Endodiabology June 2012

ENDODIABOLOGY

Endodiabology.blogspot.com

NORTHEAST

 NEWSLETTER

FOR SPECIALTY TRAINEES AND BOSSES TRAPPED

IN THE NORTHERN DEANERY

 

June 2012                                   

 Editors: SShahid Wahid

Petros Perros, Arutchelvam Vijayaraman 

Associate Editor: Atif Munir 

StR PLACEMENTS (NTN year of training from 1^st 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  

·       8^th-12^th June 2012 American Diabetes Association 72^nd Annual Scientific Sessions, Philadelphia, USA. Contact meetings@diabetes.org .

·       23^rd-26^th June 2012 ENDO 2012, Houston, USA. Contact endostaff@endo-societ.org or www.endo-society.org/scimeetings .

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

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

·       1^st-5^th October 2012 48^th EASD annual meeting, Berlin, Germany. Contact www.easd.org

·       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 .

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. The next meeting is on 13^th June 2012, Lumley Castle, 6pm “Dealing with the Media”. Also see the letters section for a management article. It is also well worth reading “Leadership development for early career doctors” by Cordelia EM Coltart et al in the Lancet 2012;379-1847-1849.

Study Leave See the letters section.

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

·        That famous media celebrity RQ did a telephone interview with Mike Parr on BBC Radio Tees show on Monday 30 April in relation to sunlight, SPF-sunscreens and vitamin D. You can find it on BBC i-player. Start it at 1hr 36 minutes into the show. Also a quote from RQ “Colecalciferol 800IU (20mcg) capsules have been licensed by the MHRA ("Fultium-800"), so worthwhile getting this onto hospital formularies.” Disclaimer supplied on request!

·        Welcome to Atif Munir to the ENDODIABOLOGY team as Associate Editor-read his articles in the letters section.

·        A message from Paul Peter “After a short period of uncertainty with a few colleagues moving on, it is indeed our pleasure to let you all know that the consultant team in CDDFT is now  up to  full strength. We have appointed three superb colleagues in the past 6 months and I take this opportunity to welcome them to the Northern region. Dr Tarigopula following his training in Leicester rotation joined us in October 2011,   Dr Srikanth Mada whom we all lovingly know as the Northern deanery Diabetes and Endocrinology trainee rep joined us in November 2011 and last but not the least Dr Praveen Partha, who trained in Manchester joined us in March 2012”.

·        Simon Pearce has received further MRC funding for a follow on study to the RADS study, a quote from Simon “From July, when we hope to 'go live' with recruitment, I will be very keen to know about new-onset Addison's disease patients with a week or so of diagnosis. Suitable and willing patients will be offered 2 doses of rituximab and 12 weeks of ACTH injections. People who don't want 'active' therapy can also be recruited to part B of the study where they will be 'observed' on normal therapy- involving a baseline and 1yr bloods and synacthen test only”.

·        Well done to RQ again on BES Harrogate, March 2012 Clinical Endocrinology Trust Top-scoring Clinical abstract (OC1.1) George J, Quinton R, Young J, Veldhuis J, Millar R, Anderson R. Functional characterisation and translational clinical applications of kisspeptin-10.

·        Ravi Erukalapati (who many of you will remember) has opened his very own Endocrinology & Fertility centre in Hyderabad and has appeared in person to advertise this on Hyderabad local TV.

·        Ravi Balasubramian (who many of you will remember) passed all his USA Exams and is now a Licensed Physician in the State of Massachusetts. He has been appointed to the post of Instructor in Medicine at the Reproductive Endocrine Unit, Harvard Medical School & Massachusetts General Hospital. “Instructor” at Harvard is equivalent to Assistant Prof at most other US medical schools.

LETTERS

Thyroid Meetings-Simon Pearce

The European Thyroid Association annual meeting is in Pisa this year, Sept 8th-12^th (www.eta2012.0rg). Its dirt cheap for a 4 day meeting (40 euro to become a member of the ETA and 60 euro to register for the meeting) and there is a direct flight from Newcastle. It has a strong clinical theme (3/4 of the meeting is either clinical or 'translational'). If any one needs their membership proposal seconding, either myself, Petros, or Salman will oblige.

The BTA meeting will be on Dec 3rd and 4th, 2012 at RCPath in London, with a half day of interactive SpR clinical teaching on the 3rd, and a full day of the latest in thyroid disease on the 4th. We ran the interactive teaching for the first time last year and got very positive feedback from it. Once again, this is a cheap meeting (I think 60 quid for trainees).

Study Leave Tips from Atif Munir

Study leave in terms of number of days and budget has to be very carefully planned during specialty training. Most of us end up using our annual study leave budget but are left with number of unused days every year. I hope you will find the following list of learning activities useful with regards to not only their practical utility, cost (all Young Diabetologist Forum YDF courses are free including accommodation hence are filled up within hours/days of being advertised) but also in terms of ticking boxes from the Diabetes (in particular) & Endocrinology curriculum.

1. YDF Diabetes Foundation course:

Aimed primarily for those in the first two years of training. The aims of the course are to introduce and increase confidence in management of some of the common clinical scenarios. 

2. YDF Community Diabetes Course:

As future consultants we will be faced with increasingly integrated care delivery across the interface between primary and secondary care.  This is reflected by the fact that “community diabetes” is now a recognised part of our curriculum. If you are one of the many who are lacking in community diabetes experience, this course is for you. 

3. Insulin Pump Course:

Learn all you need to be confident and knowledgeable about selecting patients, setting up and using pumps, as well as the principles relating to their ongoing management such as carbohydrate counting. Locally this course is held at James Cook Hospital Middlesbrough, alternatively YDF hold one too.

4. YDF Retinopathy Course:

With diabetic retinopathy being screened with digital photography and referred directly to ophthalmologists with little involvement of the diabetologist there is little opportunity to learn about retinal screening and grading during our training.

5. YDF Research day:

It is designed to cater for the needs of current clinical research fellows as well as specialty trainees who would like to undertake a period of research.

6. YDF Finishing school:

This event is suitable for trainees coming to the end of their training and is designed to cover cutting edge and highly specialist areas of clinical care and also to prepare for consultant interviews and posts. 

7. DAFNE Doctor Programme:

The National DAFNE Programme offers ten annual fellowships for specialty trainees to train as DAFNE doctors. The Fellowship is fully sponsored. It is a structured training programme for consultant Diabetologists and registrars, specifically designed for doctors who, while not intending to train as educators, will support patient graduates of the course and the courses themselves. It aims to provide doctors with the skills required to provide the leadership and clinical support that enables DAFNE to be incorporated into routine service delivery. The training will expose you to the DAFNE principles, give the opportunity to see it in practice and learn with colleagues how to support structured education in insulin usage in your own services. It gives unparalleled opportunity to learn how to support patients to use insulin flexibly and obtain better diabetes control. The fellowship comprises of a full 5-day DAFNE course delivered at a DAFNE centre followed by a one day educational workshop.

8. Diabetes In-Patients Module (Leicester University):

It aims to meet the needs of medical professionals with a particular interest in diabetes inpatient care. It covers diabetic emergencies, their presentation and management, and broader aspects of managing inpatients with diabetes. Learners will be able to critically appraise current research and national directives which support the clinical management for diabetes in patient care.

9. National Training Scheme for the use of Radioiodine in Benign Thyroid Disease:

This one day course represents an essential component of the new national training scheme aiming to allow application for ARSAC (The Administration of Radioactive Substances Advisory Committee) certification. The programme comprises of sessions on medical physics, radiation protection and clinical case scenarios and will give an overview of the Royal College of Physicians National guidelines on the use of radioiodine in the management of benign thyroid disease

10. Thyroid Ultrasound Course:

This one-day course is an essential part of the national training scheme for certification for the use of ultrasound in the management of thyroid diseases by non-radiologists. The workshop includes sessions on the theory, principles and practice of ultrasound and its application to neck and thyroid examination and biopsy.

Doing Things You Do Not Like-Shaz Wahid

I am not talking about grudgingly agreeing with my Dad that the Toon have done well (or indeed that rather boisterous Gastroenterologist I work with-who incidentally is keen to tattoo Papis Cisse on my splenic flexure) but things like VTE risk assessments, 4-hour targets (its not just A&E but the diabetic foot has joined the party!), engaging with the new “strategic” changes (I did enter my conscientious objector vote for both the RCP London and Edinburgh surveys) and oh introducing mandatory e-portfolios for ALL Consultants in the Trust (surprisingly folk still talk to me, for now…) in preparation for revalidation. I guess as you get older (fatter & bald but apparently more “senior” as Jeevan & Khaled keep reminding me) and have moved in the Trust’s political circles you realise that kicking up a fuss about things you can not do anything about does no good other make you even more frustrated than watching Liverpool. So what has come from doing things I do not like: encouraging the completion of the VTE assessments should bring in £40,000 to the Trust’s coffers paying for the increased junior Drs on the twilight and weekends; delivering targets allows significant service changes, with ambulatory emergency care being the most satisfying service I have set up, resulting in demonstrable better patient care; engaging with the CGS and other offshoots in a perverse way will lead to better and comprehensive integrated diabetes care in the district; and finally re-building appraisal systems in the Trust from the ground up has been extremely satisfying as it allows me to return to my Educationalist (RQ hates them) roots. So the motto of the story is “sometimes you have to do thinks you do not like or disagree with just to get things done for the better”. A “manager” taught me that………..

Feel the pulse of people with Type 1 Diabetes, attend DAFNE-Atif Munir

Type 1 Diabetes takes a lot of psychosocial freedoms away but DAFNE is perhaps the best attempt to give the pleasure and freedom of eating along with a strong sense and belief of being in control back to our patients.

Having attended a DAFNE course recently as part of my fellowship I feel responsible to share this unique experience with colleagues. This is also my tribute to team DAFNE.

A lot in the course was contrary to my expectations. Yes the primary focus was on carbohydrate estimation and insulin dose titration but detailed practical sessions on management of hypoglycaemia, glycaemic management during exercise and illness, complications along with covering relevant aspects of Diabetes with regards to driving, work and travel make this a very comprehensive education package.

All participants on the course I attended were middle aged with average duration of Diabetes being about 10 years. All had more than one complication of Diabetes. Interestingly all had similar motives to attend, to narrow the fluctuations in their readings and improve quality of life.

Their perceptions about Diabetes, insulin regimens, food, exercise and illness were very diverse but all were exceptionally motivated and their enthusiasm during the course was persistent. Practical issues around injection techniques, needle change & sharps disposal etc revealed a lot of misconceptions.

The learning curve was pretty steep over the five days. Changing the way they had managed their Diabetes for years was not easy but with the help and support of educators the participants were not only able to come to terms with but also started to apply DAFNE principles right from day one. Some had minor hiccups on route but most even just by the end of the course felt in control and seemed to be staring their Diabetes right in the eyes rather than shying away from it. The results were apparent by their readings, the swings were narrowing. Everyone relished the liberty of when, what and how much they could eat. The true spirit of Diabetes care “patient empowerment” was being exercised.

DAFNE educators (Diabetes specialist nurse and dietician) on the course need a special mention here. Their efforts, empathy and perseverance with participants were exemplary. I have always wished to possess the communication skills of a Diabetes specialist nurse but continue to fail.

I would like to wrap up by expressing my conclusion that DAFNE should be offered to all people with Type 1 Diabetes much earlier after being diagnosed. For my colleagues this is a must attend if you wish to a have true insight into the life of your patients living with Diabetes apart from being able to support DAFNE graduates. Yes some would still not achieve perfect control but at least as healthcare professionals we would have played our part in educating them around most aspects of the condition with which they have to live for the remaining years of their lives.

RECENT PUBLICATIONS FROM THE NORTHEAST

1.      Chakera A, Pearce SH, Vaidya B. Treatment for primary hypothyroidism: current approaches and future possibilities. Drug Design, Development and Therapy 2012; 6: 1–11

2.      Pearce SHS, Vaisman M, Wemeau JL. Management of subclinical hypothyroidism: The thyroidologists’ view. Eur Thyroid J 2012; 1: 45-50.

3.      Mitchell AL, Pearce SHS. Pathogenesis and genetic complexity of autoimmune Addison’s disease. Nat Rev Endocrinol 2012; 8: 306-16 (doi 10.1038/nrendo.2011.245).

4.      Razvi S, Weaver JU, Butler TJ, Pearce SHS. Levothyroxine treatment of subclinical hypothyroidism, fatal and nonfatal cardiovascular events and mortality. Arch Intern Med 2012; Apr 23 (doi:10.1001/archinternmed.2012.1159)

5.      Boos C, Hodkinson P, Mellor A, Green N, Woods D. The effects of acute hypobaric hypoxia on arterial stiffness and endothelial function and its relationship to changes in pulmonary artery pressure and left ventricular diastolic function. High Alt Med Biol 2012, in press.

6.      Raivio T, Avbelj M, McCabe MJ, Romero CJ, Dwyer AA, Tommiska J, Sykiotis GP, Gregory LC, Diaczok D, Tziaferi V, Elting M, Padidela R, Plummer L, Martin C, Feng B, Zhang C, Zhou QY, Beenken A, Mohammadi M, Quinton R, Sidis Y, Radovick S, Dattani MT, Pitteloud N. 2012 Genetic overlap in Kallmann syndrome, combined pituitary hormone deficiency, and septo-optic dysplasia. Journal of Clinical Endocrinology & Metabolism. 97: E694-699.

7.      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.

8.      Quinton R. Improvised explosive devices and testicular trauma. BMA News. 14 April 2012. p8.

9.      Quinton R. Accounting costs lives. BMA News. 15 May 2012. p5.

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

Dual rennin-angiotensin system blockade. Peter W de Leeuw. BMJ 2012;344:e656. Well worth reading this editorial for an update and which comments on the linked article by Ziv Harel et al (BMJ 2012;344:e42)-the bottom line id do not combine aliskerin with ACE inhibitors or A2R blockers and indeed even the combination of ACE inhibitor and A2R should be sued in extreme caution if at all.

Delayed Puberty. Palmert MR et al. NEJM 2012;366:443-453. An excellent practical article.

A 12-month phase 3 study of pasireotide in Cushing’s disease. Calao A et al. NEJM 2012;366:914-924. A broad spectrum somatostatin binding drug with particular affinity for sub-type 5 that reduces cortisol levels significantly and adds to the therapeutic options for Cushing’s disease. Only draw back is the significant number of patients (118 out of 162) who developed hyperglycaemia, that in the long term may reduce its effectiveness.

Insulin degludec: a new ultra-longacting insulin. AA Tahrani, CJ Bailey and AH Barnett. Lancet 2012;379:1465-1467. A balanced editorial that examines this new insulin and the linked articles in both Type 1 (S Heller et al. Lancet 2012;379:1489-1497) and Type 2 (AJ Garber et al. Lancet 2012;379:1498-1507) diabetes. Personally, it remains a 3^rd line agent for me (although I do have a list of patients in whom I will be trialling it!).

Putting Patients First. Simon Eaton et al. BMJ 2012;344:e2006. A provocative editorial that is linked to  the article: Improving the experience of care for people using NHS services: summary of Nice guidance. NO Flynn et al. BMJ 2012;344:d6422). I had to read through a 60 page Board paper recently on this very issue, which sets the strategy for our Trust for the next 3 years when it comes to gathering patient experience data for every clinical service area.

Differences in blood pressure between arms. Dae Hyun Kim. BMJ 2012;344:e2033. Do differences in blood pressure between arms matter? RJ McManus and J Mant. Lancet 2012;379:872-873. Two excellent editorials that review this area and the two linked article by Christopher E Clark et al (BMJ 2012;344:e1327 AND Lancet 2012;379:905-914). I am seriously considering changing my practice as I review the Nurse protocols for my renal diabetes clinic-would you agree?

Could FFAR1 assist insulin secretion in type 2 diabetes? Clifford J Bailey. Lancet 2012;379:1370-1371. An excellent editorial that reviews the agonism of the Free Fatty Acid Receptor-1 (also known as G-protein-coupled receptor 40 (GPR40)) in increasing insulin secretion linked to the 12-week phase 2 study by CF Burant et al (Lancet 2012;379:1403-1411). An exciting agent but with many questions to be researched.

Glycaemic management of Type 2 diabetes mellitus. Faramarz Ismail-Beigi. NEJM 2012;366:1319-1327. Not bad if you are looking for a practical update. My practice will not change after reading it.

The role of dipeptidyl peptidase-4 inhibitors. D Lasserson and J Mant. BMJ 2012;344:e1213. An editorial that reviews this area and the linked article by T Karagiannis et al (BMJ 2012;344:e1369) that for me confirms my practice of using these agents as 3^rd line and only 2^nd line if hypos occur.

Diagnosis and management of primary hyperparathyroidism. S Pallan et al. BMJ 2012;344:e1013. A useful read.

Meta-analysis of individual patient data in randomised trials of self monitoring of blood glucose in people with non-insulin treated type 2 diabetes. AJ Farmer et al. BMJ 2012;344:e486. Well worth waving this article under the PCTs Pharmaceutical advisor nose the next time you meet! The effect on HbA1c was small, but significant. In other words patients who will utilise the data should benefit.

Thyrotoxicosis. JA Franklyn and K Boelaert. Lancet 2012;379:1155-1166. Wee worth a read if you are after an update.

Subclinical thyroid disease. DS Cooper and B Biondi. Lancet 2012;379:1142-1154. An excellent update on the literature in the filed with practical advice.

Lowering plasma cholesterol by raising LDL receptors-revisited. SG Young and LG Fong. NEJM;366:1154-1155. An excellent editorial that links to the primary research paper by EA Stein et al (NEJM 2012;366:1108-1118) that uses a monoclonal antibody to bind to Proprotein Convertas Subtilisin/Kexin 9 (PCSK9). This prevents the binding pf PCSK9 to the LDL receptor preventing their degradation and hence reducing plasma LDL levels. Exciting times!

Diabetic Retinopathy. DA Antonetti et al. NEJM 2012;366:1227-1239. An excellent article that explores the pathogensis of diabetic retinopathy and how the different therapies fit into this.

Anti-vascular endothelial growth factor treatment for eye diseases. N Cheung et al. BMJ 2012;344:e2970. An excellent editorial that explores the clinical aspects of anti-VEGF therapy. There is plenty of politics behind Lucentis vs Avastin. Personally I am bored of politics! If you are not read BMJ 2012;344:e2941.

Insulin-pump therapy for Type 1 diabetes mellitus. John C Pickup. NEJM 2012;366:1616-1624. An excellent practical article that is well worth a read.

Surgery or Medical therapy for obese patients with type 2 diabetes? Paul Zimmet and K George MM Alberti. NEJM 2012;366:1635-1636. A balanced editorial that reviews the 2 landmark trials by PR Schauer et al (NEJM 2012;366:1567-1576) and G Mingrone et al (NEJM 2012;366:1577-1585). The bottom line is that we all need to explore and develop our pathways to offering the surgical option as a treatment for type 2 diabetes.

Radioiodine for thyroid cancer is less more? EK Alexander and PR Larsen. NEJM 2012;366:1732-1733. The answer is yes reviewing the 2 linked trails by M Schlumberger et al (NEJM 2012;366:1663-1673) and Ujjal Mallick et al (NEJM 2012;366:1674-1685) in patients with low risk thyroid cancer. However, the use of thyrotropin alfa in preparing patients for thyroglobulin measurement and radioiosotope scanning in these times of austerity may not be appropriate.

NEXT NEWSLETTER Due out beginning of October 2012 so keep the gossip coming.