
are often much more rewarding.
Whilst the
issue is being debated nationally and curricula eventually changed I would
encourage trainees to try and undertake the following activity:
-Mortality
and Morbidity reviews with action plans.
-Root cause
analysis of any incidents.
-Service/process
mapping with hard improvement end points.
-Audit that
is part of a process mapping to inform any change cycle.
-Readmissions
review with action plans.
I have
brought this issue to the attention of our STC and we will hopefully tackle
this issue pragmatically whilst we await national guidance.
Maternal Medicine-Shaz Wahid
Traditionally
our specialty has produced trainees with enough training and experience to
undertake the non-diabetic/endocrine care of women in obstetric medicine
clinics. With the EWTD and the ever dwindling time in clinics, add to which
that tertiary centres now have specific specialists undertaking maternity
medicine (renal for renal, neurology for neurology, etc) the exposure to
maternal medicine for our trainees is slim compared to the past. As a
comparison I undertook 122 obs/med clinics in the region over 5-yrs and talking
to my 2 colleagues between them they got no where near that number. I then for
5-yrs had the experience of working with Tony Jones and John Parr in the
obs/med clinic. Both being Gurus in the field.
The other
issues to face in maternal medicine is the increasing impact of underlying
known about and unknown about medical conditions being the biggest contributor
to maternal death and morbidity. Add to this the growing number of diabetic
patients in an obs/med clinic and the increasing use of insulin pump therapy meaning that the numbers
are large. In our own service we were ranging between 40 to 60 patients a
clinic for one Consultant! Hence, we have now split the patients into a weekly
antenatal diabetes clinic and a weekly Maternal Medicine clinic (also includes
Endocrinology) undertaken by yours truly to maintain a GOLD standard service as
argued by our Obstetrician. Furthermore, as one of our patients pointed out
last week “this is no longer a cattle market”! Furthermore, personally I find
running the clinic highly satisfying.
I would
argue that our trainees are in an enviable position of truly developing an
interest in Maternal Medicine if they so wish and I personally would encourage
them to do so (it adds another string to ones bow and keeps the Trusts
interested!). They need to grasp the nettle and have demonstrable evidence in
their training of experience in Maternal Medicine by documenting:
-Reading a
book! I grew up with Medical Disorders in Obstetric Practice by Michael de
Swiet, but have discovered and read the slimmer book Handbook of Obstetric
Medicine by Catherine Nelson-Piercy. My advice read the latter and top with
individual topics for more detail using de Swiet’s book.
-Try to get
your training programme structured in units that allow you to do
obstetric/medicine and not just antenatal diabetes/endocrinology.
-Undertake
CPD in maternal medicine at least 3 times in 5-yrs. I would suggest visiting
the MacDonald Obstetric Medicine Society (MOMS) and British Fetal and Maternal
Medicine Society web-sites for specific training and educational events.
-If you
wish to go the whole hog consider an OOPE. Catherine Nelson-Piercy’s unit run a
1-year training programme specifically in Maternal Medicine and it was recently
advertised.
Our STC
will be debating this issue, whilst awaiting a national steer, and if any one
wishes to chat my door is open……………………………………………
Join the Search…Rose
Lee-Gough
2.9 million People in the UK are living
with diabetes.
850,000 may have Type 2 diabetes and
not know it.
Would you like to be part of the search
for the undiagnosed?
We’re recruiting volunteer Risk
Assessors to help at Diabetes UK Healthy Lifestyle Road shows in 2012.
The road shows provide important
information about how leading a healthier lifestyle can reduce your risk of
developing Type 2 diabetes, as well as providing general information about the
condition. Diabetes UK will be offering Risk Assessments at our Road shows, and
alerting people to their risk of developing Type 2 diabetes. Any one at a higher risk of diabetes
will be referred on to their GP for further tests relating to diabetes.
In 2011 we visited 55 locations across
England, Scotland, Wales and Northern Ireland, and have assessed over 11,000
people to determine their risk of developing Type 2 diabetes. This has resulted
in referring over 5,000 people to their GP.
Qualified health care professionals
will be provided with a pack of information prior to the road shows, so that
they are prepared for the event.
Any one who is not a qualified health care professional will be provided
with a days training for the volunteer role.
Society for
Endocrinology Visiting Professor-Prof Berenice Mendonca
Wednesday
March 7, 2012
Venue
- Medicinema in the New Victoria
Wing. RVI, Newcastle-upon-Tyne
Professor Mendonca’s Areas of interest are detailed below. The 6
cases presented during the afternoon will reflect these topics.
Programme
1.30 -
Start - 4 cases (each consisting
of a 10 minute
presentation
+ 10 minute discussion)
2.50 - Tea
3.20 - 2
further cases
4pm -
Society for Endocrinology visiting Professor lecture
‘Disorders of Sex Development:
Assessment and Prognosis’
Professor Mendonca’s other areas of
interest include:
·
Congenital adrenal hyperplasia diagnosis and treatment
·
Phenotype and genotype of LHRH mutations in both sexes
·
Genetic causes of primary ovarian failure
·
Genetic causes of hypogonadotropic hypogonadism
·
Spectrum of SF1 mutations
·
Adrenal tumors in children
·
Glucocorticoid Resistance Syndrome
·
Central precocious puberty: diagnosis and treatment
·
Hypogonadotropic Hypogonadism in Males
·
Short stature due to SHOX mutations
RECENT PUBLICATIONS FROM THE NORTHEAST
1.
Lavender
TW, Martineau AR, Quinton R, Schwab U. 2012. Severe hypercalcaemia
following vitamin D replacement for tuberculosis-associated hypovitaminosis D. International
Journal of Tuberculosis & Lung Disease. 16: 140.
2.
Marc
Evans, Stephen Bain, Simon Hogan and Rudy
W. Bilous. Irbesartan delays progression of nephropathy as measured by estimated
glomerular filtration rate: post hoc analysis of the Irbesartan Diabetic
Nephropathy Trial. Nephrology, Dialysis, Transplantation (2011) 0: 1–9 doi: 10.1093/ndt/gfr696
3.
DR Woods, J Begley, M Stacey, C Smith, CJ
Boos, T Hooper, A Hawkins, P Hodkinson, N Green and A Mellor. Severe Acute
Mountain Sickness, Brain Natriuretic Peptide and NT-proBNP in humans. Acta
Physiologica, 2012. DOI: 10.1111/j.1748-1716.2012.02407.x
4.
Woods DR, Davison A, Stacey M, Smith C, Hooper T, Neely D, Turner S, Peaston
R, Mellor A. The cortisol response
to hypobaric hypoxia at rest and post-exercise. Horm Metab Res, 2012, in press.
5.
RECENT PUBLICATIONS IN DIABETES & ENDOCRINOLOGY THAT HIT THE NEWS OR
THAT MAY HAVE A SIGNIFICANT IMPACT ON MANAGEMENT
CPAP for the
metabolic syndrome in patients with obstructive sleep apnea. SK Sharma et al.
NEJM 2011;365:2277-2286.
An interesting trial that shows 3-months of CPAP therapy in patients with OSA
classed as moderate to severe significantly reduces blood pressure, HbA1c,
LDL-cholesterol, total-cholesterol. There was a moderate effect of reversing
metabolic syndrome with CPAP.
Intensive
diabetes therapy and glomerular filtration rate in Type 1 Diabetes. DCCT/EDIC
research group. NEJM 2011;265:2366-76. Further excellent data from this landmark trial demonstrating that over
22-yrs of follow-up those intensively treated vs conventionally treated for glycaemic control were 50% less
likely to develop impaired GFR, and of these there was a further 50% reduction
in the development of end-stage-renal-failure.
Effects on
11-year mortality and morbidity of lowering LDL cholesterol with simvastatin
for about 5 years in 20 536 high-risk individuals: a randomised controlled
trial. Heart Protection Study Collaborative group. Lancet
DOI:10:1016/S0140-6736(11)61125-2 . Results of the post HPS trial follow-up demonstrating continued benefits
of cholesterol lowering at a mean of 11 years with no safety concerns. The
accompanying editorial by P Kohli and CP Cannon (Lancet
DOI:101016/S0140-6736(11)51544-4) is well worth a read.
Niacin at 56
years of age-Time for an early retirement? RP Guigliano. NEJM
2011;365:2318-2320. I would say 99%
of the time! An excellent editorial that distils the trials utilising Niacin in
the last 56 years into a neat conclusion and is accompanies by the AIM-HIGH
investigators trial (NEJM 2011;365:2255-2267).
Primary
Hyperparathyroidism. C Marcocci & F Cetani. NEJM 2011;365:2389-2397. Wee worth reading this update on a very
common condition we need to deal with.
Diagnosis and
management of maturity onset diabetes of the young (MODY). G Thanabalasingham
& KR Owen. BMJ 2011;343:d6044. An excellent practical article well worth a read.
Increased risk
of glucose intolerance and type 2 diabetes with statins. CD Byrne & SH
Wild. BMJ2011;343:d5004. Make
your own mind up, but I am very dubious that they do.
Risk of adverse
pregnancy outcomes in women with polycystic ovary syndrome:population based
cohort study. N Roos et al. BMJ 2011;343:d6309. The investigators demonstrated increased risks
for gestational diabetes, pre-eclampsia, caesarean section, pre-term birth,
neonatal morbidity and LFGA. I do not find this surprising and would suggest
that any such women have their risk factors assessed carefully at booking, with
carefull screening and preventive therapy when appropriate. The accompanying article
by Macklon (BMJ2011;343:d6407) is well worth a read.
Dalcetrapid:
turning the tide for CETP inhibition? ESG Stroes and DF van Wijk. Lancet
DOI:10.1016/S0140-6736(11)61421-9 . An excellent editorial updating us on where we are with CETP inhibitor
therapy for lipid therapy.
Effect of two
intensive statin regimens on progression of coronary disease. SJ Nicholls et
al. NEJM 2011;365:2078-2087. An interesting article demonstrating that despite the slightly better
reduction in LDL and rise in HDL achieved with high dose rosuvastatin compared
to high dose atorvastatin there was no difference in coronary atherosclerosis.
Personalised
medicine for hypertension. MJ Brown. BMJ2011;343:d4697. An excellent editorial discussing the benefits
of plasma renin testing in resistant hypertension with a pragmatic pathway.
Hyperglycaemia
in acute coronary syndromes: summary of NICE guidance. A Senthinathan et al.
BMJ 2011;343:d6646. Hmm, found this
confusing. Let’s just say our updated guidance developed by Jeevan are compliant.
This does fit the bill for a regional audit for an interested trainee?
Intensive
glycaemic control for patients with type 2 diabetes: systematic review with
meta-analysis and trial sequential analysis of randomised clinical trials. B
Hemmingsen et al. BMJ 2011;343:d6898. Salman loves meta-analysing I hate them and what is a TSA? Either way
more ammunition for a Cardiologist to ask me stop treating the high sugar!
Proprotein
covertases in health and disease. AW Artenstein & SM Opal. NEJM
2011;365:2507-2518. An excellent
article discussing the role of this group of proteolytic enzymes in both normal
hormone function and when things go wrong explaining endocrine disease.
Bone-density
testing interval and transition to osteporosis in older women. ML Gourlay et
al. NEJM 2012;366:225-233.
An excellent article demonstrating that in women with a normal or mildly
osteopaenic bone scan over a 15-year period 10% will go on to develop
osteoporoses, with those displaying more advanced stages of osteopaenia
progression to osteoporoses would significantly happen over 5 years in moderate
osteopaenia and 1-year in advanced osteopaenia.
A Mutation in
the thyroid hormone receptor alpha gene. E Bochukova et al. NEJM
2012;366:243-249. A case report
describing a genetic mutation explaining hypothyroidism in a child with the
clinical features but not the classical biochemical profile.
Diabetic
Stem-Cell “Mobilopathy”. JF DiPersio. NEJM 2011;365:2536-2638. For those who like translational research
well worth a read.
Risk of pulmonary
embolism in patients with autoimmune disorders: a nationwide follow-up study
from Sweden. B Zoller et al. Lancet 2012;379:244-249. Well worth a read along with the accompanying
editorial. From a range of autoimmune disorders the risk(95%CI) of PE 1 year
post hospital admission for Addison’s 7.75(5.3-10.95), Type 1 DM
6.38(3.28-11.18), Hashimoto’s thyroiditis 5.26(4.83-5.73), Graves’ disease
6.5(5.84-7.23).
Increasing
requests for Vitamin D measurement: costly, confusing, and without credibility.
Naveed Sattar et al. Lancet 2012;379:95-96. An excellent argument that puts the other side. A
debate between Richard Quinton and Naveed would be well worth attending!
Risk models and
scores for type 2 diabetes: systematic review. BMJ 2011;343:d7163. Conclusion, plenty
robust tools available but only a handful are routinely utilised.
Chronic Kidney Disease.
AS Levey & J Coresh. Lancet 2012;379:165-180. An excellent update article.
NEXT NEWSLETTER Due out beginning of June 2012 so keep
the gossip coming.
posted by Arutchelvam at 10:28 PM
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