Endodiabology

Endodiabology October 2011 Issue 3

2011-11-19T21:44:00.001Z

ENDODIABOLOGY
Endodiabology.blogspot.com

NORTHEAST
NEWSLETTER
FOR SPRs AND BOSSES TRAPPED
IN THE NORTHERN DEANERY

October 2011
Editors: Shaz Wahid (shahid.wahid@stft.nhs.uk) and
Petros Perros (petros.perros@ncl.ac.uk) and Arut Vijayaraman (riarut@aol.com )
Associate Editor: Srikanth Mada

StR PLACEMENTS (NTN year of training from 1st October 2010)
• Newcastle- Alison Heggie (2), Sudeep Manohar (5), Nimanthe De Alwis (3), Rohana Wright (3), Anjali SanthaKumar (3), Naveen Siddaramaiha (5), , Vacant, Vacant
• North Tyneside/Wansbeck- Asgar Madathil (4) from Jan 2012, Arif Ullah and 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) from Jan 2012
• North Tees/Hartlepool- Naveen Aggarwal (3), Atif Munir (4)
• Middlesbrough- Jacog Buckovan (2), Shunmugam Nellaiappan (1) till Jan 2012, Agnieska Sawiecicka (2), Stuart Little (3) from Jan 2012
• Bishop Auckland/Darlington/Durham- Humza Ali Khan (3)
• NGH- Arif Ullah/ Sajid Ethol Kalathil (3) job share
• 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)

MEETINGS / LECTURES / ANNOUNCEMENTS
• 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. Sheffield. Contact www.endocrinology.org/meetings
• 10th-12th November 2012 ABCD autumn meeting, London. Contact www.diabetologists.org.uk followed by SpRs meeting.
• 16th November 2011 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Sue Archibald 0191 223 1247 sue.archibald@nuth.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 Sue Archibald 0191 223 1247 sue.archibald@nuth.nhs.uk .
• 30th November-1st December 2012 60th British Thyroid Association Annual meeting, London, www.british-thyroid-association.org .
• 12th December 2011 SfE Clinical Cases. Exeter. Contact www.endocrinology.org/meetings
• 18th January 2012 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Sue Archibald 0191 223 1247 sue.archibald@nuth.nhs.uk .
• 24th January 2012 Northern Endocrine & Diabetes Winter CME, Freeman Hospital. Contact Sarah Steven(sarah.steven@doctors.org.uk ) or Srikanth Mada (srikanth.mada@nhs.net ) or Rohana Wright rohanawright@doctors.org.uk
• 29th February 2012 SfE Clinical Cases. London. Contact www.endocrinology.org/meetings
• 7th-9th March 2012 Diabetes UK APC. Glasgow. Contact www.diabetes.org.uk/conference
• 14th March 2012 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Sue Archibald 0191 223 1247 sue.archibald@nuth.nhs.uk .
• 19th-22nd March 2012 BES 2012. Harrogate. Contact www.endocrinology.org/meetings
• 18th April 2012 Acute Medicine Conference, Freeman Hospital. Contact Sue Archibald 0191 223 1247 sue.archibald@nuth.nhs.uk .
• 8th May 2012 Northern Endocrine & Diabetes Summer CME, Sunderland. Contact Sarah Steven(sarah.steven@doctors.org.uk ) or Srikanth Mada (srikanth.mada@nhs.net ) 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 .
• 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 Srikanth Mada (srikanth.mada@nhs.net) or Rohana Wright rohanawright@doctors.org.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
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.
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. Please see Jacob’s article.
MERRIT The regional training for StRs is in place and has been delivered on 3 occasions. Contact Stuart and Srikanth for future dates. I really enjoyed preparing for and delivering the South Tyneside session. I was disappointed by the poor attendance given that I (Shaz) cancelled a clinic and then overbooked the preceding clinic by 100% to deliver the session. Hopefully attendance will improve.
Management Training A regional management programme is in place for StRs. Contact Nimantha De Alwis nimdeal@googlemail.com for more information.
Call For Mentors Please read the information in the letters section from Baldev Singh sent to the Editorial Team from Gillian Hawthorne.
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- 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; Consultant member-Salman Razvi salman.razvi@ghnt.nhs.uk ; Consultant member-Paul Peter paul.peter@cddah.nhs.uk ; SpR representative-Srikanth Mada srikanth.mada@nhs.net ; SpR representative-Stuart Little stuartlittle@doctors.org.uk

NEWS FROM THE NORTHEAST
• Congratulations to Arut on his formal appointment as TPD. Please read his article below.
• Congratulations to Sarah Stevens on her Research Fellowship award.
• Welcome to Gus Brookes, who has joined Jim Shaw as a research fellow from Bristol.
• Philip Home is retiring from his NHS post in Newcastle with effect from 31 December 2011. He continues in part time employment from Newcastle University thereafter. A personal thank you to him for his support over the years.
• Congratulations to Terry Aspray on his award of a grant from Arthritis Research UK to study the effects of vitamin D supplementation on bone health in men and women aged over 70: "Optimising Vitamin D Status in Older People: A Randomised Controlled Trial of Vitamin D Supplementation" Grant Code 19544 ; Lead Applicant Name Dr Terence Aspray; Total Amount Requested £ 660,398.
• Congratulations to Srikanth Mada on his appointment as Consultant Endocrinologist for County Durham & Darlington NHS FT.

LETTERS
10 top tips for the e-portfolio-Jacob Bukowczan
1.Don’t get hung up on where to put what.
2. Try and write in your natural style.
3. It’s all about quality not quantity.
4. Visit your e-portfolio regularly: making entries in a timely way and reviewing
the “whole picture” regularly.
5. Don’t put if off until tomorrow, there is never enough time to do it.
6. Review the range of your competencies on a regular basis.
7. Reflection is everything – do it at least once a month.
8. Use your on-calls wisely – ask consultant for an ACAT form after each post take ward round and keep record of all the patients you reviewed that day/night.
9. Use your library – scan and upload all your certificates, presentations, feedback forms early.
10. Link assessments/experiences to the curriculum as soon as possible.

The British Thyroid Association Meeting 30th November & 1st December 2011-Prof Simon Pearce
The BTA meeting in London includes a new half day SpR clinical teaching session on the Wednesday afternoon followed by the full-day clinical and scientific session the day after. Once again, we have a great programme of international speakers for both thyroid cancer and thyroid eye disease, as well as the usual suspects from Newcastle... Registration will be snip- most likely forty or 50 quid for SpRs: see the BTA website for a registration form shortly.
SpRs with interesting 'grey cases' in hyperthyroidism are welcome to submit a short synopsis to myself or Bijay Vaidya.

Call for Mentors: The National Diabetes Consultant Mentorship Programme (NDCMP)-Baldev Singh
May I update you regarding the NDCMP which is to run under the full regulation of the Association of British Clinical Dialectologists with Eli Lilly as the funding body?

Taking up a new consultant post in diabetes and endocrinology is both exciting and challenging. Acquiring experience, expertise and wisdom to develop in this role takes time and such development is not always best met by the standard processes of CME and CPD. Mentorship programmes are valued for their ability to offer independent, trusted and expert support, advice and guidance in relationship to professional development. Mentorship programmes already exist but they vary in their structure and quality, they are not always offered locally and there are none available that are specific to the speciality. Universally, senior SpRs express a high desire for effective Mentorship.

Arrangements are now formalised and the NDCMP will be fully established in early 2012. It will be well structured, well governed and sustained in to the long term. The programme will be systematically offered to all newly appointed consultants in Diabetes and Endocrinology. Mentees will be able to access ABCD accredited Mentors from within their own region and avail themselves of the benefits of a mentoring relationship lasting between 12 to 24 months.

Crucially to NDCMP will be our expert Mentors. They will be drawn from amongst established colleagues who have respect and reputation within the speciality. They will have:
• a minimum of 5 years service experience in substantive posts
• expertise in key other areas such as teaching and training, leadership and management, and service development and perhaps have undertaken extension roles such as (but not limited to) Clinical Director, College Tutor, Clinical Tutor, Undergraduate Lead, Specialist Training, Research, relevant District / Regional / National Committees.

Could those colleagues who feel they fit the bill and who are enthusiastic to be NDCMP Mentors please make themselves known to me (baldev.singh@nhs.net). A brief self nomination form will subsequently be dispatched. Please note that a Mentor group meeting is planned for the 18th (Friday late afternoon) and 19th of November 2011 at a central location (provisionally Coombe Abbey, Warwickshire, www.coombeabbey.com).

A message from our new TPD Arut
From October 1st, I will be taking over as the TPD, (I heard that this is the most desired and thankful job in the whole world, hence I applied!) I join you all in thanking Nicky Leech for managing the programme so well in the last few years. Despite all the challenges ahead, I am quite thrilled to take up this position and keen to work with everybody to uphold the high standards.
The main challenge is to continue to recruit high quality candidates into the specialty-training programme. Looking at the application ratios, our specialty is one of those with a lower ratio. Our region being for away from London does not help. However having highly reputed trainers and high standard research programmes available in the region, I expect will continue to make it attractive. We need to work further on popularising our specialty. I will be very grateful for your suggestions.
The other issue is, high number of outcome 2 in the ARCP, particularly in GIM. It is disheartening to note that some excellent trainees got this adverse outcome, simply because of issues with the e portfolio. This was distressing both for the trainers and the concerned trainees. We will work on continuously finding ways to engage with the e portfolio, by learning from each other’s good practice. I welcome trainees and trainers to share their practices. For example, our trainees at JCUH regularly bring cases for discussion and a NHS topic every fortnight to the educational supervisor and will do an assessment at the end. I noticed the trainees have done a large number of assessments by this way. We also encourage do get the SpR to lead the ward round frequently and do an ACAT at the end. Reviewing the validity of ALS is essential. I suggest that we have a target that no one fails in the forthcoming ARCP except for major training reasons.
We have the next round of interviews in October and we hope to recruit enough candidates, which will fill most gaps in the training programme. I thank all of you in advance for your help, support and guidance in the forthcoming years. Please keep in regular touch with your suggestions.
Regional Insulin Safety and Knowledge Programme-Jan Finn
This project is an initiative to review insulin safety and knowledge in the region. It is going to have a board which will meet 1-2hours bi-monthly (1st meeting 18th Oct 4-6pm venue tbc) so it would be beneficial for each service to have representation at this - someone who leads on diabetes/insulin safety.

There will also be 3 work streams
1/ Hospital insulin charts –An attempt to standardise common features on the hospital insulin charts across the region.
2/ National Insulin Passport-following NPSA guidance.
3/ Professional training - this work stream is going to develop a regional training programme for hospital based health care professionals. Ultimately it will work towards this training programme becoming a mandatory aspect of all health care workers training requirements.

Please send comments to jan.finn@nhs.net

RECENT PUBLICATIONS FROM THE NORTHEAST
1. Mellor A and Woods D. Serum Neutrophil Gelatinase Associated Lipocalin in Ballistic Injuries: A comparison between blast injuries and gunshot wounds. Journal of Critical Care, 2011.
2. Tornberg J, Sykiotis G, Keefe K, Plummer L, Hoang X, Hall JE, Quinton R, Seminara SB, Hughes VA, van Vliet G, van Uum S, Crowley WF, Jr., Habuchi H, Kimata K, Pitteloud N, Bülow H. 2011 Proceedings of the National Academy of Sciences of the United States of America. 108: 11524-11529.
3. Wahab F, Quinton R, Seminara SB. The kisspeptin signaling pathway and its role in human isolated GnRH deficiency. Molecular & Cellular Endocrinology. 2011; June 17 [epub ahead of print].
4. Chan YM, Broder-Fingert S, Paraschos S, Lapatto R, Au M, Hughes V, Bianco SD, Min L, Plummer L, Cerrato F, De Guillebon A, Wu IH, Wahab F, Dwyer A, Kirsch S, Quinton R, Cheetham T, Ozata M, Ten S, Chanoine JP, Pitteloud N, Crowley WF Jr, Martin KA, Schiffmann R, Van der Kamp HJ, Nader S, Hall JE, Kaiser UB, Seminara SB. GnRH-Deficient Phenotypes in Humans and Mice with Heterozygous Variants in KISS1/Kiss1. J Clin Endocrinol Metab. 2011 Aug 31. [Epub ahead of print].
5. A Munir, SL Toh, V Arutchelvam. Insulinoma in a patient with Type 2 Diabetes-Case report, published in Practical Diabetes , Volume 28 Issue 5 (June 2011).
6. Gan EH, Mitchell AL, Macarthur K, Pearce SH 2011 The role of a nonsynonymous CD226 (DNAX-accessory molecule-1) variant (Gly 307Ser) in isolated Addison's disease and autoimmune polyendocrinopathy type 2 pathogenesis. Clin Endocrinol (Oxf), 75(2):165-8.
7. Yarnall AJ, Hayes L, Hawthorne GC, Candlish CA, Aspray TJ. Diabetes in care homes: current care standards and residents' experience. Diabet Med. 2011 Jul 25. doi: 10.1111/j.1464-5491.2011.03393.x. [Epub ahead of print] 2.
8. Aspray TJ, Francis RM. Calcium and vitamin D supplementation and cardiovascular disease: quo vadis? Maturitas. 2011 Aug;69(4):285-6.
9. Sinclair AJ, Aspray TJ et al ; Task and Finish Group of Diabetes UK. Good clinical practice guidelines for care home residents with diabetes: an executive summary. Diabet Med. 2011 Jul;28(7):772-7. doi: 10.1111//.1464-5491.2011.03320.x.
10. Martin-Ruiz C, Jagger C, Kingston A, Collerton J, Catt M, Davies K, Dunn M, Hilkens C, Keavney B, Pearce SH, Elzen WP, Talbot D, Wiley L, Bond J, Mathers JC, Eccles MP, Robinson L, James O, Kirkwood TB, von Zglinicki T. Assessment of a large panel of candidate biomarkers of ageing in the Newcastle 85+ study. Mech Ageing Dev. 2011 Aug 16. [Epub ahead of print]
11. Vanderpump MP, Lazarus JH, Smyth PP, Laurberg P, Holder RL, Boelaert K, Franklyn JA; British Thyroid Association UK Iodine Survey Group (including Razvi S, Pearce SH). Iodine status of UK schoolgirls: a cross-sectional survey. Lancet. 2011 Jun 11;377(9782):2007-12.
12. Newby PR, Pickles OJ, Mazumdar S, Brand OJ, Carr-Smith JD, Pearce SH, Franklyn JA; Wellcome Trust Case-Control Consortium (WTCCC), Evans DM, Simmonds MJ, Gough SC. Follow-up of potential novel Graves' disease susceptibility loci, identified in the UK WTCCC genome-wide nonsynonymous SNP study. Eur J Hum Genet. 2010 Sep;18(9):1021-6.

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

Management of hypertension: summary of NICE guidance. T Krause et al. BMJ 2011;343:d4891. An excellent summary of the guidelines with implications for our patients and services. Get ambulatory monitoring entrenched!
Investigating mixed hyperlipidaemia. A Viljoen and AS Wierzbicki. BMJ 2011;343:d5146. A useful clinical practice paper.
Electronic Health Records and Quality of Diabetes Care. RD Cebul et al. NEJM 2011;365:825-833. An excellent article that can be extrapolated to the UK and provides ammunition for those of us wishing to develop an interactice web-based system for both clinical interactions and register use.
Autoimmune encephalitis. SR Irani et al. BMJ 2011;342:d1918. An excellent editorial detailing 2 condition sthat we should be far more vigilant for than we are.
Multiple endocrine abnormalities. CMPG van Durne et al. Lancet 2011;378:540. An excellent case report of a rare cause for pituitary hypophisitis.
Weighing the benefits of high-dose Simvastatin against the risk of myopathy. A Egan & E Colman. NEJM 2011365:285-287. A perspective well worth a read and a reminder that we should no longer be going to Simvastatin 80mg.
Intensive glucose lowering treatment in type 2 diabetes. D Preiss & KK Ray. BMJ 2011;343:d4343. A thought provoking editorial and rather controversial?
Salt reduction lowers cardiovascular risk: meta-analysis of out come trials. FJ He & GA MacGregor. Lancet 2011;378:380-382. An excellent editorial reviewing the effectiveness of salt reduction. Make sure you have salt-reduction leaflets for your hypertensive patients in clinic.
Glycaemic control in type 1 diabetes during real time continuous glucose monitoring compared with self monitoring of blood glucose: meta-analysis of randomised controlled trial using individual patient data. JC Pickup et al. BMJ 2011;343:d3805. An excellent article that should change your practice if not already.
Diabetic ketoacidosis at the onset of type 1 diabetes. BMJ 2011;343:d3278. It is still common! The article acts a s a reminder and should provoke some thoughts on how you should reduce it in your locality.
Glucocorticoid-Induced Bone Disease. RS Weinstein. NEJM 2011;365:62-70. An excellent overview on clinical practice that is well worth a read.
The Lancet volume 378 2011 number 9786 9-15th July. This edition of the Lancet is essential reading. It includes 4 wonderful primary research papers on diet & Physical activity vs. usual care on diagnosis of Type 2 DM by Rob Andrews (some of you may remember Rob) and co, incidence of heart failure in type 1 DM by Lind et al, HbA1c use for pre-diabetes by Heianza et al and MRFIT on screen detected Type 2 DM by Griffin et al. The 4 accompanying Editorials add to the essential read.
National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2.7 million participants. G Danaei et al. Lancet 2011;378:41-40. A mammoth and impressive study adding to the world perspective of diabetes.
Anti-CD3 antibodies for Type 1 diabetes: beyond expectations. JF Bach. Lancet 2011;378:459-460. See linked paper Lancet 2011;378:487-497.
Arresting type 1 diabetes after diagnosis: GAD is not enough. C Mathieu & P Gillard. Lancet 2011;378:291-292. see linked paper Lancet 2011;378:319-327.
New hope for immune intervention therapy in type 1 diabetes. BO Roep. Lancet 2011;378:376-378. See linked paper Lancet 2011;378:412-419.
The above 3 editorials with their linked primary research papers are a must read for an update on immunotherapy in type 1 diabetes.
Bardoxolone Methyl and Kidney Function in CKD with Type 2 Diabetes. PE Pergola et al. NEJM 2011;365:327-336. An antioxidant inflammation modulator useful in CKD. However a very mixed group of CKD patients.
Sharp: a stab in the right direction in chronic kidney disease. KK Stevens, AG Jardine. Lancet 2011;377:2153-2154. See linked paper Lancet 2011;377:2181-2192. An excellent editorial that critically reviews the linked paper and statin therapy in CKD.
Iodine status of UK schoolgirls: a cross-sectional survey. MP Vanderpump et al. Lancet 2011;377:2007-2012. An excellent study with a thought provoking conclusion. This should be a call to action.
Diagnosis, classification, and treatment of diabetes. A Farmer & R Fox. BMJ 2011;342:d3319. An excellent practical editorial.
Time trends in mortality in patients with type 1 diabetes: nationwide population based cohort study. V Harjutsalo et al. BMJ 2011;343:d5364. An interesting study demonstrating improving mortality in early onset type 1 diabetes but increasing mortality in type 1 late onset type 1 diabetes. Read on……………………………………………………………………………………….

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

Endodiabology May 2011 Issue 2

2011-06-03T21:25:00.001+01:00

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 February 2011 Issue 1

2011-01-31T23:38:00.001Z

ENDODIABOLOGY
Endodiabology.blogspot.com

NORTHEAST
NEWSLETTER
FOR SPRs AND BOSSES TRAPPED
IN THE NORTHERN DEANERY

February 2011
Editors: Shaz Wahid (shahid.wahid@sthct.nhs.uk) and
Petros Perros (petros.perros@ncl.ac.uk) and Arut Vijayaraman (riarut@aol.com )
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- Eeelin Lim (5)
• Sunderland- Jacog Buckovan (1), vacant
• North Tees/Hartlepool- Sudeep Manohar (4), vacant
• Middlesbrough- Arif Ullah (4), Naveen Siddaramaiha (4), Shunmugam Nelliyappan (1)
• Bishop Auckland/Darlington/Durham- Sathia Rajhavan(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), Kathryn Stewart (3)

MEETINGS / LECTURES / ANNOUNCEMENTS
• 1st March 2011 SfE National Clinical Cases Meeting, Royal Society of Medicine, London. Contact conferences@endocrinology.org NOTE submissions deadline is 25th October 2010.
• 16th March 2011 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk
• 24th March 2011 Newcastle Magnetic Resonance Centre Symposium, Lindisfarne Room, 1st Floor, Kings Road Centre, NCLE. Contact beverly.hailstone@ncl.ac.uk We have both Hannele Yki-Jarvivnen and Michael Roden, two of the world’s most sought after speakers talking about the cutting edge of diabetes knowledge. There is no registration fee.
• 30th March – 1st April 2011 DUK Annual Professional Conference, London, ExCel ICC. Contact www.diabetes.org.uk NOTE abstract submission deadline 31st October 2010.
• 7th & 8th April 2011 Insulin Infusion Pump Course, JCUH, Middlesbrough. Contact nicky.skippon@stees.nhs.uk
• 11th-14th April 2011 SfE British Endocrine Societies annual conference, Birmingham ICC. Contact conferences@endocrinology.org NOTE abstract submissions deadline 15th November 2010.
• 13th April 2011 Northern Region Acute Medicine Study Day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk
• 5th-6th May 2011 ABCD spring meeting, London. Contact www.diabetologists.org.uk
• 11th May 2011 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk
• 17th May 2011North East Obesity Forum, Obesity and Pregnancy, Stockton, Durham University, Queens Campus. Contact Louisa.ells@nepho.org.uk or Helen.moore@durham.ac.uk or Rachel.gallo@newcastle.ac.uk
• 18th May 2011 Northern Endocrine & Diabetes Summer CME, University Hospital of North Durham. Contact Sarah Steven sarah.steven@doctors.org.uk or Srikanth Mada srikanth.mada@nhs.net
• 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
• 12th October 2011 Northern Endocrine & Diabetes Autumn CME, JCUH, Middlesbrough. Contact Sarah Steven(sarah.steven@doctors.org.uk ) or Srikanth Mada (srikanth.mada@nhs.net )
• 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
• 24th & 25th November 2011 Insulin Infusion Pump Course, JCUH, Middlesbrough. 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 completion deadline is Friday May 13th 2011 therefore you must have worked with your supervisors well in advance of this (book time in their diary now!). This year an incomplete portfolio is likely to result in non-progression through training therefore please all do more than the minimum!
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.
INFORMATION for QA Could each individual trainer send the following to Simon Pearce: educational qualifications, any training positions held and any educational courses attended.
MORE INFORMATION for QA Could each unit’s Training Lead please send to Simon Pearce a completed training unit information report and an updated SpR/StR job description.
Trainers & Trainees meeting The next T&T is on 14th June 2011. Details to be confirmed nearer the time, but please note in your diary.
ARCPs 2011 Mon 23rd, Tues 24th, Weds 25th May 2011. SpRs keep these dates free and volunteers for the panel please contact Nicky Leech. Minimal requirements will be: thorough portfolio documentation, 4 Case based Discussions, Reflective accounts, Personal library evidence of teaching attendance and reflection, 4 new Mini-CEXs since last ARCP, MSF from current unit with at least 12 returns and 3 consultants, Updated PDP This should be drawn up and discussed with your supervisor within 4 weeks of starting your new post and Supervisors sign off and report. PLEASE NOTE, add patient survey (use the RCP survey forms), audit assessment/reflection and teaching observation to the minimal requirements.
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
Medicine ARCP Will remain separate next year. Date 17th May 2011. Continue to add evidence to the curriculum and demonstrate progression. Keep detailed anonomised logs and link them. Make the portfolio easy to navigate. You will need a MSF, Patient survey, 6 ACATs, 6 CEX s, 4 CBDs, and be involved in a medical audit cycle.
Training Committee Chair- Simon Pearce, s.h.s.pearce@ncl.ac.uk; Regional Speciality Advisor- Shaz Wahid, shahid.wahid@sthct.nhs.uk; Programme Director- Nicky Leech nicola.leech@nuth.northy.nhs.uk; Consultant member (SAC rep)- Richard Quinton, Richard.Quinton@nuth.nhs.uk; Consultant member-Jean MacLeod, Jean.Macleod@nth.nhs.uk; Consultant member (TPD elect)-Arutchelvam Vijayaraman Vijayaraman.Arutchelvam@stees.nhs.uk ; 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
• April 5th 2011- Professor James Fegan is the SFE visiting professor this year. He will be visiting Newcastle on this day. There will be a series of case presentations on that afternoon followed by his lecture at 17.00. Meeting will be held at Freeman Hospital Education centre. Clinical session will be followed by a Networking dinner. This will be an excellent opportunity for regional SpR’s to present cases and attend the networking meeting. For more details contact Steve.ball@nuth.nhs.uk, srikanth.mada@nhs.net
• Congratulations to Latika Sibal on her new Consultant appointment at Addenbrooke's Hospital.
• Welcome to Dr Shunmugam Nelliyappan as new StR in the region.
• Congratulations to Stuart Little as the new trainee rep on the STC.
• Congratulations to Arut on his nomination by the STC as our next TPD. His name will be forwarded to the Deanery. The aim will be for him to take over from Nicky in June 2011. Nicky will move into the Chair of the STC. We would like to thank Simon Pearce for his excellent work whilst the Chair of the STC.
• Philip Home has been invited by the ADA Programme Committee to talk in their annual meeting San Diego 2011 - this will be the fourth such invited lecture in 5 years. This time the topic is “Biosimilar insulins”.
• Congratulations to Terry Aspray on his recent appointment as Consultant in Metabolic Bone Disease at Freeman Hospital from 1st March 2011.
• It was an absolute pleasure to have Bill Kelly and Eric Young say a few words at NERRAG when presenting the prize named after their esteemed selves. Their words will live long in the memory.
• David Carr has now fully retired. ENDODIABOLOGY would like to wish him all the best and thank him for his contribution to the specialty in the region.
• Congratulations to Chandima Idampitya on her new Consultant appointment in Cumbria.
• Congratulations to Jola Weaver on being appointed a visiting Professor to King Abdulaziz University, Jeddah, SA.
• Congratulations to Roy Taylor on 5 yrs of the MRC, see meeting symposium details above, publication of a paper which was featured in the No. 1 spot on the cover of Dec Diabetes Care and shortly in the correspondence columns of DC and the award of a grant from the European Foundation for the Study of Diabetes. Evaluation of pancreas structure and function during return to normal glucose tolerance in type 2 diabetes. Euro 95,000.

LETTERS
Medical Leadership training on-line SHAZ WAHID
I personally am undertaking further management and leadership training using the Medical Leadership programme available on the e-learning for healthcare website www.e-lfh.org.uk . It is free! It is for all stages, whether you are experienced or a beginner. There are 6 folders: introductory modules, effective leadership, quality improvement, effective management in healthcare, ensuring effective health care, concluding modules. Each folder is further divided into modules to complete. I am partway through the introductory folder and can only highly recommend it to everyone. I would expect all StRs in Diabetes&Endo or Acute Medicine rotating to STNHSFT to undertake this programme as part of their management training under my supervision. This programme would highly complement the “7-habits of effectiveness” course that I encourage StRs under my supervision to attend at STNHSFT, again this is free other than the personal time you will have to give up over a weekend.
Book review-Textbook of Diabetes. 4th Edition, 2010. RI Holt, CS Cockram, A Flyvberg, BJ Goldstein. Wiley-Blackwell. SHAZ WAHID.
This was my staple reading when in SpR training. I invested in the new edition in November 2010 and I am not disappointed. The content is exceptional covering basic and clinical science with a focus on clinical application and healthcare delivery. There is both fun historical context and an international flavour to this new edition. Furthermore, the on-line access to the content and figures (for down load) adds value and prolongs the life of this edition. I have read about 1/3rd of the content (adolescent & transitional diabetes, monogenic diabetes, all the historical and social context section, diabetic nephropathy as examples) and have been impressed. I would highly recommend this new edition to both trainees and trainers.
My experience of on-line Recruitment & Selection training. SHAZ WAHID.
I was pleasantly surprised at how much I enjoyed the above training that is available on www.elearningworkpsychology.com/northern/ . It is mandatory for all interviewers and it will take no longer than 1-hour to complete. The FOCUS mnemonic sticks in the memory: Familiarise, Observe, Record, Classify, and Evaluate. Not only is useful for interviews but I would suggest when you next attend a service meeting or indeed any meeting! What I got most out of this training is the time I saved by not allocating a half day to the activity. If only Trust Mandatory training could be condensed into 1 hour………………………….

King’s Fund Diabetes Specialist Registrars Leadership Programme: May 09-13th 2011. Sponsored by the YDF- Srikanth Mada
I had the pleasure of attending the leadership course last year along with two other colleagues in the region. The course is held at Oxford and run by very experienced kings fund faculty over 5 days. A number of management issues such as Myers Briggs Personality indicator and preferred style of working, NHS finance (Macro financial flows & Micro budgeting), Belbin team roles, team working, and working across organization were covered in detail with practical workshops. Health policies and diabetes policies were dealt with Dr Sue Roberts. We had the opportunity to understand the principles of business case and developing new services, and a practical workshop to develop and present a new business case as a team.
Later half of the course concentrates on personality development, advanced communications skills, negotiating skills and presentation skills. Professional actor facilitated these sessions. Final day concentrates on preparing oneself for the consultant job, interview preparation and video recorded mock interview.
This is an excellent opportunity for every registrar to develop leadership skills mainly for those who are in their final 2 years. A Unique opportunity to meet colleagues from different regions which helps to establish networking. The course is free of cost including stay but one has to be a member of ABCD.

MERIT (Master class in Endocrinology and diabetes; Regional Interactive Teaching) Programme: Srikanth Mada, Stuart Little, Sarah Stevens.
The recent PMETB survey by the specialty trainees in this region identified areas of excellent training as well as areas where training opportunities could be improved.
As trainee representatives we invited constructive feedback from all trainees and subsequently a number of enthusiastic colleagues suggested ways of improving training opportunities. As a result of all the feedback obtained a pilot training programme (MERIT: Master class in Endocrinology and diabetes; Regional Interactive Teaching) has been drafted and was presented at the STC meeting in December. The revamped CME, which is mapped to cover all the aspects of curriculum has been a huge success and received a positive feedback. We do not want to replicate similar programme, instead we plan to give the responsibility of this programme to the trainees themselves i.e. a trainee led, consultant facilitated site specific teaching programme.
The location of the teaching will rotate between all training hospitals in the region and will take place in the first week of each month starting April 2011. It will be the responsibility of the resident trainee at each respective hospital to host the teaching and liaise with the consultant (host consultant) to agree the training programme for the afternoon. The session will consist of a trainee presentation (Hot topic/ topic over view etc) followed by a consultant facilitated master class/tutorial. Management topics can also be included within the programme.
It will be mandatory for every trainee to attend the sessions and if attendance is not possible it is each trainee’s responsibility to inform either of the trainee STC representatives (Srikanth or Stuart) so that it can be documented in the report to the STC panel. This will mean discussing with the consultants to make necessary arrangement so that clinical care is not impacted and consultants reducing the clinics on the day. Further information regarding the proposed programme will be circulated in due course.
The STC chair and the panel have agreed to implement the programme, the success of which will be reviewed at the next STC meeting.

GAINS (Grants for attending International & National symposium) Programme.
Srikanth Mada, Sarah Stevens, Stuart Little.
The SPARROWS programme has been an excellent and unique training opportunity for the year 3-5 SpR’s to attend the ADA followed by a presentation at the trainers and trainee meeting to share the experience and updates with rest of the colleagues. Unfortunately because of the financial constraints and ABPI rules of the funding bodies have withdrawn their support to the programme. We as the CME & STC committee are keen to keep this unique opportunity available as long as possible to all the registrars. The committee would be able to part fund two registrars to attend one diabetes and one endocrine symposium per year. A grant of £ 1000/ per SpR / year is available as a part of this programme. Application and the selection process remain same as before followed by a SpR presentation at the trainers and trainee meeting. Applications and further information to follow…
Are you proactive enough regarding your future?
An Honorary Research Assistant post at Newcastle University and Gateshead Trust will be advertised in the near future. Research area: vascular stem cells and endocrine disorders. The post will commence in August 2011 and is aimed to lead to MD/PhD (as a staff member of the Institute for Cellular Medicine reduced postgraduate degree fees will be payable). The first RA appointed to this post was Salman Razvi. He was then followed by Akheel Syed, Abdul Shakoor, Asgar Madathil, all as part of Out Of Programme Research (OOPR) scheme. For informal enquiries please contact Jola Weaver J.U.Weaver@ncl.ac.uk
My experience of the Specialty Examination MRCP Diabetes&Endo-Atif Munir
The SCE is now a compulsory component of assessment for CCT for all UK trainees in Diabetes & Endocrinology. Trainees who have gained the Certificate in Endocrinology and Diabetes and who are recommended for a CCT will be entitled to apply for the post nominal MRCP (UK) (Endocrinology and Diabetes).
The SCE in Endocrinology and Diabetes is delivered once a year & is a computer-based two-paper test with a total of 200 questions. Each paper contains 100 questions and lasts three hours. The papers are based on the MRCP (UK) ‘best of five’ multiple choice questions format & there is no negative marking. The exam fee has been increased from £800 to £825 for 2011. Candidates can attempt the Specialty Certificate Examination as many times as they wish, subject to continuing satisfaction of the eligibility criteria.
Although The Royal College guidance states that trainees should have at least attempted the examination once before their penultimate year assessment I would strongly encourage colleagues to take it when they feel confident. This would to quite an extent depend upon your clinical experience as this is purely a clinically oriented examination & most of the scenarios I thought were from everyday clinical practice. Hence clinical experience in my view would take preference over theoretical knowledge for this particular examination.
Royal college does not recommend any specific reading material however I can share my personal experience. Exam blueprint & sample questions can be downloaded from the MRCP website (www.mrcpuk.org/SiteCollectionDocuments/SCEEandDSampleQs.pdf) (www.mrcpuk.org/SiteCollectionDocuments/SCE_ED_blueprint.pdf). If you are pushed for time, which all of us are these days I would recommend going through Oxford Handbook of Diabetes & Endocrinology (Turner & Wass) which was perhaps my key to success. This is the most comprehensive tool to cover a wide range of high yield topics in a short span of time. WWW. Endotext.org would be my second resource for preparation. Going through up to date NICE guidance, in particular guidance related to management of diabetes during pregnancy is a must as there were quite a few questions directly based on current guidance. DVLA guidance regarding driving and Diabetes is worth a glance. Apart from NICE, publications for professionals by societies like ABCD, SFE, and BTA & DUK should be read to polish your preparation apart from keeping abreast of updates in core specialty topics. I would not recommend subscribing to online websites to access their questions banks as the exam is still in its early years and hence there is not a large pool of questions out there. I found such an endeavour a waste of time and money. There were a few pituitary MRI scans & retinal screening photographs hence familiarizing yourself with these can earn a few bonus points.
Last but not the least, I would strongly urge all appearing for the exam to try and take a few days off as study leave immediately before the examination day to revise and regroup your scattered thoughts.
I wish all my colleagues best of luck for their examination.

RECENT PUBLICATIONS FROM THE NORTHEAST
1. Rodondi N, den Elzen WP, Bauer DC, Cappola AR, Razvi S, Walsh JP, Asvold BO, Iervasi G, Imaizumi M, Collet TH, Bremner A, Maisonneuve P, Sgarbi JA, Khaw KT, Vanderpump MP, Newman AB, Cornuz J, Franklyn JA, Westendorp RG, Vittinghoff E, Gussekloo J; Thyroid Studies Collaboration. Subclinical hypothyroidism and the risk of coronary heart disease and mortality. JAMA. 2010 Sep 22;304(12):1365-74.
2. Simms RJ, Sayer JA, Quinton R, Walker M, Ellard S, Goodship TH. Monogenic diabetes, renal dysplasia and hypopituitarism: a patient with a HNF1A mutation. QJM. 2010 Nov 4. [Epub ahead of print].
3. Quinton R, Ball SG, Sayer J, Pearce SHS. Primary hyperparathyroidism: just how “primary” is it really? Therapeutic Advances in Endocrinology & Metabolism. 2010; 1: 191-196.
4. Here comes the sun, good news for bone health. Aspray TJ, Francis RM. Age Ageing. doi: 10.1093/ageing/afq164 Epub 2010 Dec 22.
5. Diabetes, falls and fractures. Mayne D, Stout NR, Aspray TJ. Age Ageing. 2010 Sep;39(5):522-5. Epub 2010 Jul 14.
6. Vitamin D and fractures: where are we now? Aspray TJ, Francis RM. Maturitas. 2010 Jul;66(3):221-2. Epub 2010 Apr 7.
7. Increased maternal homeostasis model assessment of insulin resistance (HOMA-IR) associated with older age at diagnosis of Type 1 diabetes in offspring. NJ leech, JO O Sullivan, P Avery, C Howey, K Burling, S Iyer, L Pascoe, M Walker and T Cheetham. Diabetic Medicine Dec 2010 Vol 27; 12 ; 1450.
8. Chen MJ, Jovanovic A, Taylor R. Utilizing the Second-Meal Effect in Type 2 Diabetes: Practical Use of a Soya-Yogurt Snack. Diabetes Care 33: 2552-4, 2010

RECENT PUBLICATIONS IN DIABETES & ENDOCRINOLOGY THAT HIT THE NEWS OR THAT MAY HAVE A SIGNIFICANT IMPACT ON MANAGEMENT
Bisphosphonates for Osteporoses. MJ Favus. NEJM 2010;363:20272035. A practical review article well worth a read for an update.
Safer administration of insulin: summary of a safety report from the National patient Safety Agency. TA Lamont et al. BMJ 2010;341:c5269. A useful summary of this essential reading report. Many of you have probably or are in the process of producing action plans for the recommendations.
Managing diabetic retinopathy. Z Okcrim, D Yorston. BMJ 2010;341:c5400. A useful read for an update. It is worth reading the individual seminal papers cited in this update.
Teriparatide for bone loss in the jaw. A Grey. NEJM 2010;363;2458-2459. An excellent editorial citing the evidence behind this therapy for osteonecrosis of the jaw. Well worth a read along with the linked letter.
Glycemic control in the ICU. BP Kavanagh, KC McCowen. NEJM 2010;363:2540-2546. An update that I do not entirely agree with. I believe the ADA guidance is spot on for this issue. Debate welcome………………………
Vitamin D Insufficiency. Clifford J Rosen. NEJM 2011;364:258-254. An excellent review and well worth a read.
Diagnosis and management of hereditary haemochromatosis. MA van Bokhoven et al. BMJ 2011;342:218-223. An excellent practical update that is essential reading for trainees and trainers.
Cholesterol efflux capacity, high-density lipoprotein function, and atherosclerosis. Khera AV, et al. NEJM 2011;364;127-135. The authors hypothesized that the capacity of HDL to accept cholesterol from macrophages would serve as a predictor of atherosclerotic burden. This is termed as cholesterol efflux capacity, and was measured in 203 healthy volunteers who underwent assessment of carotid artery intima-media thickness, 442 patients with angiographically confirmed coronary artery disease, and 351 patients without such angiographically confirmed disease by using a validated ex vivo system involving incubation of macrophages with apolipoprotein B-depleted serum from the study participants. The levels of HDL cholesterol and apolipoprotein A-I were significant determinants of cholesterol efflux capacity but accounted for less than 40% of the observed variation. An inverse relationship was noted between efflux capacity and carotid intima-media thickness both before and after adjustment for the HDL cholesterol level. Furthermore, efflux capacity was a strong inverse predictor of coronary disease status (adjusted odds ratio for coronary disease per 1-SD increase in efflux capacity, 0.70; 95% confidence interval [CI], 0.59 to 0.83, p<0.001). This relationship was attenuated, but remained significant, after additional adjustment for the HDL cholesterol level (OR 0.75[0.63-0.90], p=0.002) or apolipoprotein A-I level (OR 0.7[0.61-0.89], p=0.002). Additional studies showed enhanced efflux capacity in patients with the metabolic syndrome and low HDL cholesterol levels who were treated with pioglitazone, but not in patients with hypercholesterolemia who were treated with statins. The authors conclude that cholesterol efflux capacity from macrophages, a metric of HDL function, has a strong inverse association with both carotid intima-media thickness and the likelihood of angiographic coronary artery disease, independently of the HDL cholesterol level. It is well worth reading the accompanying editorial by Jay Heinecke that along with this article suggests that we will be in a better position to see whether raising HDL cholesterol with pharmacotherapy in individuals would be of any benefit utilising this method in the future or allow us to better target pharmacotherapy.
Selective vitamin D receptor activation with paricalcitol for reduction of albuminuria in patients with type 2 diabetes (VITAL study): a randomised controlled trial. de Zeeuw D. Lancet 2010;376:1543-51. In this placebo-controlled, double-blind trial, the investigators enrolled patients with type 2 diabetes and albuminuria who were receiving ACE inhibitors or angiotensin receptor blockers. Patients were assigned to receive 24 weeks’ treatment with placebo (n=88),1 μg/day paricalcitol (n=92), or 2 μg/day paricalcitol (n=92). The primary endpoint was the percentage change in geometric mean urinary albumin-to-creatinine ratio (UACR) from baseline to last measurement during treatment for the combined paricalcitol groups versus the placebo group. Change in UACR was: –3% (from 61 to 60 mg/mmol;95% CI –16 to 13) in the placebo group; –16% (from 62 to 51 mg/mmol; –24 to –9) in the combined paricalcitol groups, with a between-group difference versus placebo of –15% (95% CI –28 to 1; p=0.071); –14% (from 63 to 54 mg/mmol; –24 to –1) in the 1 μg paricalcitol group, with a between-group difference versus placebo of –11%(95% CI –27 to 8; p=0.23); and –20% (from 61 to 49 mg/mmol; –30 to –8) in the 2 μg paricalcitol group, with a between-group difference versus placebo of –18% (95% CI –32 to 0; p=0.053). Patients on 2 μg paricalcitol showed a nearly, sustained reduction in UACR, ranging from –18% to –28% (p=0.014 vs placebo). Incidence of hypercalcaemia, adverse events, and serious adverse events was similar between groups receiving paricalcitol versus placebo. This study suggests that the addition of 2 μg/day paricalcitol to RAAS inhibition safely lowers residual albuminuria in patients with diabetic nephropathy. I guess we should have vitamin D in the water supply! The accompanying editorial by Merlin Thomas and Mark Cooper is well worth a read to look into this novel therapy for diabetic nephropathy.

NEXT NEWSLETTER Due out beginning of June 2011 so keep the gossip coming.

Endodiabology October 2010

2011-01-20T20:56:00.002Z

ENDODIABOLOGY
Endodiabology.blogspot.com

NORTHEAST
NEWSLETTER
FOR SPRs AND BOSSES TRAPPED
IN THE NORTHERN DEANERY

OCTOBER 2010
Senior Editors: Shaz Wahid, Petros Perros and Arutchelvam Vijayaraman
Associate Editor: Srikanth Mada

StR PLACEMENTS (NTN year of training from 1st October 2008)
• 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- Eeelin Lim (5)
• Sunderland- Jacog Buckovan (1), vacant
• North Tees/Hartlepool- Sudeep Manohar (4), vacant
• Middlesbrough- Arif Ullah (4)/Kathryn Stewart (3), Naveen Siddaramaiha (4), Vacant
• Bishop Auckland/Darlington/Durham- Sathia Rajhavan(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), Arif Ullah (4-Prof Bilous from 3/11)
• Maternity Leave Rohana Wright (3), Anjali SanthaKumar (3), Kathryn Stewart till 3/11 (3)

MEETINGS / LECTURES / ANNOUNCEMENTS
• 7 October 2010 British Thyroid Association annual meeting: Royal college of pathologists; London: Contact
• 15th-17th October 2010 Autumn Endocrine Retreat. Contact conferences@endocrinology.org
• 18 October 2010 National training scheme for the use of radioiodine in benign thyroid disease : Birmingham, UK ; Contact helen.flood@uhb.nhs.uk
• 21st October 2010 North East Obesity Forum, 4-6pm, Obesity & Ethnicity, Durham University. Contact Catherine Stone Catherine.Stone@aso.org.uk
• 26- 30 October 2010 : American Thyroid Association meeting : Palmsprings, USA : Website: www.thyroid.org
• 8th-10th November 2010 Society for Endocrinology Clinical Update, venue TBC. Contact www.endocrinology.org
• 9th November 2010 RCP Updates in Medicine, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
• 17th November 2010 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
• 18th-19th November 2010 ABCD autumn meeting, London. Contact www.diabetologists.org.uk followed by SpRs meeting 19th-21st November 2010.
• 24th November 2010 Northern Endocrine Region Research and Audit Group annual meeting, Lumley Castle, Durham 2pm-8pm. Contact shahid.wahid@sthct.nhs.uk
• 25th November 2010 Northern England Diabetes & Obesity Collaborative Research Meeting, The Marriot Hotel, Leeds 0900-1630. contact jane.mann@manchester.ac.uk
• 25th & 26th November 2010 Middlesbrough Insulin infusion Pump Course, James Cook University Hospital. Contact nicky.skippon@stees.nhs.uk
• 19th January 2011 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
• 26th January 2011 Northern Endocrine & Diabetes Winter CME, Freeman Hospital. Contact Sarah Steven or Srikanth Mada
• 1st March 2011 SfE National Clinical Cases Meeting, Royal Society of Medicine, London. Contact conferences@endocrinology.org NOTE submissions deadline is 25th October 2010.
• 16th March 2011 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk
• 30th March – 1st April 2011 DUK Annual Professional Conference, London, ExCel ICC. Contact www.diabetes.org.uk NOTE abstract submission deadline 31st October 2010.
• 11th-14th April 2011 SfE British Endocrine Societies annual conference, Birmingham ICC. Contact conferences@endocrinology.org NOTE abstract submissions deadline 15th November 2010.
• 13th April 2011 Northern Region Acute Medicine Study Day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk
• 5th-6th May 2011 ABCD spring meeting, London. Contact www.diabetologists.org.uk
• 11th May 2011 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk
• 24th May 2011 Northern Endocrine & Diabetes Summer CME, JCUH, Middlesbrough. Contact Sarah Steven(sarah.steven@doctors.org.uk ) or Srikanth Mada (srikanth.mada@nhs.net )
• 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
• 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
• 12th October 2011 Northern Endocrine & Diabetes Autumn CME, Durham. Contact Sarah Steven(sarah.steven@doctors.org.uk ) or Srikanth Mada (srikanth.mada@nhs.net )
• 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
• 30th November 2011 RCP Updates in Medicine, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.

TRAINING ISSUES
DIABETES & ENDOCRINOLOGY PIMD WEBSITE Our specialty website is available on http://mypimd.ncl.ac.uk/PIMDDev . Click onto the specialty training tab then follow to Diabetes & Endocrinology. This site is essential reading, especially for ARCP preparation.
Registering with PMETB It is essential that all new SpRs/StRs (even LATs) register with the PMETB through the newly created Joint Royal Colleges of Physicians Training Board (formally the JCHMT) on www.jrcptb.org.uk. Not doing so means your training is not counted.
Log Book/Portfolio Documentation It is a trainee’s responsibility to make sure their portfolio/log book is prospectively completed and the necessary signatures obtained. Any experience that is not signed off by your educational supervisor at the time cannot be counted towards training. The e-portfolio for DM&ENDO is available now for StRs.
Assessment tools Please see www.jrcptb.org.uk; it is the trainee’s responsibility to give all the appropriate forms to their Educational or Clinical Supervisor. It is the trainee’s responsibility to make sure that the appropriate assessment summaries are available in their portfolio for ARCP purposes, e.g. MSF Summary Form.
Documenting CCU and ITU experience It is essential that trainees document their CCU and ITU experience. This is best done by keeping a summary log of the cases seen on CCU and ITU and linking it with reflection or assessment. This should then be signed off by your Educational Supervisor to be of any use at the Acute Medicine PYAs.
Audit Assessment tool This is now available in draft form on the JRCPTB website. Its use is highly recommended.
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 year sees the inaugural prize for SpRs passing the MRCP Diabetes & Endocrinology exam with the highest mark in the region. Richard Quinton secures the funding of £800 and it is named after 2 distinguished former Endocrinologists in the region, Bill Kelly and Eric Young. The prize will be presented at this year’s NERRAG meeting by both Bill and Eric to the 3 SpRs sharing the prize: Atif Munir, Nimanthe De Alwis and Sajid Ethol Kalathil.
INFORMATION for QA Could each individual trainer send the following to Simon Pearce: educational qualifications, any training positions held and any educational courses attended.
MORE INFORMATION for QA Could each unit’s Training Lead please send to Simon Pearce a completed training unit information report and an updated SpR/StR job description.
Trainers & Trainees meeting The next T&T is on 14th June 2011. Details to be confirmed nearer the time, but please note in your diary.
Another Trainee Rep on STC With Jeevan’s Consultant appointment a vacancy will exist from July 2010. Could interested SpRs please contact Nicky Leech.
TRAINERS EVENT 13th October 2010 This morning session is specifically for the faculty of trainers in Diabetes&Endocrinology in the Region. It promises to be an interesting morning with sessions on NHS Education England, Trainees in difficulty and on the job work based assessments.
ARCPs 2011 Mon 16th, Tues 17th, Weds 18th May 2011. SpRs keep these dates free and volunteers for the panel please contact Nicky Leech. Minimal requirements will be: thorough portfolio documentation, 4 Case based Discussions, Reflective accounts, Personal library evidence of teaching attendance and reflection, 4 new Mini-CEXs since last ARCP, MSF from current unit with at least 12 returns and 3 consultants, Updated PDP This should be drawn up and discussed with your supervisor within 4 weeks of starting your new post and Supervisors sign off and report.
NEDS CME Has undergone a revamp. See letter from Rohana Wright below.
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
Medicine ARCP Will remain separate next year. Date 19th May 2011. Continue to add evidence to the curriculum and demonstrate progression. Keep detailed anonomised logs and link them. Make the portfolio easy to navigate. You will need a MSF, Patient survey(if available), 6 ACATs, 6 CEX s, 4 CBDs, and be involved in a medical audit cycle.
Training Committee Chair- Simon Pearce, s.h.s.pearce@ncl.ac.uk; Regional Speciality Advisor- Shaz Wahid, shahid.wahid@sthct.nhs.uk; Programme Director- Nicky Leech nicola.leech@nuth.northy.nhs.uk; Consultant member (SAC rep)- Richard Quinton, Richard.Quinton@nuth.nhs.uk; Consultant member-Jean MacLeod, Jean.Macleod@nth.nhs.uk; Consultant member-Arutchelvam Vijayaraman Vijayaraman.Arutchelvam@stees.nhs.uk ; Consultant member-Simon Eaton, simon.eaton@northumbria-healthcare.nhs.uk; SpR representative-Srikkant Mada SpR representative

NEWS FROM THE NORTHEAST
• Congratulations to Shafie Kamruddin on his new appointments Consultant at Northallerton.
• Latika Sibal won the prize for best submitted oral presentation at the Heart UK meeting this summer. The work presented was part of the work in Newcastle for her PhD, awarded earlier this year. She continues in the locum consultant post at Addenbrooke's Hospital.
• Philip Home was invited by the American Diabetes Association to speak for the third time in four years at its Annual Congress in Orlando in June.
• Philip Home is now a member of the Steering Committee of the T-Emerge-8 CV outcomes study on taspoglutide, and the data safety boards of the Alecardio CV outcomes study on aleglitazar and the CANVAS study of canaglifloxicin, the latter for which he is Chair.
• For NICE Philip Home continues to chair the extended review of lapatinib, a novel breast cancer drug acting on the protein (tyrosine) kinase part of the growth factor receptor.
• Congratulations to Srikanth Made as a new Associate Editor for ENDODIABOLOGY.
• Congratulations to all 10 StRs in the region who sat the MRCP Endocrine exam and passed! 3 were 1st yr StRs. Well done to all.
• Sarah Steven and Srikanth Mada have joined Rohana Wright and Steve Ball on the NEDs CME committee.
• Srikanth Mada and Nimanthe De Alwis have taken over from Jeevan Mettayil in organising the SpR Management Forum.
• Srikanth Mada has joined the School of Medicine STC and Executive Committee as a trainee representative.
• Richard Quinton did an excellent job at the debate on testosterone in Type 2 Diabetes in the ABCD meeting. He was against the motion with Hugh Jones for the motion. Well done Richard.

LETTERS
The NEDS CME undergoes a revamp-Rohana Wright
This is just a reminder that the next CME day takes place on Tuesday 5th October at James Cook. This will follow the usual 9.30am-4.30pm structure as this date was booked prior to the decision to alter our format. And the dates for 2011 have now been confirmed:
Wednesday 26th January, Freeman Hospital; Tuesday 24th May, Durham; Wednesday 12th October, James Cook.

These days will all follow a new format, beginning at 1.30pm, finishing at 6.30pm, and will follow our curriculum based approach. There will also be non-clinical sessions incorporated into the programme. As you can see we are going to hold the May session in Durham, for a bit of a change of scenery, and we hope to use additional venues throughout the region in the coming years.

As I am now on maternity leave, any CME-related queries should be addressed to Sarah Steven (sarah.steven@doctors.org.uk ) or Srikanth Mada
(srikanth.mada@nhs.net ) who will be taking over my organisational duties while I am off.

DUK- Giggleswick Children’s summer camp-Srikanth Mada
I had a wonderful opportunity to volunteer as a clinical lead for DUK children’s summer camp held at Giggleswick school, north Yorkshire. It’s a week long camp consisting 60 children with type 1 diabetes between age groups 7 to 14 years. Each group consists of 10 children, one clinical lead, one dietician, two group leaders and a group supporter. Clinical leads take the handover of children from the parents and agree to achieve 3-4 objectives during their stay. The holiday is packed with high adrenaline activities such as caving, canoeing, kayaking, labyrinth, rock-climbing, high ropes, archery, abseiling,
and all day trip to Blackpool pleasure beech. Apart for all the fun it is an excellent opportunity to get a real time experience in understanding what it is living with diabetes and managing type 1 diabetes out side clinic setting. We get to teach them how to check BM’s, how to rotate sites, insulin titration, CHO counting and managing hypos. This camp gave me a real insight into living with diabetes, how disturbing and frightening a hypoglycaemic episode can be. An opportunity to understand managing diabetes in non clinic setting. One of the duty of group leads is to do midnight “hyporounds” as per rota to check kid’s at risk of nocturnal hypo following hectic day activity and manage them appropriate, which its self is a good learning experience. It is highly rewarding to see that kids injecting insulin on their own (who has never done before), successfully manage to rotate injection site, understand managing hypo and learn carbohydrate counting.
There were only 2 diabetologist’s (myself and the camp organiser) and rest 4 clinical lead slots were filled in by our specialist nurse colleagues- probably an opportunity that trainees need to grab in future. I strongly recommend all my colleagues SpR’s to consider attending one of these camps during their training, its great fun and excellent learning opportunity.

7-habits course at South Tyneside-Shaz Wahid.
New and old Consultants along with any StRs rotating to South Tyneside will be offered attendance at the in-house 7-habits course our Training & Development Dept. deliver 3 times a year. I am please to say Nimanthe has accepted the offer, just need to get Jon onto it before he retires! Here is the blurb:
“Stephen R. Covey is an internationally respected leadership authority. His book ‘The 7 Habits of Highly Effective People’ is an international best-seller and has been named as one of the 10 most influential management books ever. This flagship leadership programme has received very positive feedback from recent delegates and we would strongly encourage you to attend as part of your personal and professional development. The Signature Course has been modified to enable us to deliver this training in a 2-day workshop format – commencing at 8am and finishing around 5pm on both days. The venue for this event is to be confirmed but will be either Training & Development or the Ingham Wing Conference Room.

The aim of the workshop is to turn ineffectiveness into effectiveness with The 7 Habits which are briefly outlined below:
Habit 1: Be Proactive
Recognise how choices based on personal experience or beliefs can profoundly impact your effectiveness, both positively and negatively.
Habit 2: Begin with the End in Mind
Develop a clear definition of what is and is not important to you by creating your Personal Mission Statement.
Habit 3: Put First Things First
Increase the balance and fulfillment of your professional and personal life by investing a few minutes each day in the planning process.
Habit 4: Think Win-Win
Build a team that finds faster and better solutions through clear expectations, shared responsibilities, and an understanding of priorities.
Habit 5: Seek First to Understand Then to Be Understood
Develop the skills of effective communication that lead to greater influence and faster problem solving.
Habit 6: Synergize
Value and celebrate differences and understand how they contribute to more innovative and intelligent solutions.
Habit 7: Sharpen the Saw
Maintain and increase your newfound effectiveness by continually renewing yourself mentally and physically.”
Will be working on an 8th habit course soon!

RECENT PUBLICATIONS FROM THE NORTHEAST
1. Diabetes, falls and fractures. Mayne D, Stout NR, Aspray TJ. Age Ageing. 2010 Sep;39(5):522-5. Epub 2010 Jul 14.
2. Vitamin D and fractures: where are we now? Aspray TJ, Francis RM. Maturitas. 2010 Jul;66(3):221-2. Epub 2010 Apr 7.
3. Advani A, Johnson SJ, Nicol MR, Papacleovoulou G, Evans DB, Vaikkakara S, Mason JI, Quinton R. 2010 Adult-onset hypogonadotropic hypogonadism caused by aberrant expression of aromatase in an adrenocortical adenocarcinoma. Endocrine Journal. May 13. [Epub ahead of print].

4. Sykiotis GP, Plummer L, Hughes VA, Au M, Durrani S, Nayak-Young S, Quinton R, Hall JE, Gusella JF, Seminara SB, Crowley WF, jr, Pitteloud N. 2010 The oligogenic basis of idiopathic hypogonadotropic hypogonadism. Proceedings of the National Academy of Sciences of the United States of America. 107:15140-150144.

5. Gianetti E, Tusset C, Noel SD, Au MG, Dwyer AA, Hughes VA, Abreu AP, Carroll J, Trarbach E, Silveira LG, Costa EM, de Mendonça BB, de Castro M , Lofrano A, Hall JE, Bolu E, Özata M, Quinton R, Amory JK, Stewart SE, Arlt W, Cole TR, Crowley WF jr., Kaiser UB, Latronico AC, Seminara SB. 2010 TAC3/TACR3 mutations reveal preferential activation of gonadotropin-releasing hormone release by neurokinin B in neonatal life followed by reversal in adulthood. Journal of Clinical Endocrinology & Metabolism. 95: 2857-2867.

6. David Woods. Angiotensin-Converting Enzyme, Renin-Angiotenson System and Human Performance. Genetics and Sports. Medicine and Sport Science 2009, Vol 54, pp 72-87.

7. Boos CJ, Wheble GA, Campbell MJ, Tabner KC, Woods DR. Self-administration of exercise and dietary supplements in deployed British military personnel during Operation TELIC 13. J R Army Med Corps. 2010 Mar;156(1):32-6.

RECENT PUBLICATIONS IN DIABETES & ENDOCRINOLOGY THAT HIT THE NEWS OR THAT MAY HAVE A SIGNIFICANT IMPACT ON MANAGEMENT
Carcinoid Syndrome R Srirajaskanthan et al. BMJ 2010341:c3941. An excellent case reminding us how easy it can be to miss Carcinoid syndrome.
Opioid induced hypogonadism. RG Reddy et al. BMJ 2010;341:c4462. 2 case reports suggesting an association between opioids and hypogonadism. I certainly came across a case of this in a 23 yr-old woman when I was a SpR in PIU at the RVI (many moons ago!).
Primary ovarian insufficiency. M De Vos et al. Lancet 2010;376:911-921. An excellent review article well worth a read.
“Liberating the NHS”-another attempt to implement market forces in English health care. Nick Black. NEJM 2010;363:1103-1105. I have read plenty of articles on the white paper in the medical literature, but none as good as this. However, the best articles have been in the Health Service Journal that I read as part of my management role. I dare you to read it………………………………………………………….
Large prolactinoma. M Ahmed & O Al-Nozha. NEJM 2010;363:177. An excellent picture for teaching.
Management of people with diabetes wanting to fast during Ramadan. E Hui et al. BMJ 2010;340:c3053. A wonderful, practical review article that should be staple reading for trainees and an annual reminder for us senior folk.
Functional hypothalamic amenorrhoea. CM Gordon. NEJM 2010;363:365-371. A practical review article worth a read.
Diabetic Nephropathy. N Cheung et al. Lancet 2010;376:124-136. An excellent update well worth a read.
Calcium kidney stones. EM Worcester & FL Coe. NEJM 2010;363:954-963. Kidney stones are now on the new specialty curriculum, hence this article is very timely and good to boot!
Obesity therapy trials. 2 recent trilals detailing treatment with naltrexone&bupropion and Lorcaserin for weight management are worth a read with their accompanying editorials: FL Greenway et. Lancet 2010;376:595-605; SR Smith et al. NEJM 2010;363:245-256.
Lancet Diabetes Theme Issue. The 2010 volume 375 June 26-July2 edition of the Lancet is worth a read in its entirety. It includes new therapy options with dapaglifozin and a head to head comparison of glargine insulin and once-weekly exenatide.
Investigating secondary hyperhidrosis. AN Paisley & HM Buckler. BMJ 2010;341:c4475. An excellent article reviewing the steps in investigating this common referral to Endocrine clinic.
Effects of medical therapies on retinopathy progression in type 2 diabetes. The ACCORD study group. NEJM 2010;363:233-244. In the ACCORD randomised trial 10,251 participants with type 2 diabetes who were at high risk for cardiovascular disease to receive either intensive or standard treatment for glycaemia (target HbA1c , <6.0% or 7.0 to 7.9%, respectively) and also for dyslipidaemia (160 mg daily of fenofibrate plus simvastatin or placebo plus simvastatin) or for systolic BP control (target, <120 or <140 mm Hg) were enrolled. A subgroup of 2856 participants was evaluated for the effects of these interventions at 4 years on the progression of diabetic retinopathy by 3 or more steps on the Early Treatment Diabetic Retinopathy Study Severity Scale or the development of diabetic retinopathy necessitating laser photocoagulation or vitrectomy. At 4 years, the rates of progression of diabetic retinopathy were 7.3% with intensive glycaemia treatment, versus 10.4% with standard therapy (adjusted odds ratio, 0.67; [95% CI], 0.51-0.87; P=0.003); 6.5% with fenofibrate for intensive dyslipidaemia therapy, versus 10.2% with placebo (adjusted odds ratio, 0.60 [0.42-0.87]; P=0.006); and 10.4% with intensive blood-pressure therapy, versus 8.8% with standard therapy (adjusted odds ratio, 1.23[0.84-1.79]; P=0.29). The authors conclude that intensive glyacemic control and intensive combination treatment of dyslipidaemia, but not intensive blood-pressure control, reduced the rate of progression of diabetic retinopathy. An excellent trial that adds weight to fenofibrate use in diabetic retinopathy in addition to statin therapy. Nice to see glycaemic control does not get a knocking and still a little baffled with the BP effect, however UKPDS did last longer.
Identification of late-onset hypogonadism in middle-aged and elderly men. Wu FC et al. NEJM 2010;363:123-135. The authors surveyed a random population sample of 3369 men aged 40 to 79 years at eight European centres, using questionnaires. The collected data included the subjects' general, sexual, physical, and psychological health. Levels of total testosterone were measured in morning blood samples by mass spectrometry, and free testosterone levels were calculated with the use of Vermeulen's formula. Data were randomly split into separate training and validation sets for confirmatory analyses. In the training set, symptoms of poor morning erection, low sexual desire, and erectile dysfunction, inability to perform vigorous activity, depression, and fatigue were significantly related to the testosterone level. Increased probabilities of the three sexual symptoms and limited physical vigour were discernible with decreased testosterone levels (ranges, 8.0 to 13.0 nmol/l for total testosterone and 160 to 280 pmol/l for free testosterone). However, only the three sexual symptoms had a syndromic association with decreased testosterone levels. An inverse relationship between an increasing number of sexual symptoms and a decreasing testosterone level was observed. These relationships were independently confirmed in the validation set, in which the strengths of the association between symptoms and low testosterone levels determined the minimum criteria necessary to identify late-onset hypogonadism. This trial suggests that late-onset hypogonadism can be defined by the presence of at least three sexual symptoms associated with a total testosterone level of less than 11 nmol/l and a free testosterone level of less than 220 pmol/l.
Adverse events associated with testosterone administration. Basaria S and Coviello AD, et al. NEJM 2010;363:109-122. In this trial Community-dwelling men, 65 years or older, with limitations in mobility and a total serum testosterone level of 3.5 to 12.1 nmol/l or a free serum testosterone level < 173 pmol/l were randomly assigned to receive placebo gel or testosterone gel, to be applied daily for 6 months. The data and safety monitoring board recommended that the trial be discontinued early because there was a significantly higher rate of adverse cardiovascular events in the testosterone group than in the placebo group. A total of 209 men (mean age, 74 years) were enrolled at the time the trial was terminated. At baseline, there was a high prevalence of hypertension, diabetes, hyperlipidaemia, and obesity among the participants. During the course of the study, the testosterone group had higher rates of cardiac, respiratory, and dermatologic events than did the placebo group. A total of 23 subjects in the testosterone group, as compared with 5 in the placebo group, had cardiovascular-related adverse events. The relative risk of a cardiovascular-related adverse event remained constant throughout the 6-month treatment period. As compared with the placebo group, the testosterone group had significantly greater improvements in leg-press and chest-press strength and in stair climbing while carrying a load. In this population of older men with limitations in mobility and a high prevalence of chronic disease, the application of a testosterone gel was associated with an increased risk of cardiovascular adverse events. The small size of the trial and the unique population Limit extrapolation about the safety of testosterone therapy and certainly should not deter further trials. It is well worth reading the editorial by William Bremner (NEJM 2010;363:189-191) in relation to both of the above trials.
Effectiveness of sensor-augmented insulin-pump therapy in type 1 diabetes. Bergenstal RM, Tamborlane WV, et al. NEJM 2010;363:311-320. In this 1-year, multicentre, randomised, controlled trial, the efficacy of sensor-augmented pump therapy (pump therapy) with that of a regimen of multiple daily insulin injections (injection therapy) in 485 patients (329 adults and 156 children) with inadequately controlled type 1 diabetes was studied. Patients received recombinant insulin analogues and were supervised by expert clinical teams. At 1 year, the baseline mean HbA1c(8.3% in the two study groups) had decreased to 7.5% in the pump-therapy group compared with 8.1% in the injection-therapy group (P<0.001). The proportion of patients who reached an HbA1c <7% was greater in the pump-therapy group than in the injection-therapy group. The rate of severe hypoglycaemia in the pump-therapy group (13.31 cases per 100 person-years) did not differ significantly from that in the injection-therapy group (13.48 per 100 person-years, P=0.58). There was no significant weight gain in either group. This trial confirms the efficacy of the newer insulin pump technology in both adults and children with inadequately controlled type 1 diabetes.
Efficacy and safety of exenatide once weekly versus sitagliptin or pioglitazone as an adjunct to metformin for treatment of type 2 diabetes (DURATION-2): a randomised trial. Bergenstal RM, Wysham C et al. Lancet 2010;376:431-439. In this 26-week randomised, double-blind, double-dummy, superiority trial, patients with type 2 diabetes who had been treated with metformin, and at baseline had a mean HbA1c of 8.5%(SD 1.1), fasting plasma glucose of 9.1 mmol/L (2.6), and weight of 88.0 kg (20.1), were randomly assigned to receive: 2 mg injected exenatide once weekly plus oral placebo once daily (170-pts); 100 mg oral sitagliptin once daily plus injected placebo once weekly (172-pts); or 45 mg oral pioglitazone once daily plus injected placebo once weekly (172-pts). Primary endpoint was change in HbA1c between baseline and week 26. Analysis was by intention to treat, for all patients who received at least one dose of study drug. 491 patients received at least one dose of study drug and were included in the intention-to-treat analysis (160 on exenatide, 166 on sitagliptin, and 165 on pioglitazone). Treatment with exenatide reduced HbA1c(least square mean -1.5%, 95% CI -1.7 to -1.4) significantly more than did sitagliptin (-0.9%, -1.1 to -0.7) or pioglitazone (-1.2%, -1.4 to -1.0). Treatment differences were -0.6% (95% CI -0.9 to -0.4, p<0.0001) for exenatide versus sitagliptin, and -0.3% (-0.6 to -0.1, p=0.0165) for exenatide versus pioglitazone. Weight loss with exenatide (-2.3 kg, 95% CI-2.9 to -1.7) was significantly greater than with sitagliptin (difference -1.5 kg, 95% CI -2.4 to -0.7, p=0.0002) or pioglitazone (difference -5.1 kg, -5.9 to -4.3, p<0.0001). No episodes of major hypoglycaemia occurred. The most frequent adverse events with exenatide and sitagliptin were nausea (n=38, 24%, and n=16, 10%, respectively) and diarrhoea (n=29, 18%, and n=16, 10%, respectively); upper-respiratory-tract infection (n=17, 10%) and peripheral oedema (n=13, 8%) were the most frequent events with pioglitazone. This trial confirms what we could have all predicted, that exenatide once weekly is more effective with less weight gain when added in second line compared to sitagliptin and pioglitazone. Personally, therapies for Type 2 diabetes have promulgumated and individualizing treatment is the correct thing to do. However, the basic tenants of lifestyle advice, metformin therapy and structured education remain the bedrock of all therapies.

NEXT NEWSLETTER Due out beginning of February 2011 so keep the gossip coming.

Endodiabology June 2010 issue 2

2010-06-15T22:24:00.001+01:00

ENDODIABOLOGY
Endodiabology.blogspot.com

NORTHEAST
NEWSLETTER
FOR SPRs AND BOSSES TRAPPED
IN THE NORTHERN DEANERY

JUNE 2010
Editors: Shaz Wahid (shahid.wahid@sthct.nhs.uk) and
Petros Perros (petros.perros@ncl.ac.uk) and Arut Vijayaraman (riarut@aol.com )
Associate Editors: Shafie Kamarrudin, Ravi Erukulapati

SpR PLACEMENTS (NTN year of training from 1st October 2008)
• Newcastle- Ravi Erukalapati(5), Sudeep Manohar (3), Nimanth De Alwis (1), Arif Ullah (3), Srikanth Mada(3) Naveen Siddaramaiha (2), Sarah Steven (2)
• North Tyneside/Wansbeck- Anjali Santhakumar (3), Vacant
• South Tyneside- Rohanna Wright (2),
• Gateshead- Preeti Rao (3)
• Sunderland- Naveen Aggarwal (1), Chandima Idampitiya (5)
• North Tees/Hartlepool- Shafie Kamarrudin (4), Hamza Ali Khan (1)
• Middlesbrough- Freda Razvi (5), Atif Munir (1), Sajid Ethol Kalathil (1), Catherine Napier (1)
• Bishop Auckland Vacant
• Durham- Jeevan Mettayil (4)
• NGH/QEH- Vacant
• Research with numbers (supervisor)- Eelin Lim(5-Prof Taylor); Stuart Little (2-Dr Shaw) & Asgar Madathil (4-Dr Weaver)

MEETINGS / LECTURES / ANNOUNCEMENTS
• 8th June 2010 Northern Endocrine & Diabetes Spring CME, Freeman Hospital. Contact mshafie_kamaruddin@yahoo.co.uk
• 8 June 2010 Association for study of obesity (ASO) conference: Cardiff: Contact: Catherine.stone@aso.org.uk
• 19th – 22nd June 2010 ENDO 2010, San Diego, USA. Contact endostaff@endo-societ.org or www.endo-society.org/scimeetings .
• 25th – 29th June 2010 American Diabetes Association 70th Annual Scientific Sessions, Orlando, Florida, USA. Contact meetings@diabetes.org .
• 7 July 2010 SpR management training session : Managing service change: Management team from SothTyneside: Lumley castle 6- 8 pm. Contact: anjalisan@yahoo.com & jmjeevan@yahoo.com
• 10- 15 July International Congress of Neuroendocrinology: Rouen, France: Contact hubert.vaudry@univ-rouen.fr
• 14th July 2010 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
• 14- 17 July Mayo clinic Endocrine course: Rochester, Minnesota, USA Contact: hinchley.rebecca@mayo.edu
• 6 September 2010: UKI NETS (UK Ireland Neuroendocrine Tumour Society) conference Belfast: Contact joy.ardill@qub.ac.uk
• 11- 16 September 2010: International Thyroid Congress: Paris, France Website: www.itc2010.com
• 15th September 2010 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
• 20th – 24th September 2010 46th EASD Annual meeting, Stockholm, Sweden. Contact www.easd.org
• 7 October 2010 British Thyroid Association annual meeting: Royal college of pathologists; London: Contact s.h.s.pearce@ncl.ac.uk
• 18 October 2010 National training scheme for the use of radioiodine in benign thyroid disease : Birmingham, UK ; Contact helen.flood@uhb.nhs.uk
• 26- 30 October 2010 : American Thyroid Association meeting : Palmsprings, USA : Website: www.thyroid.org
• 8th-10th November 2010 Society for Endocrinology Clinical Update, venue TBC. Contact www.endocrinology.org
• 9th November 2010 RCP Updates in Medicine, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
• 17th November 2010 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
• 18th-19th November 2010 ABCD autumn meeting, London. Contact www.diabetologists.org.uk followed by SpRs meeting 19th-21st November 2010.
• 24th November 2010 Northern Endocrine Region Research and Audit Group annual meeting, Lumley Castle, Durham 2pm-8pm. Contact shahid.wahid@sthct.nhs.uk

TRAINING ISSUES
DIABETES & ENDOCRINOLOGY PIMD WEBSITE Our specialty website is available on http://mypimd.ncl.ac.uk/PIMDDev . Click onto the specialty training tab then follow to Diabetes & Endocrinology. This site is essential reading, especially for ARCP preparation.
SPR management training session: “Managing Service Change”-Management Team from South Tyneside. Lumley Castle 6-8pm 7th July 2010. Contact anjalisan@yahoo.com & jmjeevan@yahoo.com
for more information.
Registering with PMETB It is essential that all new SpRs/StRs (even LATs) register with the PMETB through the newly created Joint Royal Colleges of Physicians Training Board (formally the JCHMT) on www.jrcptb.org.uk. Not doing so means your training is not counted.
Log Book/Portfolio Documentation It is a trainee’s responsibility to make sure their portfolio/log book is prospectively completed and the necessary signatures obtained. Any experience that is not signed off by your educational supervisor at the time cannot be counted towards training. The e-portfolio for DM&ENDO is available now for StRs.
Assessment tools Please see www.jrcptb.org.uk; it is the trainee’s responsibility to give all the appropriate forms to their Educational or Clinical Supervisor. It is the trainee’s responsibility to make sure that the appropriate assessment summaries are available in their portfolio for ARCP purposes, e.g. MSF Summary Form.
Documenting CCU and ITU experience It is essential that trainees document their CCU and ITU experience. This is best done by keeping a summary log of the cases seen on CCU and ITU and linking it with reflection or assessment. This should then be signed off by your Educational Supervisor to be of any use at the Acute Medicine PYAs.
Audit Assessment tool This is now available in draft form on the JRCPTB website. Its use is highly recommended.
General Internal Medicine Curriculum is now updated and available on www.jrcptb.org.uk. All trainees appointed ST3 from August 2009 will be offered entry to train for this CCT. Trainees before this date can easily apply to train in this CCT (i.e. dual accredit), again detailed in the website. The transference process to the G(I)M curriculum has gone smoothly for our specialty.
MRCP Diabetes & Endocrinology This exam has to be completed and passed by all trainees appointed after August 2007 before their PYA. We recommend sitting it ASAP and well before your PYA.
INFORMATION for QA Could each individual trainer send the following to Simon Pearce: educational qualifications, any training positions held and any educational courses attended.
MORE INFORMATION for QA Could each unit’s Training Lead please send to Simon Pearce a completed training unit information report and an updated SpR/StR job description as per Nicky Leech’s e-mail.
Trainers & Trainees meeting The next T&T is on 24th June 2010. Details to be confirmed nearer the time, but please note in your diary.
Another Trainee Rep on STC With Jeevan’s Consultant appointment a vacancy will exist from July 2010. Could interested SpRs please contact Nicky Leech.
More Associate Editors for ENDODIABOLOGY I am sure you will agree that since its inception in October 2002 ENDODIABOLOGY has been a great success. With the current associate editors moving onto pastures new soon could interested SpRs please contact Shaz Wahid.
TRAINERS EVENT 13th October 2010 This morning session is specifically for the faculty of trainers in Diabetes&Endocrinology in the Region. It promises to be an interesting morning with sessions on NHS Education England, Trainees in difficulty and on the job work based assessments. Details to follow from Simon Pearce.
Training Committee Chair- Simon Pearce, s.h.s.pearce@ncl.ac.uk; Regional Speciality Advisor- Shaz Wahid, shahid.wahid@sthct.nhs.uk; Programme Director- Nicky Leech nicola.leech@nuth.northy.nhs.uk; Consultant member (SAC rep)- Richard Quinton, Richard.Quinton@nuth.nhs.uk; Consultant member-Jean MacLeod, Jean.Macleod@nth.nhs.uk; Consultant member-Arutchelvam Vijayaraman Vijayaraman.Arutchelvam@stees.nhs.uk ; Consultant member-Simon Eaton, simon.eaton@northumbria-healthcare.nhs.uk; SpR representative- Anjali Santhakumar anjalisan@yahoo.com ; SpR representative- Jeevan Mettayil jmjeevan@yahoo.com

NEWS FROM THE NORTHEAST
• Congratulations to Jeevan Mettayil and Khaled Dukhan on their new appointments as Consultants at South Tyneside.
• Congratulations to Kathryn Stewart on the birth of her baby Daughter.
• Preethi Rao will be undertaking an interdeanery transfer to Sheffield where her husband has a post. We will miss her!
• Congratulations to Ravi Erukalapati on his Acute Physician Consultant post at Sunderland.
• Welcome to Dr Rajarshi Mukhopadyay who joined County Durham & Darlington NHSFT formally from April 2010 as consultant in Diabetes and endocrinology. Raj obtained his CCST from West Midlands. In addition he obtained his MD in General Medicine and a DM in endocrinology from Calcutta, India. His base hospital is Darlington.
• ABCDs visit to the North East on 6th May was a success. A good day with plenty of networking. Hopefully, they will be in town in the future.
•
LETTERS
The Dreaded portfolio review station-Shaz Wahid
It was good to meet colleagues and interview a good field at the recent StR interviews. We have offered numbers to excellent candidates of whom all are from the region. The only downer when I began the day was being allocated the portfolio review station. I have avoided this station for 3-yrs, perceiving it to be boring. The only positive was being paired with Jean MacLeod, allowing a good natter and catch up. Although, Jean did warn Nicky that Shaz and I on the same station will really make time management of the station a real challenge due to our gifts of being able to talk the hind leg of a horse! Imagine my surprise when I found the station to be really good and thinking to myself what have I been missing. It is just like an old style interview. You really do get a chance to get under the psyche of candidates and challenge them. What was even more surprising was that our time management of the station was meticulous, probably something to do with the stop whatch and Jean using a gag when I meandered too much. To conclude, I would recommend the portfolio review station as the best station to undertake.

British Thyroid Association Annual meeting-Simon Pearce
The BTA annual meeting has a new date and venue. October 7th 2010, at Royal College of Pathologists, London. There is a focus on thyroid nodules in the morning and thyroid disease in pregnancy during the afternoon with overseas speakers including Susan Mandel (Philadelphia), Victor Pop (NL) and Domenico Salvatore (Naples). Promises to be an excellent one day meeting, I think £50 for SpRs & nurses, £70 for consultants.

Book Review-“Gods of Management” by Shaz Wahid
I would highly recommend this book by Charles Handy, published by Arrow in paperback edition, for its fun value and not only its more serious message. There are four Gods. Zeus is the leader, represented by a spider’s web. He is feared, respected and occasionally loved. Such leaders are powerful, charismatic, impulsive and benevolent all at the same time. We all need Zeus leaders, but an organisation where the Zeus leader predominates can only lead to a club culture often described as an “old-boys” culture. It runs entirely on Trust.

Apollo is the God of order and rules. Apollonian management brings control to an organisation by breaking down work into separate, specific job description. The symbol of Apollo is a temple. The top is linked by management, e.g. the head of each department, with the pillars representing functions and roles in the organisation. All of this is controlled by rules and regulations. An organisation where Apollo predominates can be described as role orientated. Apollonian leaders can be described as administrators.

Athena is the arch problem solver of craftsmen and sea captains. Her symbol is a net, where power lies at the interconnecting nodes not at the centre as in Zeus or at the top as in Apollo. The Athenian leader deals in solutions. An organisation where Athena predominates is described as task orientated.

Dionysus is the God of individualism. In the Dionysian organisation the organisation is the servant of the individual. The symbol of Dionysus is a cluster of stars surrounded by a circle. Drs and solicitors are the archetypal individuals that exist in a Dionysian organisation. The culture is all about the person.

However, many of you can see where there can be clashes between Dionysian individuals (Drs) and Apollonian organisations (The management). We live in hard times that will only become more challenging. Many have asked why Management Shaz? It could be any of “I am easily bored” “I am good at service change” amongst plenty of valid reasons. But, ultimately it is my desire to act as bridge in my organisation to help the 4 cultures of “club”, “role”, task” and “person” each with their own God to work together for the benefit of our patients. I wish to develop a kinder Apollonian organisation with the symbol of a village. In a softer Apollonian organisation we realise that not every task is professional, there are still mundane repetitive tasks that need covered. Employs that do these tasks are human and although under more management control than the professionals they are still treated as individuals. Even the most Apollonian task should have a Dionysian tinge. The village is the best symbol as it represents a small personal place where everyone has a name, character and personality. I sincerely hope you read this book.

RECENT PUBLICATIONS FROM THE NORTHEAST
1. Gan EH, Quinton R. Physiological significance of the rhythmic secretion of hypothalamic and pituitary hormones. Progress in Brain Research. 2010; 181: 111-125.
2. Maccoll GS, Quinton R, Bülow HE. Biology of KAL1 and its orthologs: implications for X-Linked Kallmann syndrome and the search for novel candidate genes. Front Horm Res. 2010; 39:62-77.
3.Gianetti E, Tusset C, Noel SD, Au MG, Dwyer AA, Hughes VA, Abreu AP, Carroll J, Trarbach E, Silveira LF, Costa EM, de Mendonça BB, de Castro M, Lofrano A, Hall JE, Bolu E, Ozata M, Quinton R, Amory JK, Stewart SE, Arlt W, Cole TR, Crowley WF, Kaiser UB, Latronico AC, Seminara SB. TAC3/TACR3 Mutations Reveal Preferential Activation of Gonadotropin-Releasing Hormone Release by Neurokinin B in Neonatal Life Followed by Reversal in Adulthood. J Clin Endocrinol Metab. 2010 Mar 23. [Epub ahead of print]
4. Wright RJ, Kanagasundaram NS, Quinton R. Darbepoetin alfa and chronic kidney disease. N Engl J Med. 2010; 362: 653.
5. Razvi S, Weaver JU, Vanderpump MP, Pearce SH. The incidence of ischemic heart disease and mortality in people with subclinical hypothyroidism: reanalysis of the Whickham Survey cohort. J Clin Endocrinol Metab. 2010 Apr;95(4):1734-40.
6. Razvi S, Weaver JU, Pearce SH. Subclinical thyroid disorders: significance and clinical impact. J Clin Pathol. 2010 May;63(5):379-86.
7. Dias RP, Chan LF, Metherell LA, Pearce SHS, Clark AJL. Isolated Addison’s Disease is unlikely to be caused by mutations in MC2R, MRAP or StAR, three genes responsible for familial glucocorticoid deficiency. Eur J Endocrinol 2010; 162:357-9.
8. Turner JJ, Christie PT, Pearce SH, Turnpenny PD, Thakker RV. Diagnostic challenges due to phenocopies: lessons from Multiple Endocrine Neoplasia type1 (MEN1). Hum Mutat 2010; 31:E1089-101.
9. Pearce SH, Cheetham TD. Diagnosis and management of vitamin D deficiency. BMJ 2010; 340: 142-147.
10. Boelaert K, Newby PR, Simmonds MJ, Holder RL, Carr-Smith JD, Heward JM, Manji N, Allahabadia A, Armitage M, Chatterjee KV, Lazarus JH, Pearce SH, Vaidya B, Gough SC, Franklyn JA. Prevalence and relative risk of other autoimmune diseases in subjects with autoimmune thyroid disease. Am J Med 2010; 123:183.e1-9.
11. Newby PR, Pickles OJ, Mazumdar S, Brand OJ, Carr-Smith JD, Pearce SH, Franklyn JA, WTCCC, Evans DM, Simmonds MJ, Gough SCL. Follow up of potential novel Graves’ disease susceptibility loci, identified in the UK WTCCC genome-wide non-synonymous SNP study. Eur J Hum Genet 2010; in press
12. Frontiers in Hormone Research, Vol 39. Kallmann Syndrome & Hypogonadotropic Hypogonadism. Editor: R Quinton, Karger AG, Zurich
ISBN 978-8055-8617-7.

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

Loss of vision? Clear as crystal! Ranjeet J Pandit et al. Lancet 2010;375:610.An excellent case report of an unusual presentation of primary hyperparathyroidism.
Familial adenomatous polyposis and hypertension. Hopkins TG et al. Lancet 2010;375:1752. The association of FAP with Primary Hyperaldosteronism represented in a case report.
Investigating suspected bone infection in the diabetic foot. James Teh et al. BMJ 2010;340:415-421. A useful summary.
Porphyrias. Puy H et al. Lancet 2010;375:924-937. An excellent review article.
Effects of intensive blood-pressure control in type 2 diabetes mellitus. ACCORD Study Group N Engl J Med. 2010;362(17):1575-85. The authors investigated whether therapy targeting normal systolic blood pressure (i.e., <120 mm Hg) reduces major cardiovascular events in patients with type 2 DM at high risk for cardiovascular events by randomizing 4733 participants with type 2 DM to intensive therapy, targeting SBP < 120 mm Hg, or standard therapy, targeting SBP < 140 mm Hg. The primary composite outcome was nonfatal myocardial infarction, nonfatal stroke, or death from cardiovascular causes. The mean follow-up was 4.7 years. After 1 year, the mean SBP was 119.3 mm Hg in the intensive-therapy group and 133.5 mm Hg in the standard-therapy group. The annual rate of the primary outcome was 1.87% in the intensive-therapy group and 2.09% in the standard-therapy group with a hazard ratio with intensive therapy of 0.88; 95% confidence interval [CI], 0.73-1.06; p=0.20. The annual rates of death from any cause were 1.28% and 1.19% in the two groups, respectively (HR, 1.07;0.85-1.35; p=0.55). The annual rates of stroke, a prespecified secondary outcome, were 0.32% and 0.53% in the two groups, respectively (HR,0.59; 95% 0.39-0.89; p=0.01). Serious adverse events attributed to antihypertensive treatment occurred in 3.3% of people in the intensive-therapy group and 1.3% people in the standard-therapy group (p<0.001). This trial suggests In patients with type 2 DM at high risk for cardiovascular events, targeting a systolic blood pressure of less than 120 mm Hg, as compared with less than 140 mm Hg, did not reduce the rate of a composite outcome of fatal and nonfatal major cardiovascular events. The same group have also shown the ineffect of combination lipid therapy in type 2 DM, i.e. combining fibrate with statin therapy. This trial has certainly thrown the cat among the pigeons. Does it change my practice. Not really, I have always bucked the trend recently in that: I have stopped being a fan of combination lipid therapy and accept TRIGS < 5mmol/l; I target a BP < 140/80 mmHg in patients only aiming for a SBP < 130 mmHg in patient with renal disease. The accompanying editorial by Peter Nilsson is a balanced read.

NEXT NEWSLETTER Due out beginning of October 2010 so keep the gossip coming.

Endodiabology February 2010

2010-04-08T12:12:00.000+01:00

ENDODIABOLOGY
Endodiabology.blogspot.com

NORTHEAST
NEWSLETTER
FOR SPRs AND BOSSES TRAPPED
IN THE NORTHERN DEANERY

FEBRUARY 2010
Editors: Shaz Wahid (shahid.wahid@sthct.nhs.uk) and
Petros Perros (petros.perros@ncl.ac.uk) and Arut Vijayaraman (riarut@aol.com )
Associate Editors: Shafie Kamarrudin, Ravi Erukulapati

SpR PLACEMENTS (NTN year of training from 1st October 2008)
• Newcastle- Ravi Erukalapati(5), Sudeep Manohar (3), Nimanth De Alwis (1), Arif Ullah (3), Srikanth Mada(3) Naveen Siddaramaiha (2), Sarah Steven (2)
• North Tyneside/Wansbeck- Anjali Santhakumar (3), Kathryn Stewart (3)
• South Tyneside- Rohanna Wright (2),
• Gateshead- Preeti Rao (3)
• Sunderland- Beas Bhattacharya (5) then Naveen Aggarwal (1), Chandima Idampitiya (5)
• North Tees/Hartlepool- Shafie Kamarrudin (4), Hamza Ali Khan (1)
• Middlesbrough- Freda Razvi (5), Atif Munir (1), Sajid Ethol Kalathil (1), Catherine Napier (1)
• Bishop Auckland Khaled Mansur-Dukhan (5)
• Durham- Jeevan Mettayil (4)
• NGH/QEH- Vacant
• Research with numbers (supervisor)- Eelin Lim(5-Prof Taylor); Stuart Little (2-Dr Shaw) & Asgar Madathil (4-Dr Weaver)

MEETINGS / LECTURES / ANNOUNCEMENTS
• 23rd February 2010 SfE National Clinical Cases meeting, venue TBC. Contact www.endocrinology.org
• 3rd- 5th March 2010 DUK Annual Professional Conference, Liverpool. Contact www.diabetes.org.uk
• 6th March 2010 Association of Physicians, 9am-1pm, Bishop Auckland. Contact clive.kelly@ghnt.nhs.uk
• 15th – 18th March 2010 BES 2010, Manchester. Contact www.endocrinology.org.
• 17th March 2010 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
• 28th April 2010 RCP Acute Medicine symposium, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
• 6th-7th May 2010 ABCD Spring Meeting, The Hilton, GATESHEAD. Contact www.diabetologists.org.uk
• 12th May 2010 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
• 8th June 2010 Northern Endocrine & Diabetes Spring CME, Freeman Hospital. Contact
• 19th – 22nd June 2010 ENDO 2010, San Diego, USA. Contact endostaff@endo-societ.org or www.endo-society.org/scimeetings .
• 25th – 29th June 2010 American Diabetes Association 70th Annual Scientific Sessions, Orlando, Florida, USA. Contact meetings@diabetes.org .
• 14th July 2010 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
• 15th September 2010 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
• 20th – 24th September 2010 46th EASD Annual meeting, Stockholm, Sweden. Contact www.easd.org
• 8th-10th November 2010 Society for Endocrinology Clinical Update, venue TBC. Contact www.endocrinology.org
• 9th November 2010 RCP Updates in Medicine, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
• 17th November 2010 ½ day SpR G(I)M teaching, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
• 18th-19th November 2010 ABCD autumn meeting, London. Contact www.diabetologists.org.uk followed by SpRs meeting 19th-21st November 2010.
• 24th November 2010 Northern Endocrine Region Research and Audit Group annual meeting, Lumley Castle, Durham 2pm-8pm. Contact shahid.wahid@sthct.nhs.uk

TRAINING ISSUES
DIABETES & ENDOCRINOLOGY PIMD WEBSITE Our specialty website is available on http://mypimd.ncl.ac.uk/PIMDDev . Click onto the specialty training tab then follow to Diabetes & Endocrinology. This site is essential reading, especially for ARCP preparation.
SPR management training session: “what works in the NHS and what does not”-David Hambleton. Lumley Castle 6-8pm 24th February 2010. Contact anjalisan@yahoo.com for more information.
ARCP (RITA) The next round was due on Weds 12th, Thurs 13th & Fri 15th May 2010, however due to clashes this may be changed to week beginning 24th May 2010. Trainees please keep these dates free as possible. Those trainees transferring on to the new GIM curriculum will have a separate ARCP on 18th May 2010. More information to follow.
Registering with PMETB It is essential that all new SpRs/StRs (even LATs) register with the PMETB through the newly created Joint Royal Colleges of Physicians Training Board (formally the JCHMT) on www.jrcptb.org.uk. Not doing so means your training is not counted.
Log Book/Portfolio Documentation It is a trainee’s responsibility to make sure their portfolio/log book is prospectively completed and the necessary signatures obtained. Any experience that is not signed off by your educational supervisor at the time cannot be counted towards training. The e-portfolio for DM&ENDO is available now for StRs.
Assessment tools Please see www.jrcptb.org.uk; it is the trainee’s responsibility to give all the appropriate forms to their Educational or Clinical Supervisor. It is the trainee’s responsibility to make sure that the appropriate assessment summaries are available in their portfolio for ARCP purposes, e.g. MSF Summary Form.
Acute Care Assessment Tool The ACAT is a tool that is commendable. It provides a method of assessing how Trainees managed their on-call period. It is recommended that at least one is available for ARCP purposes. It can be downloaded from the JRCPTB website.
Case Based Discussions (CbD) The pilot form is available from the JRCPTB website. It is a must for trainers to use as a tool to document feedback in clinic. This has always been done informally, but now there is a method to formally document it. It can be used for when a SpR presents a new case in clinic.
Documenting CCU and ITU experience It is essential that trainees document their CCU and ITU experience. This is best done by keeping a summary log of the cases seen on CCU and ITU and linking it with reflection or assessment. This should then be signed off by your Educational Supervisor to be of any use at the Acute Medicine PYAs.
Audit Assessment tool This is now available in draft form on the JRCPTB website. Its use is highly recommended.
General Internal Medicine Curriculum is now updated and available on www.jrcptb.org.uk. All trainees appointed ST3 from August 2009 will be offered entry to train for this CCT. Trainees before this date can easily apply to train in this CCT (i.e. dual accredit), again detailed in the website. Reviewing the new curriculum for G(I)M each trainee will need 6 ACATs, 4-CBDs and 4 Mini-CEXs in G(I)M as well as the specialty work based assessments. The publication of this curriculum and the formation of a National SAC in G(I)M separate from the Acute Medicine SAC really does mean that in practical terms the 2 specialties will be split. Our current G(I)M/Acute Medicine STC is preparing for this split this year. It is important that trainees keep a record of all GIM patients they have seen either as emergency or out-patient. There are plans to introduce an audit system.
MRCP Diabetes & Endocrinology This exam has to be completed and passed by all trainees appointed after August 2007 before their PYA. We recommend sitting it ASAP and well before your PYA.
INFORMATION for QA Could each individual trainer send the following to Simon Pearce: educational qualifications, any training positions held and any educational courses attended.
MORE INFORMATION for QA Could each unit’s Training Lead please send to Simon Pearce a completed training unit information report and an updated SpR/StR job description as per Nicky Leech’s e-mail.
Trainers & Trainees meeting The next T&T is on 24th June 2010. Details to be confirmed nearer the time, but please note in your diary.
Training Committee Chair- Simon Pearce, s.h.s.pearce@ncl.ac.uk; Regional Speciality Advisor- Shaz Wahid, shahid.wahid@sthct.nhs.uk; Programme Director- Nicky Leech nicola.leech@nuth.northy.nhs.uk; Consultant member (SAC rep)- Richard Quinton, Richard.Quinton@nuth.nhs.uk; Consultant member-Jean MacLeod, Jean.Macleod@nth.nhs.uk; Consultant member-Arutchelvam Vijayaraman Vijayaraman.Arutchelvam@stees.nhs.uk ; Consultant member-Simon Eaton, simon.eaton@northumbria-healthcare.nhs.uk; SpR representative- Anjali Santhakumar anjalisan@yahoo.com ; SpR representative- Jeevan Mettayil jmjeevan@yahoo.com

NEWS FROM THE NORTHEAST
• Congratulations to Anjali Santhakumar as our new Trainee rep.
• Arut will be remaining on the STC as a Consultant member.
• Congratulations to Ana Jovanovic on her MD.
• Congratulations to Latika Sibal on her PhD, she is currently in a Locum Consultant post at Adenbrookes.
• ABCD is coming to town. Please note that this excellent national meeting will be visiting the region on 6-7th May 2010 at the Hilton in Gateshead. See above.
• In Nov 2009, RQ spent 3 days in November 09 as Elliot B. Shoolman visiting lecturer/professor at the Reproductive Endocrinology Unit of Harvard University/Massachusetts General Hospital. Stayed in Boston with Balasubramanian Ravikumar, former NorthEast trainee, who is now a Research Fellow in that Unit.
• Welcome to Dr SoPye who was started work 21st December 2009 at University Hospital Hartlepool. He trained in Leicester. He is appointed as an Acute Physician with interest in D & E.

LETTERS
Book review-Shaz Wahid: Clinical Leadership-Bridging the Divide by Emma Stanton, Claire Lerner and James Mountford published by Quay Books.
An excellent short book that I regard as essential reading for all trainees and a must for Consultants to dip into. It is written by trainees supported by experienced NHS leaders. Its style of exploring history and putting it into context in the modern NHS reads very well. Its tips on personal development are superb. It focuses on the individual followed by the team followed by the organization and then National strategy. After reading it I am sure everyone would be interested in something they read in it and follow this up with further reading and courses. Reading this book has taught me new tricks and changed my practice. I have often been asked by trainees how do I demonstrate management skills when applying for jobs. Firstly, management skills are really leadership skills. Well on page 94 there is a wonderful template that lists workplace opportunities to develop leadership skills as a postgrad trainee. The broad areas identified are (in brackets I have put personal examples from when I were a lad (SpR)):
-Identifying areas for change (foot care at QEH)
-Rota Management (The Diabetes centre and Freeman hospital clinic rota)
-Department induction (Inducing juniors to the ward)
-Guideline development (glucose Mx in MI at QEH)
-Teaching/education/supervision (final year teaching course at North Tees)
-People and performance management (looking after the yunguns!)
-Attending and contributing to meetings (NEDS CME organizer)
-Operational matters (Associate College Tutor at QEH)
-Service quality and improvements (multiple service delivery audits)
-Identifying key players in the Trust (have sat down with CDs, Execs at Hartlepool)
-Understanding Trust Strategy (LDSAGs, Physicians meetings)
-National Strategy (NRDSAG)

I hope this review has provoked interest and action.

Efficient Clinical Coding- A Means to Improving Costing- Dr.Ravi Erukulapati
What is Clinical Coding?
The translation of medical terminology, as written by the clinician, to describe a patient’s complaint, problem, diagnosis, treatment or reason for seeking medical attention, into a coded format which is nationally and internationally recognised.

Why do we do it?
• Forms the basis of medical research and medical audit
• Population healthcare needs analysis by Health Authorities
• Essential for internal management by directorates
• Vital in examining local and national trends
• Used for research and epidemiology
• Forms the basis of case mix groups and Healthcare Resource Groups (HRG's)
Clinical Coding and Commissioning
The introduction of Payment by Results means that all Trusts in England will use a fixed price tariff for specific treatments. At the heart of these financial flows is coded clinical information. The advent of such tariffs has had an impact on the Primary Care Trusts (PCTs) and others who commission services using coded clinical data. Previously a PCT commissioned health care services without necessarily requiring a full understanding of coded clinical data, its structure, how it is gathered and how the rules and conventions are applied. The coded clinical data is grouped to meet the reporting structure of Payment by Results to ensure the trusts are paid accurately for activity. The increased importance of clinical coded data means that all commissioners of patient services now need to comprehend clinical coded data to be able to understand what they are commissioning and what the providers are saying they are delivering. Without this understanding various ‘hot topics’ related to clinical coding can arise which can result in misunderstandings between provider and commissioner. The NHS requires input of accurate data to reflect clinical activity and trusts now have a financial incentive to ensure that coding is accurate, comprehensive and timely.
How is Clinical Coding derived? The source documentation used for coding varies from hospital to hospital, but is normally the patient’s case notes.

The case notes hold:
• Discharge summaries
• Proformas
• Clinical work sheets
• Hospital, patient and GP documentation

The coding process
Patient admitted to hospital.
↓
Patient discharged following treatment.
↓
Information extracted from case notes and translated into coded format using Classifications (ICD-10 and OPCS-4)
↓
Coded information recorded on hospital’s Patient Administration System (PAS), with copy of Coding placed in case notes for doctor to verify or query.

How clinicians can help coders to achieve complete and accurate clinical coding
• Ask to meet the Clinical Coders and assist them when there is a query about a diagnosis or procedure
• Ensure that the discharge summary is complete at discharge
• Follow the guidelines when completing the Discharge summary

How is the information in case notes translated into Codes?
For Example:
Patient admitted with a closed fracture left distal radius after falling from a chair at home. The patient is a non-insulin diabetic and suffers from chronic ischaemic heart disease. Patient’s fracture treated with manipulation and skeletal traction.

The coding screen on the Trust’s Patient Administration System
(PAS) will contain the following:
DIAGNOSES:
S52.50 Fracture lower end radius, closed
W07.0 Fall involving chair, home
E11.9 Non-insulin dependant diabetes mellitus
I25.9 Chronic ischaemic heart disease

PROCEDURE:
W26.1 Manipulation of fracture of bone and skeletal traction
Z70.5 Lower end of radius
Z94.3 Left sided operation

Recording vague diagnoses
• Use of Probable vs. Possible
• Clinical coding can only be as accurate as the information that clinicians record in the patient case notes.
• If clinician records diagnoses as follows:
This patient has Chest Pain ? Angina
Then the clinical coder will only code the Chest Pain/not the Angina
• If clinician records Possible MI then the clinical coder will only code the patient’s symptoms, not the MI.
• However, if clinician records Probable MI then the clinical coder will code the MI

References and further reading
1.) Improving clinical records and clinical coding together - A project with the Audit Commission, Royal College of Physicians, August 2008, www.audit-commission.gov.uk
2.) Frequently Asked Question - Telephone Activity — NHS Connecting for Health http://www.connectingforhealth.nhs.uk/systemsandservices/data/nhsdmds/help/faqs
3.) http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/noncoders/clinicians
4.) http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/noncoders/commissioners
5.) http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/noncoders
6.) Hospital Activity Data, A Guide for Clinicians, Produced by the RCP Information Laboratory (lab)

Maximising Efficiency the “Lean” Way M S Kamaruddin
In the current economic climate, the National Heath Service (NHS) will undoubtedly face challenging times especially when massive budget cuts to the NHS is anticipated. How do we rise to this challenge without compromising quality of care? In line with the recently published NHS Operating Framework for 2010/11, it emphasises the need to maintain high quality of care despite a tighter economic climate through a process that focuses on quality, innovation, productivity and prevention.1
This reminds me of how the automotive industry revolutionised their manufacturing principles by eliminating waste. This concept have been widely adopted and practiced in the manufacturing sector and is also increasingly used in health care. Lean is a term adopted from Japanese manufacturing principles defining a philosophy that abhors waste in any form and relentlessly strives to improve quality. Waste is defined as any action that does not add value to the product; in health care terms this should be the patient experience.2 The Lean concept also empowers its staff and provide them with the tools to make changes. In the context of health care, doctors and other allied health care professionals become focused not only on taking care of the patient, but also on finding better ways to take better care of patients. They are in a position to do so as frontline staff has better insight to the task at hand.

The Lean approach in improving efficiency is first done by studying every step of the process that is being evaluated. To site an example that have been tried and tested successfully in a local hospital in North East recently is the process of a patient attending the endoscopy unit. The whole patient experience and journey from arrival to leaving the unit was evaluated at every step i.e. from arrival in the waiting room to nursing documentation, consent and right down to the procedure itself and discharge. The time line for each step is quantified into value added and non-value added (waste) steps. The team will then identify which step adds value to the patient experience and which step incurs unnecessary cost and resources.
In this case (figure 1) the unnecessary nursing documentation of details, which are often irrelevant, could be eliminated. Essential patient details such as drug allergy can be obtained during consent. The patient waiting time could also be minimized to improve patient experience. The additional nursing staff originally used for documentation could be mobilised to the discharge or recovery area. In essence the reduction of 12 minutes per case could essentially accommodate additional procedures for the session hence increasing productivity without compromising patient care.

Figure 1. Flow of patient movement through the endoscopy unit before & after application of Lean principles.

This principle could easily be applied to a typical busy acute medical admission setting. A patient typically goes through repetitive steps right from beginning in accident & emergency only to be repeated again in the medical admission unit. With careful planning much time could be saved and the patient journey could be improved upon.
References:
1. Department of Health. Guidance; The NHS operating framework for England for 2010/11. 16th December 2009
2. Eric W. Dickson, et al. Application of Lean Manufacturing Techniques in the Emergency Department.

RECENT PUBLICATIONS FROM THE NORTHEAST
1. Raivio T, Sidis Y, Plummer L, Chen H, Ma J, Mukherjee A, Jacobson-Dickman E, Quinton R, Van Vliet G, Lavoie H, Hughes VA, Dwyer AA, Hayes FJ, Xu S, Sparks S, Kaiser UB, Mohammadi M, Pitteloud N. 2009 Impaired fibroblast growth factor receptor 1 signaling as a cause of normosmic idiopathic hypogonadotropic hypogonadism. Journal of Clinical Endocrinology & Metabolism. 94: 4380-4390.

2. Hill S, Arutchelvan V, Quinton R. 2009 Enclomiphene, an estrogen receptor antagonist for the treatment of testosterone deficiency in men. Idrugs. 12: 109-119.

3. Syed AA, Jones NAG, Bliss R, Roberts T, Mallick U, Johnson S, Douglas F, Perros P, Quinton R. 2009 Metachronous testicular teratoma, testicular seminoma and papillary thyroid carcinoma occurring in a single individual: a report of two unrelated cases. European Journal of Cancer Care. Nov 11. [Epub ahead of print].

4. Gan EH, Wahid ST, Quinton R. 2009 Hypercalcaemia: two myths. BMJ. 339: b5649.

5. Quinton R. 2009 The story of Axel Munthe. Clinical Medicine. 9: 504-505.

6. Shakoor SK, Aldibbiat A, Ingoe LE, Campbell SC, Sibal L, Shaw J, et al. Endothelial Progenitor Cells in Subclinical Hypothyroidism: The Effect of Thyroid Hormone Replacement Therapy. J Clin Endocrinol Metab 2009.

7. Ramchurn N, Mashamba C, Leitch E, Arutchelvam V, Narayanan K, Weaver J, et al. Upper limb musculoskeletal abnormalities and poor metabolic control in diabetes. Eur J Intern Med 2009;20(7):718-21.

8. Cooke D, Hurel SJ, Casbard A, Steed L, Walker S, Meredith S, et al. Randomized controlled trial to assess the impact of continuous glucose monitoring on HbA(1c) in insulin-treated diabetes (MITRE Study). Diabet Med 2009;26(5):540-7.

9. Sibal L, Aldibbiat A, Agarwal SC, Mitchell G, Oates C, Razvi S, et al. Circulating endothelial progenitor cells, endothelial function, carotid intima-media thickness and circulating markers of endothelial dysfunction in people with type 1 diabetes without macrovascular disease or microalbuminuria. Diabetologia 2009;52(8):1464-73.

10. V Arutchelvam, T Heise, S Dellweg, B Elbroend, I Minns and PD Home. Plasma glucose and hypoglycaemia following exercise in people with Type 1 diabetes: a comparison of three basal insulins. Diabetic medicine 2009:26; 1027-1032.

RECENT PUBLICATIONS IN DIABETES & ENDOCRINOLOGY THAT HIT THE NEWS OR THAT MAY HAVE A SIGNIFICANT IMPACT ON MANAGEMENT
Hyperkalaemia. Moffat et al. BMJ 2009;339:1019-1024. An excellent practical review. Well worth a read.
Is haemoglobin A1c a step forward for diagnosing diabetes? Eric Kilpatrick et al. BMJ 2009;339:1288-1290. A must read review. My personal answer, NO but it does have a role. Example 75-yr old with 2 fasting glucoses of 7.0 and 6.9 mmol/l AND a HbA1c of 59 mmol/mol probably does have diabetes, hence saving an OGTT.
Aspirin for primary prevention of vascular disease in people with diabetes. Balance of benefits versus risks is unclear. Richard Haynes et al. BMJ 2009;339:1210-1211. A good editorial with the linked meta-analysis worth a read.
Metformin associated lactic acidosis. Emma Fitzgerald et al. BMJ 2009;339:1254-1256. A timely reminder case report that includes a wonderful diagrame explaining the phenomenon biochemically.
Surgery for obesity in adulthood. Daniel Richard Leff and Dugal Heath. BMJ 2009;339:740-746. An excellent review and update.
Sarcoidosis. Owen J Dempsey et al. BMJ 2009;339:620-625. An excellent review that is practical.
Osteoporosis associated with neutralizing autoantibodies against osteoprotegerin. Philip Riches et al. NEJM 2009;361:1459-1465. An interesting case report.
Renal-artery stenosis. Lance Dworkin and Christopher Cooper. NEJM 2009;361:1972-1978. A wonderful review article. Practical and useful for diabetic renal clinic.
Pre-eclampsia, soluble fms-like tyrosine kinase 1, and the risk of reduced thyroid function: nested case-control and population based study. Levine RJ, et al. BMJ. 2009 Nov 17;339:b4336. This Nested case-control study during pregnancy and population based follow-up study after pregnancy as part of the Calcium for Pre-eclampsia Prevention trial of healthy pregnant nulliparous women in the United States during 1992-5 and a Norwegian population based study(Nord-Trondelag Health Study or HUNT-2) during 1995-7 with linkage to the medical birth registry of Norway, studied serum measurements of in 141 women before 21 weeks' gestation(baseline) and after onset of pre-eclampsia (before delivery); 141 normotensive controls with serum measurements at similar gestational ages, and 7121 women in the Nord-Trondelag Health Study whose first birth had occurred in 1967 or later and in whom serum levels of TSH had been subsequently measured. The main outcome measures were: thyroid function tests and human chorionic gonadotrophin and soluble fms-like tyrosine kinase 1 concentrations in the Calcium for Pre-eclampsia Prevention cohort and odds ratios for levels of TSH above the reference range, according to pre-eclampsia status in singleton pregnancies before the Nord-Trondelag Health Study. In predelivery specimens of the Calcium for Pre-eclampsia Prevention cohort after the onset of pre-eclampsia, TSH levels increased 2.42 times above baseline compared with a 1.48 times increase in controls. The ratio of the predelivery to baseline ratio of cases to that of the controls was 1.64 [95%CI 1.29-2.08]. Free T3 decreased more in the women with pre-eclampsia than in the controls (case ratio to control ratio 0.96[0.92-0.99]. The predelivery specimens but not baseline samples from women with pre-eclampsia were more likely than those from controls to have TSH levels above the reference range (adjusted odds ratio 2.2[1.1-4.4]. Both in women who developed pre-eclampsia and in normotensive controls the increase in TSH concentration between baseline and predelivery specimens was strongly associated with increasing quarters of predelivery soluble fms-like tyrosine kinase 1 (P for trend 0.002 and <0.001, respectively). In the Nord-Trondelag Health Study, women with a history of pre-eclampsia in their first pregnancy were more likely than other women(adjusted odds ratio 1.7[1.1-2.2] to have TSH levels above the reference range. In particular, they were more likely to have high concentrations of TSH without thyroid peroxidase antibodies (adjusted odds ratio 2.6[1.3-5.0], suggesting hypothyroidism in the absence of an autoimmune process. This association was especially strong (5.8[1.3-25.5] if pre-eclampsia had occurred in both the first and the secondpregnancies. This study suggests that increased serum concentration of soluble fms-like tyrosine kinase 1 during pre-eclampsia is associated with subclinical hypothyroidism during pregnancy. Pre-eclampsia may also predispose to reduced thyroid function in later years. Should we screen all women with pre-eclampsia for hypothyroidism?
Three-year efficacy of complex insulin regimens in type 2 diabetes. Holman RR, et al. N Engl J Med. 2009 Oct 29;361(18):1736-47. In this 3-year open-label, multicentre trial 708 patients who had suboptimal glycaemic control while taking metformin and sulfonylurea therapy were randomly assigned to receive biphasic insulin aspart twice daily, prandial insulin aspart three times daily, or basal insulin detemir once daily (twice if required). Sulfonylurea therapy was replaced by a second type of insulin if hyperglycaemia became unacceptable during the first year of the study or subsequently if HbA1c more than 6.5%. The median HbA1c levels were similar for patients receiving biphasic (7.1%), prandial (6.8%), and basal (6.9%) insulin-based regimens (P=0.28). However, fewer patients had a level of 6.5% or less in the biphasic group (31.9%) than in the prandial group (44.7%, P=0.006) or in the basal group (43.2%, P=0.03), with 67.7%, 73.6%, and 81.6%, respectively, taking a second type of insulin (P=0.002). Median rates of hypoglycemia per patient per year were lowest in the basal group (1.7), higher in the biphasic group (3.0), and highest in the prandial group (5.7) (P<0.001 for the overall comparison). The mean weight gain was higher in the prandial group than in either the biphasic group or the basal group. Other adverse event rates were similar in the three groups. In conclusion it can be said that patients who added a basal or prandial insulin-based regimen to oral therapy had better glycaemic control than patients who added a biphasic insulin-based regimen. Fewer hypoglycemic episodes and less weight gain occurred in patients adding basal insulin. However, 68-82% of patients in the trial received an additional type of insulin to achieve a median HbA1c < 6.9%. Hence, in effect most patients were on “complex” insulin regimens regardless of their starting point. Does this study change my practice? No, it simply reaffirms my belief that we should aggressively lower HbA1c in patients with Type 2 diabetes to a target of < 53mmol/mol (7%) using the regimen that best suits the patients lifestyle and individual circumstances. Trying to introduce an algorithm that can be used as a one glove fits all may pamper towards pharmacia and government drive agendas, but ultimately what is required is an experienced MDT that can manage the circumstances of any individual regardless of affiliation.

NEXT NEWSLETTER Due out beginning of June 2010 so keep the gossip coming.

Endodiabology October 2009

2009-09-27T20:10:00.002+01:00

ENDODIABOLOGY
Endodiabology.blogspot.com

NORTHEAST NEWSLETTER FOR SPRs AND BOSSES TRAPPED
IN THE NORTHERN DEANERY

OCTOBER 2009

Editors: Shaz Wahid, Petros Perros, Arut Vijayaraman

Associate Editors: Shafie Kamarrudin, Ravi Erukulapati

SpR PLACEMENTS (NTN year of training from 1st October 2008)
• Newcastle- Ravi Erukalapati(5), Sudeep Manohar (3), Nimanth De Alwis (1), Arif Ullah (3), Srikanth Mada(3) Naveen Siddaramaiha (2), Sarah Steven (2)
• North Tyneside/Wansbeck- Anjali Santhakumar (3), Kathryn Stewart (3)
• South Tyneside- Rohanna Wright (2),
• Gateshead- Preeti Rao (3)
• Sunderland- Beas Bhattacharya (5) then Naveen Aggarwal (1), Chandima Idampitiya (5)
• North Tees/Hartlepool- Shafie Kamarrudin (4), Hamza Ali Khan (1)
• Middlesbrough- Freda Razvi (5), Dr Munir (1), Sajid Ethol Kalathil (1), Catherine Napier (1)
• Carlisle-
• Bishop Auckland Khaled Mansur-Dukhan (5)
• Durham- Jeevan Mettayil (4)
• NGH/QEH- Vacant
• Research with numbers (supervisor)- Eelin Lim(5-Prof Taylor); Stuart Little (2-Dr Shaw) & Asgar Madathil (4-Dr Weaver)

MEETINGS / LECTURES / ANNOUNCEMENTS
• 12th October 2009 Northern Endocrine & Diabetes Autumn CME, JCUH, Middlesbrough
• 23rd October 2009 Diabetic Foot Teaching day-for medical and surgical trainees. Freeman Hospital
• 31st October 2009 Association of Physicians, Darlington Memorial Hospital.
• 2nd-4th November 2009 Society for Endocrinology Clinical Update 2009, Manchester. Contact www.endocrinology.org
• 2nd November 2009 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
• 3rd November 2009 RCPL Medicine Update, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
• 11th November 2009 North East Obesity Forum, 1600-1830, Newcastle University. Contact
• 19th November 2009 1st Joint Meeting of The British Thyroid Association and British Association Of Endocrine and Thyroid Surgeons, St Thomas Hospital. Contact www.british-thyroid-association.org
• 19th-20th November 2009 ABCD autumn meeting, London. Contact www.diabetologists.org.uk followed by SpRs meeting 21-22nd November 2009.
• 25th November 2009 Northern Endocrine Region Research and Audit Group annual meeting, Lumley Castle, Durham 2pm-8pm. Contact
• 26th & 27th November 2009 Middlesbrough insulin pump course. Contact
• 4th December 2009 Society for Endocrinology regional cases meeting, Edinburgh. Contact www.endocrinology.org
• 26th January 2010 Northern Endocrine & Diabetes Winter CME, Freeman Hospital. Contact
• 26th January 2010 Diabetes-A Hospital Perspective, RCPL. Contact conferences@rcp.ac.uk
• 23rd February 2010 SfE National Clinical Cases meeting, venue TBC. Contact www.endocrinology.org
• 3rd- 5th March 2010 DUK Annual Professional Conference, Liverpool. Contact www.diabetes.org.uk
• 15th – 18th March 2010 BES 2010, Manchester. Contact www.endocrinology.org.
• 28th April 2010 RCP Acute Medicine symposium, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
• 6th-7th May 2010 ABCD Spring Meeting, The Hilton, GATESHEAD. Contact www.diabetologists.org.uk
• 8th June 2010 Northern Endocrine & Diabetes Spring CME, Freeman Hospital. Contact mshafie_kamaruddin@yahoo.co.uk
• 19th – 22nd June 2010 ENDO 2010, San Diego, USA. Contact endostaff@endo-societ.org or www.endo-society.org/scimeetings .
• 25th – 29th June 2010 American Diabetes Association 70th Annual Scientific Sessions, Orlando, Florida, USA. Contact meetings@diabetes.org .

TRAINING ISSUES
DIABETES & ENDOCRINOLOGY PIMD WEBSITE Our specialty website is available on http://mypimd.ncl.ac.uk/PIMDDev . Click onto the specialty training tab then follow to Diabetes & Endocrinology. This site is essential reading, especially for ARCP preparation.
A new Trainee Rep With Arut now having his CCT AND Consultant post an opportunity for a new trainee rep has arisen on the STC. SEE OUR TPDs REGULAR LETTER BELOW.
A novel training opportunity Any one interested in working towards a diploma or MSc in Public Health? If yes, SEE OUR TPDs REGULAR LETTER BELOW.
More Consultant members If you would like to be involved with the STC please do contact Nicky Leech ASAP.
ARCP (RITA) The next round is due on Weds 12th, Thurs 13th & Fri 15th May 2010. Trainees please keep these dates free as possible.
Registering with PMETB It is essential that all new SpRs/StRs (even LATs) register with the PMETB through the newly created Joint Royal Colleges of Physicians Training Board (formally the JCHMT) on www.jrcptb.org.uk. Not doing so means your training is not counted.
Log Book/Portfolio Documentation It is a trainee’s responsibility to make sure their portfolio/log book is prospectively completed and the necessary signatures obtained. Any experience that is not signed off by your educational supervisor at the time cannot be counted towards training. The e-portfolio for DM&ENDO is available now for StRs.
Assessment tools Please see www.jrcptb.org.uk; it is the trainee’s responsibility to give all the appropriate forms to their Educational or Clinical Supervisor. It is the trainee’s responsibility to make sure that the appropriate assessment summaries are available in their portfolio for ARCP purposes, e.g. MSF Summary Form.
Acute Care Assessment Tool The ACAT is a tool that is commendable. It provides a method of assessing how Trainees managed their on-call period. It is recommended that at least one is available for ARCP purposes. It can be downloaded from the JRCPTB website.
Case Based Discussions (CbD) The pilot form is available from the JRCPTB website. It is a must for trainers to use as a tool to document feedback in clinic. This has always been done informally, but now there is a method to formally document it. It can be used for when a SpR presents a new case in clinic.
Documenting CCU and ITU experience It is essential that trainees document their CCU and ITU experience. This is best done by keeping a summary log of the cases seen on CCU and ITU and linking it with reflection or assessment. This should then be signed off by your Educational Supervisor to be of any use at the Acute Medicine PYAs.
Audit Assessment tool This is now available in draft form on the JRCPTB website. Its use is highly recommended.
General Internal Medicine Curriculum is now updated and available on www.jrcptb.org.uk. All trainees appointed ST3 from August 2009 will be offered entry to train for this CCT. Trainees before this date can easily apply to train in this CCT (i.e. dual accredit), again detailed in the website. Reviewing the new curriculum for G(I)M each trainee will need 6 ACATs, 4-CBDs and 4 Mini-CEXs in G(I)M as well as the specialty work based assessments. The publication of this curriculum and the formation of a National SAC in G(I)M separate from the Acute Medicine SAC really does mean that in practical terms the 2 specialties will be split entirely in 5-10 yrs. Our current G(I)M/Acute Medicine STC is preparing for this split, but will continue to have a dual function up to the point when there are enough Acute Medicine trained Physicians in the region to allow the formation of 2 different STCs. What this space.......................................................................................
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.
Personal Development Plans Each trainee should use their ARCP/RITA report to construct a PDP and discuss with their Educational Supervisor. A copy of the PDP should be sent to Nicky Leech by 26th Nov 2009.
INFORMATION for QA Could each individual trainer send the following to Simon Pearce: educational qualifications, any training positions held and any educational courses attended.
MORE INFORMATION for QA Could each unit’s Training Lead please send to Simon Pearce a completed training unit information report and an updated SpR/StR job description as per Nicky Leech’s e-mail.
Trainers & Trainees meeting The next T&T is on 24th June 2010. Details to be confirmed nearer the time, but please note in your diary.
Training Committee Chair- Simon Pearce,; Regional Speciality Advisor- Shaz Wahid; Programme Director- Nicky Leech Consultant member (SAC rep)- Richard Quinton, Consultant member-Jean MacLeod,; Consultant member-Vacant; Consultant member-Simon Eaton,; SpR representative- Vacant; SpR representative- Jeevan Mettayil

NEWS FROM THE NORTHEAST
• Congratulations to Arut on appointment to a Consultant post at James Cook University Hospital in Diabetes&Endo. He already has his feet under the table.
• Congratulations to Jeevan Mettayil on being appointed the Regional Rep for the Young Diabetologists Forum.
• Congratulations to Ravi on his PhD “Postprandial metabolism in health and type 2 diabetes”.
• ABCD is coming to town. Please note that this excellent national meeting will be visiting the region on 6-7th May 2010 at the Hilton in Gateshead. See above.
• Simon Pearce is the new Chair of the STC.
• Keep an eye out for the annual RCP Acute Medicine Symposium on 28th April 2010 at FRH. Yours truly will be presenting with the title “Sugar and Hormones in the Acute Unit”.
• There are a number of new trainees on the scene, welcome to you all: Catherine Napier, Hamza Ali Khan, Naveen Aggarwal, Munir, Sajid Ethol Kalathil, Nimanth De Alwis. Please excuse, any spelling errors. The “drums” are not quite that accurate just yet.
• Congratulation s to Rohana Wright on her recent marriage.

LETTERS

The 8th Habit-From Effectiveness to Greatness-Shaz Wahid
I did warn you I would be writing about this and this is not at all about becoming a megalomaniac! This excellent book by Stephen Covey is a must read once you have read about the 7 habits of effectiveness and more importantly after practicing them for at least 1 year. It is all about finding your own voice and then helping others to find their voice. I have found the principles of the 8th habit very useful in my professional activities of late. I have been involved in a major change project within the Trust. As ever such a project has resulted in much angst, frustration and confrontation. I clearly found my voice in relation to this major project a long time ago and based it on sound principles of quality patient care, safe patient care, cost-effective patient care and quality training all rolled into a MISSION STATEMENT in the form of a VISSION. My organization is aligned towards this vision and the task of getting others aligned towards this vision has begun with everyone accepting the VISSION. The challenge is keeping everyone aligned towards the vision along the curvy path. This is best done by helping others to find their voice in relation to the vision and helping the alignment towards it. I have deliberately kept this description general. Those of you who know me have probably worked out this is about my activities around shaping emergency care at South Tyneside. However, I am also using the same principles in reshaping Diabetes care in the District in negotiations with the commissioners. Once you have got to grips with the 7-habits the 8th habit is a must do.

The dark side-Shaz Wahid
I think I shocked Petros when I met him at the RITAs and let it slip I will be going towards management! I have grown up with a healthy dollop of mistrust when it comes to the management. So what has changed my mind. Well it has all got to do with instituting change. Knowing the workings within my Trust has helped me institute change, although some would say or get what I want or Empire Build. But, to truly effect change and help others in contributing to change I need to be a in a position of influence. So the first steps have started with:
-getting onto the Executive Board as Clinical Lead for the Emergency Care Pathway
-getting onto and actively participating in governance groups such as the Clinical Incident Review Group and Mortality Review Group
-plans to attend a conference titled “Effective Clinical Director”, covering areas such as revalidation, measuring & monitoring clinical outcomes and PROMs, lean thinking, quality metrics and managing poor performance & dealing with difficult Drs
-Subscribing to the Health Service Journal
-Joining the British Association of Medical Managers (BAMM)
They are all first steps and I guess watch this space……………….. Although, it is important to have an escape route otherwise the trap door looms large. This route is the full retirement of an Everton supporter in 2011! For more information visit bamm.co.uk and for you yunguns, here is a plug for BAMMbino:

In recent years, it has become increasingly apparent that the medical profession needs to develop high quality leadership and management skills in order to effectively participate in the great healthcare debate. Work by the Royal Colleges, NHS Institute for Innovation and Improvement and BAMM has called for these skills to be nurtured from an early stage in doctor's careers, but there is little support and advice for those who wish to be the Clinical Directors, Medical Directors and Chief Medical Officers of the future.
At BAMMbino, we intend to create a living network of enthusiastic Junior Doctors who see medical management and leadership as an intrinsic part of their future careers. By acting as a portal for information, advice and support we will be building on the ethos of BAMM to help create a new generation of doctors who will be able to work proactively in and with the ever-changing healthcare environment.
Our intention is to deliver a service that will guide our members through the latest hot topics, encourage their own attempts to improve services for patients, and help mentor them through the ups and downs of their individual careers.
If you are a keen medical student, F1, F2, SHO or SpR who shows an interest in the ‘bigger picture' then let us know by sending their details to BAMMbino@bamm.co.uk and we will try to make their journey a little smoother than those who have gone before.
GOSSIP FROM THE TPD-Nicky Leech
Congratulations to Arut Arutchelvum on his appointment as a consultant at James Cook University Hospital. This leaves a vacancy for an SPR on the Specialist training committee. This is a position of great responsibility representing the views and needs of Diabetes & Endocrinology trainees across the NE, working with consultant members of the committee to continue to develop training in the NE Deanery. Application is by e-mail . You need to submit a 300 word maximum answer on the question ---

What recommendation would you make to the STC regarding developing the training programme to better prepare trainees for Consultanthood?

Application should be sent by e-mail to me on .. Nicola.leech@nuth.nhs.uk

Closing date: October 30th 2009. The entries will be judged and scored by the STC and the results announced at NEERAG on 18th November 2009.
Also…
I am interested in hearing from any trainees interested in training in and working towards a diploma or MSc in public Health. We have an opportunity to secure funding and supervision through “Darzi” Money for part-time training in public Health. It may be possible to combine this with clinical diabetes but the details of the job may be customised around the wishes and needs of the applicant . Therefore anyone interested at this stage should contact me personally and I will discuss it further with them.

Summer Camp for Kids with Diabetes at Marrick Priory-A Santhakumar
Attending the paediatric diabetes outpatient clinics at James Cook University hospital I got the wonderful opportunity to be a part of their annual kids camp at Marrick Priory and wish to share my experience. Set in the scenic Yorkshire Dales , the Marrick Priory has been hosting this immensely popular children’s camp for years. The enthusiasm of the children and their parents at the diabetes outpatient clinics led me to sign up as part observer/counsellor at this year’s activities camp for children with diabetes. The summer camp had 30-35 kids aged between 9-13 years and for some of them it was the first time away from their parents. The camp staff and counsellors included the camp warden, senior and junior medical officers, diabetes nurses, dieticians, psychologists and junior leaders who had diabetes themselves.

I arrived at the camp early Friday morning to find children being lined up into 4 groups. My group had 8 children and as counsellors the group had a senior paediatrician, a paediatric registrar, an adult diabetes registrar (yours truly) and a dietician. At the camp the staff to kids ratio was maintained at around 1:2 and there was close supervision during all sports and outings. To ensure safety and optimal diabetes management, multiple blood glucose determinations were made throughout each 24-h period
Attempts were made to follow the home insulin regimen of each camper as closely as possible. However, most camps have found it advisable to decrease the home insulin dosage by 10–20% (or more) on arrival at camp, especially in those children under good control who were not active before the camp session.
The day was jam packed with activities like kayaking, archery, rock climbing and obstacle courses to name just a few. The enthusiasm and the excitement of the kids were infectious and we had to remind ourselves that all these kids had type 1 diabetes and could potentially have a hypoglycaemic episode atop a tree or in a kayak!

Meal times provided an excellent opportunity to educate and encourage children about insulin adjustments and carbohydrate counting. Many of the kids gave their first independent insulin shots at the camp. The camp also provided these youngsters an opportunity to help out younger campers and learn to be responsible. Using the active camping environment as a teaching opportunity was an extremely useful way for children with diabetes to gain skills in managing their disease within the supportive camp community. It was all about having a positive experience learning how to manage their diabetes. In fact most of the kids who attend these camps frequently return and often volunteer as counsellors themselves which is indicative of how much they value their time spent in these camps.

On the whole (apart from a terrifying personal moment during a free fall exercise!) it was a thoroughly enjoyable and an extremely enriching experience for me. It gave me a whole new perspective on management of diabetes in the young and I would recommend my fellow registrars to try and attend a similar camp at least once .

What these camps offer the kids
• Diabetes camp is one of the best experiences that a child with diabetes can have. It is a place where the norm is to have diabetes and they no longer feel ‘different’.
• A fun and safe camping experience. Many will meet new friends with whom they will keep in touch for years to come.
• An emphasis on achieving good control of diabetes while adjusting to daily activities.
• Opportunity to develop self confidence and independently manage their diabetes.
• Diabetes education in an informal setting.
• It is an opportunity to gain independence from mom and dad, to be with other kids with diabetes, and simply to have a great time.
• It's also an excellent opportunity for mom and dad to take a break from diabetes!
What the camps can offer us
• Fun practical experience in insulin management during exercise.
• Insight and a whole new perspective into what it means to live with diabetes.
• Opportunity to educate in an informal environment far removed from the clinic setting and to be creative when imparting skills and knowledge!
• Understand the pathos that comes from being responsible for a young person with diabetes.
• Amazing eye opener in how quickly kids grasp new knowledge, accept change and just get on with it!
• Useful tips to incorporate informal teaching techniques in the management of young people in the adult diabetes service.
Diabetes UK has been organizing holidays for children since 1930s with about 500 kids participating each year. Details about similar camps in our region is available on their website. http://www.diabetes.org.uk/Professionals/Resources-for-patients/Care-events/
The Firbush Project, run by Perth Royal Infirmary provides a similar annual adventure camp for 16-21 year olds on Loch Tay. Details are available on NHS Tayside website http://www.diabetes-healthnet.ac.uk/HandBook/DiabetesAndTeenagers.aspx

RECENT PUBLICATIONS FROM THE NORTHEAST
1. Kamaruddin MS, Quinton R, Leech N. 2009 Inpatient diabetes care: first do no harm? Clinical Services Journal. 6: 37-40.
2. Arun CS, Al-Bermani A, Stannard KS, Taylor R. Long term impact of retinal screening upon significant diabetes related visual impairment in the working age population. Diabetic Medicine 26:489-492, 2009.
3. Jovanovic A, Leverton E, Solanky B, Snaar JEM, Morris PEG, Taylor R. The second meal phenomenon is associated with enhanced muscle glycogen storage. Clin Sci 117:119–127, 2009.
4. Al-Ozairi E, Waugh JJS, Taylor R. Termination is not the treatment of choice for severe hyperemesis gravidarum: Successful management using prednisolone. Obstetric Medicine 2: 34-37, 2009.
5. Lim EL, Burden T, Marshall SM, Davison JM, Blott MJ, Waugh JJS, Taylor R. Intrauterine Growth Rates in Pregnancies Complicated by Type 1, Type 2 and Gestational Diabetes. Obstetric Medicine 2: 21-25, 2009.
6. Jovanovic A, Gerrard J, Taylor R. The second meal phenomenon in type 2 diabetes. Diabetes Care 32:1199-1201, 2009.
7. L. Sibal, A. Aldibbiat, S. C. Agarwal, G. Mitchell, C. Oates, S. Razvi, J. U. Weaver, J. A. Shaw and P. D. Home. Circulating endothelial progenitor cells, endothelial function, carotid intima–media thickness and circulating markers of endothelial dysfunction in people with type 1 diabetes without macrovascular disease or microalbuminuria. Editors choice August 09 Diabetologia www.diabetologia-journal.org
8. Wright R J, Frier B M, Deary I J. Effects of acute insulin-induced hypoglycemia on spatial abilities in adults with type 1 diabetes. Diabetes Care 2009; 32: 1503-1506.

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

Denosumab in men receiving androgen-deprivation therapy for prostate cancer. Smith MR, Egerdie B, Hernández Toriz N et al N Engl J Med. 2009 Aug 20;361(8):745-55. Androgen-deprivation therapy is well-established for treating The authors investigated the effects of denosumab, a fully human monoclonal antibody against receptor activator of nuclear factor-kappaB ligand (RANKL) that blocks its effect on the RANK receptor reducing osteoclast activity and hence bone resorption with an intendent increase in bone mineral density, on bone mineral density and fractures in men receiving androgen-deprivation therapy (which increases fracture risk) for nonmetastatic prostate cancer. 734 patients were randomized to receive denosumab 60 mg subcutaneously every 6 months and 734 patients received placebo . The primary end point was percent change in bone mineral density at the lumbar spine at 24 months and secondary end points included percent change in bone mineral densities at the femoral neck and total hip at 24 months and at all three sites at 36 months, as well as incidence of new vertebral fractures. At 24 months, lumbar spine BMD increased by 5.6% in the denosumab group as compared with a loss of 1.0% in the placebo group (P<0.001); Denosumab therapy was also associated with significant increases in BMD at the total hip, femoral neck, and distal third of the radius at all time points. Denosumab reduced the incidence of new vertebral fractures at 36 months by 62% (1.5%, vs. 3.9% with placebo; relative risk, 0.38; 95%CI 0.19 to 0.78; p=0.006). Rates of adverse events were similar between the two groups. In this trial Denosumab was associated with increased bone mineral density at all sites and a reduction in the incidence of new vertebral fractures.

Denosumab for prevention of fractures in postmenopausal women with osteoporosis. Cummings SR, San Martin J, McClung MR N Engl J Med. 2009 Aug 20;361(8):756-65. The investigators enrolled 7868 women between the ages of 60 and 90 years with a BMD T score of < -2.5 but not <-4.0 at the lumbar spine or total hip and randomly assigned them to receive either 60 mg of denosumab or placebo subcutaneously every 6 months for 36 months. The primary end point was new vertebral fracture with secondary end points of nonvertebral and hip fractures. Compared to placebo denosumab reduced the risk of new radiographic vertebral fracture by 68% (cumulative incidence of 2.3% vs 7.2%; risk ratio, 0.32: 95%CI 0.26-0.41; p<0.001). Denosumab reduced the risk of hip fracture by 40% (cumulative incidence of 0.7% vs 1.2%; hazard ratio, 0.60: 95% CI, 0.37-0.97; p=0.04). Denosumab also reduced the risk of nonvertebral fracture by 20% (cumulative incidence of 6.5% vs 8.0%; hazard ratio, 0.80: 95% CI, 0.67-0.95; p=0.01). There was no increase in the risk of cancer, infection, cardiovascular disease, delayed fracture healing, or hypocalcaemia, and there were no cases of osteonecrosis of the jaw and no adverse reactions to the injection of denosumab. The above two trials clearly demonstrate the effectiveness of targeting RANKL to treat osteoporoses in both men and women. Denosumab is an exciting new tool for treating osteoporoses. The accompanying editorial by Sundeep Khosla (NEJM 2009;361:818-820) is well worth a read. The challenge now is construct cost effective pathways for utilising the therapies available for osteoporoses.

Recent developments in hyperthyroidism. Julia Kharlip and David S Cooper. Lancet 2009;373:1930-1932. A reasonable editorial that will point you to the true goodies to read.

Eradication of insulin resistance. Imai J, et al. Lancet 2009;374:264. An excellent case report.

Hyperparathyroidism. William D Fraser. Lancet 2009;374:145-158. An excellent review well worth a read.

A reason to panic in pregnancy. Pearson GAH et al. Lancet 2009;374:756. An excellent case report exploring catecholamine excess in pregnancy.

Insulin glargine and malignancy: an unwarranted alarm. Stuart J Pocock & Liam Smeeth. Lancet 2009;374:511-513. AND Insulin glargine and cancer: another side to the story? Edwin AM Gale. Lancet 2009;374:521. An editorial and correspondence that I think provide food for thought, pause and appraisal............

Rosiglitazone evaluated for cardiovascular outcomes in oral agent combination therapy for type 2 diabetes (RECORD): a multicentre, randomised, open-label trial. Home PD, Pocock SJ, Beck-Nielsen H, et al Lancet. 2009;373:2125-35. The investigators randomized 4447 patients with type 2 diabetes on metformin or sulfonylurea monotherapy with mean HbA1c of 7.9% to the addition of rosiglitazone (n=2220) or to a combination of metformin and sulfonylurea (active control group, n=2227). The primary endpoint was cardiovascular hospitalisation or cardiovascular death. The latter occurred in 321 people in the rosiglitazone group and 323 in the active control group during a mean follow-up of 5.5 years. The Hazard Ratio[95%CI] was 0.84[0.59-1.18]for cardiovascular death, 1.14[0.80-1.63] for MI, and 0.72[0.49-1.06] for stroke. Hospital admission for heart failure or death occurred in 61 people in the rosiglitazone group and 29 in the active control group (HR 2.10[1.35-3.27]) Upper (Risk Ratio[95%CI] 1.57[1.12-2.19], p=0.0095)and distal lower limb (2.6[1.67-4.02], p<0.0001) fracture rates were increased mainly in women assigned to rosiglitazone. Mean HbA1c was lower in the rosiglitazone group than in the control group at 5 years, mean[SE] HbA1c rosiglitazone vs sulfonylurea -0.28[0.03] vs 0.01[0.04], p<0.0001; rosiglitazone vs metformin -0.44[0.03] vs -0.18[0.04], p<0.0001. This trial really does confirm my working practice that glitazones are effective therapy for improving glycaemic control in patients with Type 2 DM, but they should not be used in patients with heart failure or at significant risk of heart failure; the fracture risk of all patients should be assessed before starting therapy AND that they do not increase overall cardiovascular mortality or morbidity. Their use really is guided by discussion with the patient. The generic advice in guidelines or to GPs of a glitazone of your choice remains for me.

The venous thrombotic risk of oral contraceptives, effects of oestrogen dose and progestogen type: results of the MEGA case-control study. van Hylckama Vlieg A, Helmerhorst FM, et al BMJ. 2009 Aug 13;339:b2921. doi: 10.1136/bmj.b2921. This population based case-control study assessed the thrombotic risk associated with oral contraceptive use with a focus on dose of oestrogen and type of progestogen of oral contraceptives in premenopausal women <50 years old who were not pregnant, not within four weeks postpartum, and not using a hormone excreting intrauterine device or depot contraceptive, with a population of 1524 patients and 1760 controls. Currently available oral contraceptives increased the risk of venous thrombosis fivefold compared with non-use (odds ratio 5.0, 95%CI 4.2 to 5.8). The risk clearly differed by type of progestogen and dose of oestrogen. The use of oral contraceptives containing levonorgestrel was associated with an almost fourfold increased risk of venous thrombosis (odds ratio 3.6, 2.9 to 4.6)compared to non-users, whereas the risk of venous thrombosis compared with non-use was increased 5.6-fold for gestodene (5.6, 3.7 to 8.4), 7.3-fold for desogestrel (7.3, 5.3 to 10.0), 6.8-fold for cyproterone acetate (6.8, 4.7 to 10.0), and 6.3-fold for drospirenone (6.3, 2.9 to 13.7). The risk of venous thrombosis was positively associated with oestrogen dose. There was a high risk of venous thrombosis during the first months of oral contraceptive use irrespective of the type of oral contraceptives. Reviewing the results of this study and another study (Hormonal contraception and risk of venous thromboembolism: national follow-up study. Lidegaard O, et al. BMJ 2009;339:b2890doi10.1136/bmj.b2890) along with an excellent review (Contraception for women: an evidence based overview. Jean-Jacques Amy & Vrijesh Tripathi. BMJ 2009;339:b2895 doi10.1136/bmj.b2895) in the same issue of the BMJ show that when discussing oral contraception with women we should recommend those containing levonorgestrel or norethisterone with as low a dose of oestrogen as possible. The accompanying editorial by Nick Dunn (BMJ 2009;339:b3164doi:10.1136/bmj.b3164) is well worth a read.

NEXT NEWSLETTER Due out beginning of February 2009 so keep the gossip coming.

Endodiabology June 2009

2009-06-02T21:53:00.003+01:00

ENDODIABOLOGY
NORTHEAST
NEWSLETTER
FOR SPRs AND BOSSES TRAPPED
IN THE NORTHERN DEANERY

JUNE 2009
Editors: Shaz Wahid (shahid.wahid@sthct.nhs.uk) and
Petros Perros (petros.perros@ncl.ac.uk) and Vijayaraman Arutchelvam (riarut@aol.com )
Associate Editors: Shafie Kamarrudin, Ravi Erukulapati

SpR PLACEMENTS (NTN year of training from 1st October 2008)
• RVI- Shafie Kamarrudin (3), Beas Bhattacharya (5), Asgar Madathil (4), Kathryn Stewart (2), Rohanna Wright (1), Chandima Idampitiya (4), Preeti Rao (2) (Kenneth Muir (1) & Ethol Kalathil (1) from Aug 09)
• North Tyneside/Wansbeck- Ravi Erukalapati(4), Sudeep Manohar (2)
• South Tyneside- Sukesh Chandran(5)
• Gateshead- Dr De Alwis (1)
• Sunderland- Jeevan Mettayil (3), Sarah Steven (1)
• North Tees/Hartlepool- Khaled Mansur-Dukhan (5), Stuart Little (1) (Catherine Napier from Aug 09 (1))
• Middlesbrough- Anjali Santhakumar (2), Arif Ullah (2), Yahya Maghoub
• Carlisle- Naveen Siddaramaiha (1)
• Bishop Auckland Srikanth Mada(2)
• Durham- Dr Munir (1) from Aug 09
• NGH/QEH- Freda Razvi (5)
• Research with numbers (supervisor)- Eelin Lim(5-Prof Taylor); Stuart Little (Dr Shaw) & Asgar Madathil (Dr Weaver)-both from Aug 09.

MEETINGS / LECTURES / ANNOUNCEMENTS
• 5th-9th June 2009 American Diabetes Association 69th Annual Scientific Sessions, New Orleans, USA. Contact meetings@diabetes.org .
• 10th-13th June 2009 ENDO 2009, Washington, USA. Contact endostaff@endo-societ.org or www.endo-society.org/scimeetings .
• 24th June 2009 Northern Endocrine & Diabetes Summer CME, Freeman Hospital. Contact mshafie_kamaruddin@yahoo.co.uk
• 26th June 2009 RCPE Symposium: Recent Advances in Medicine, University Hospital of North Tees. Contact sue.dent@nth.nhs.uk
• 1st July 2009 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk
• 9th July 2009 Association of Physicians, 6-9pm, Gateshead. Contact clive.kelly@ghnt.nhs.uk
• 10th September 2009 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk
• 27th September-1st October 2009 45th EASD Annual meeting, Vienna, Austria. Contact www.easd.org
• 1st October 2009 RCPE symposium; Diabetes & Endocrinology: Clinical challenges & expert advice, Edinburgh. Contact c.berwick@rcpe.ac.uk
• 12th October 2009 Northern Endocrine & Diabetes Autumn CME, JCUH, Middlesbrough. Contact mshafie_kamaruddin@yahoo.co.uk
• 2nd-4th November 2009 Society for Endocrinology Clinical Update 2009, Manchester. Contact www.endocrinology.org
• 2nd November 2009 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk
• 3rd November 2009 RCPL Medicine Update, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk
• 19th November 2009 1st Joint Meeting of The British Thyroid Association and British Association Of Endocrine and Thyroid Surgeons, St Thomas Hospital. Contact www.british-thyroid-association.org
• 19th-20th November 2009 ABCD autumn meeting, London. Contact www.diabetologists.org.uk followed by SpRs meeting 21-22nd November 2009.
• 25th November 2009 Northern Endocrine Region Research and Audit Group annual meeting, Lumley Castle, Durham 2pm-8pm. Contact shahid.wahid@sthct.nhs.uk
• 26th & 27th November 2009 Middlesbrough insulin pump course. Contact Rudy.Bilous@stees.nhs.uk
• 4th December 2009 Society for Endocrinology regional cases meeting, Edinburgh. Contact www.endocrinology.org

TRAINING ISSUES
DIABETES & ENDOCRINOLOGY PIMD WEBSITE Our specialty website is available on http://mypimd.ncl.ac.uk/PIMDDev . Click onto the specialty training tab then follow to Diabetes & Endocrinology. This site is essential reading, especially for ARCP preparation.
A new Trainee Rep With Arut now having his CCT an opportunity for a new trainee rep has arisen on the STC. If you are interested please contact nicola.leech@nuth.northy.nhs.uk
Trainers & Trainees meeting (provisional date, will be confirmed) This will occur on Tuesday 23rd June 2009, 1600 at University Hospital of North Tees, Postgrad Centre. It will be followed by the SPARROWS feedback meeting from 1730. Contact nicola.leech@nuth.northy.nhs.uk
Registering with PMETB It is essential that all new SpRs/StRs (even LATs) register with the PMETB through the newly created Joint Royal Colleges of Physicians Training Board (formally the JCHMT) on www.jrcptb.org.uk. Not doing so means your training is not counted.
Log Book/Portfolio Documentation It is a trainee’s responsibility to make sure their portfolio/log book is prospectively completed and the necessary signatures obtained. Any experience that is not signed off by your educational supervisor at the time cannot be counted towards training. The e-portfolio for DM&ENDO is available now for StRs.
Assessment tools Please see www.jrcptb.org.uk; it is the trainee’s responsibility to give all the appropriate forms to their Educational or Clinical Supervisor. It is the trainee’s responsibility to make sure that the appropriate assessment summaries are available in their portfolio for ARCP purposes, e.g. MSF Summary Form.
Acute Care Assessment Tool The ACAT is a tool that is commendable. It provides a method of assessing how Trainees managed their on-call period. It is recommended that at least one is available for ARCP purposes. It can be downloaded from the JRCPTB website.
Case Based Discussions (CbD) The pilot form is available from the JRCPTB website. It is a must for trainers to use as a tool to document feedback in clinic. This has always been done informally, but now there is a method to formally document it. It can be used for when a SpR presents a new case in clinic.
Documenting CCU and ITU experience It is essential that trainees document their CCU and ITU experience. This is best done by keeping a summary log of the cases seen on CCU and ITU and linking it with reflection or assessment. This should then be signed off by your Educational Supervisor to be of any use at the Acute Medicine PYAs.
Audit Assessment tool This is now available in draft form on the JRCPTB website. Its use is highly recommended.
Management experience It is essential to have demonstrable evidence of management experience during your training, attending a course is not good enough. Undertaking a significant project for a Trust that leads to service change as a result of your management skills is probably the easiest method to demonstrate management activity. However, see Arut’s excellent letter below for more information and tips!
Training Committee Chair- Vacant; Regional Speciality Advisor- Shaz Wahid, shahid.wahid@sthct.nhs.uk; Programme Director- Nicky Leech nicola.leech@nuth.northy.nhs.uk; Consultant member (SAC rep)- Richard Quinton, Richard.Quinton@nuth.nhs.uk; Consultant member-Jean MacLeod, Jean.Macleod@nth.nhs.uk; Consultant member (Research Advisor)-Simon Pearce, s.h.s.pearce@ncl.ac.uk; Consultant member-Simon Eaton, simon.eaton@northumbria-healthcare.nhs.uk; SpR representative- Vacant; SpR representative- Jeevan Mettayil jmjeevan@yahoo.com

NEWS FROM THE NORTHEAST
• Congratulations to Sukesh Chandran on appointment to a Consultant post in Bishop Auckland from 1st October 2009. He will be an Acute Physician with an interest in Diabetes&Endo.
• Some of you may remember Liz McIntyre as a SpR. She is now a proud mother with a baby daughter.
• Philip Home has been invited by the ADA to lead his international team in presentation of the RECORD study (rosiglitazone) results at the ADAs Annual Meeting in New Orleans in June.
• Philip Home is to head up the A1chieve Study of 60000 people on five continents starting insulin.
• Richard Quinton to take over from Alan Patrick as SAC rep on the Diabetes/Endo Section of UEMS (European Union of Medical Specialists).
• 47 candidates have stumped up for the MRCP (Diabetes & Endocrinology) exam this year, half of them from the UK. Best of luck to our boys & girls.
• Jola Weaver has finished her term as STC Chair. Our thanks go to her for her hard work.
• Our thanks go to Arut for serving the needs of trainess as the SpR rep on the STC. He has handed the reins for the NEDS CME over to Rohanna Wright and Shafie Kamarrudin.
• Congratulations to Stuart Little (research with Dr Shaw) and Asgar Madathil (research with Dr Weaver) on their OOPEs to start ASAP.

LETTERS

A plug from Simon Pearce-There is a must-have book available now!! including chapters from yours truly on immunogenetics, Petros and Jane Dickinson on TAO, and Kate Owen and Tim Cheetham on polyendocrinopathy syndromes as well as a further 9 excellent chapters by international experts in the field..... Including: Evidence-based management of Graves' disease (Hegedus); Modern approaches to replacement in Addison's disease (Arlt); Immunomodulatory treatment of T1D (Herold), and lots more........ Its a snip at £49.00!! Pearce SHS, Ed. Autoimmune Endocrine Disorders: Endocrinology and Metabolism Clinics of North America 2009; 38 (2).

Research Update on the RADS (Rescue of Addison's Disease) study-Simon Peace. We have recruited 2 patients (of 5 referred), and both have tolerated rituximab well. It's too early to tell if its working yet, but there certainly isn't deterioration in the patient who has been retested. We are still keen to meet anyone with newly diagnosed Addison's disease within 4 weeks of diagnosis, to talk through the ins and outs of the study with them (just email me: s.h.s.pearce@ncl.ac.uk and we'll see the person within 5 days). The study will be recruiting for another 18 months, so more updates will be coming. Many thanks to those who have been pro-active in referring patients in so far.

New trial for medullary thyroid cancer-Petros Perros. Newcastle will soon be recruiting patients for a phase 3 randomized, placebo-controlled, double-blinded study of XL184 as single-agent oral therapy in patients with unresectable, locally advanced, or metastatic medullary thyroid cancer (MTC). The primary endpoint will be duration of progression-free survival. XL184 is a small molecule anticancer compound targeting the MET, RET, and VEGFR2 receptor tyrosine kinases. XL184 has exhibited dose-dependent tumour growth inhibition and tumour regression in a variety of tumour models, including breast cancer, colon cancer, MTC, non-small cell lung cancer, and glioblastoma. Main inclusion criteria are histologically confirmed MTC, and documented progressive disease on imaging within last 14 months. For further information or if you wish to discuss or refer potential participants please contact Dr P Perros 0191 2820590, or e-mail petros.perros@nuth.nhs.uk

Atul Gawande: a worthy read-Shaz Wahid (book review)
You have heard me bang on about the 7-habits (you wait till I start on the 8th habit), but these 2 books written by an Endocrine Surgeon in Boston USA (considered a GOD in the states) are a must read: Complications: a surgeon’s notes on an imperfect science; Better: a surgeon’s notes on performance. Both books cover a huge amount of ground in relation to hand hygiene, why we get sued, the difficult cases-sweating, obesity, why the computer is better than the world’s best Cardiologist at interpreting ECG (oh yes they are-as long as it is a perfect trace),systems management, chronic pain and much, much more. My favourite quote (that I have adjusted) is: “We (individuals or organisations) go into this work (medicine) thinking it is all a matter of canny diagnosis, technical prowess, slick technology, being the best, being the first AND some ability to empathise with people, but it is not.
We must grapple with systems, resources, circumstances, people-and our own shortcomings, as well. We face many variety of obstacles. But, somehow we must
– Advance
– Refine
– Improve
– PUT SIMPLY WE MUST STRIVE TO BE BETTER”

Management opportunities for SpRs within our regional specialty training programme-Vijayaraman Arutchelvam
Prof John Took in his report mentioned ‘The doctor's frequent role as head of the healthcare team and commander of considerable clinical resource requires that greater attention is paid to management and leadership skills regardless of specialism. An acknowledgement of the leadership role of medicine is increasingly evident. Role acknowledgement and aspiration to enhanced roles be they in subspecialty practice, management and leadership, education or research are likely to facilitate greater clinical engagement" (Tooke report 2008: Aspiring to Excellence)

We all are aware of the importance of developing management and leadership skills during our specialty training. The high standards and quality of training in the field of diabetes and endocrinology across our region is well recognised in the country. Equally importantly the opportunities we are provided with developing our leadership and managerial skills in our region are outstanding. This was pointed out to me by many SpR colleagues from other regions in recent times.

We have plenty of opportunities for formal training, and chances to put this training into practical experience and convert this experience into achievements. I herewith outline a few.

Formal training
We have a deanery approved 6 day course run by Mr Belton ( a former chief executive of a hospital ) at Durham thrice a year. This course comprehensively teaches you about all aspects of leadership and management with lots of practical group exercises. For example, groups are put in a task of real time negotiation to pick a charity to which all members will donate a negotiated amount of money. There were around 25 SpRs negotiating their heart out. In another exercise, you are expected to present a business case proposal to a team of managers, who choose 1 proposal which wins a prize( I felt proud to win that prize when I attended the course last year which boosted my confidence significantly). With help and support from our training programme director and regional specialty advisor, Shafie organised an accredited independent leadership course in April this year. 12 SpRs from our specialty attended this 3 day course and found it very useful.

The Northern deanery organises many management courses including courses on appraisal, good practice in educational supervision, feedback: heart of learning, Careers’ guidance for educational supervisors, recruitment and selection, developing effective educational plans and many more. You can book onto these courses online via the deanery website (http://mypimd.ncl.ac.uk/training).
I have attended many of these 1 day courses which had a direct impact on my performance. Organising ourselves onto these courses will need advanced planning and wise use of study leave during the whole training period. By itself it will demonstrate our management skills.

Opportunities to gain management experience
Specialty Training Committee : trainee representative
• 2 SpRs are elected by the STC to work within the STC for a minimum period of 2 years.
• Our STC encourages the trainee representative to be an active member and entrust them with responsibilities.
• Get to attend all the STC meetings, actively participate in the development of training modules, to collaborate with the Deanery in the local administration and delivery of specialist training (i.e. SpR/StR Programmes, recruitment and selection) within the regulations and guidelines of the College, to understand the rigorous ARCP process and understand the changes in training programmes at national level ( for example the chaos caused by MTAS).
• Communicating with SpR colleagues and represent their issues to the TPD and STC.
• More opportunities like representing in GIM STC meetings.
• Given a chance to get involved in developing the Medical education quality assessment report for the specialty and to attend this meeting with the post-graduate dean and other officials from the deanery.
• Given senior responsibilities like leading the JRCPTB pilot study.
• Encouraged to take positions at national level.
Interviewing skills:
• If you have done the courses on recruitment and selection AND equality and diversity you are given chances to get involved with the recruitment process for both specialty interviews and CMT interviews. I personally had the opportunity to sit in 3 specialty interview sessions and 4 CMT sessions.
CME organising committee:
• This is an unique feature of our region. SpRs are given total freedom in organising these tri-annual meetings across the region.
• The lead SpR will generate around £4000 annually by donations, maintain a cost centre account in the university and wisely manage it to cover the expenses.
• External and internal speakers are invited.
• Maintain excellent communication and conduct the meetings successfully covering the curriculum over a 3 year period.
• Register with the Royal college CPD programme and get approval for 5 CPD points.
• This is an excellent opportunity to improve our organisational skills, financial management, time management and networking skills.
• There will be challenging times and this will bring the best out of you ( to recollect an event, an external speaker cancelled with 6 days to go for the CME due to family reasons, we came out with an idea of a SpR presentation competition, arranged in that short period. This turned out to be an instant hit and now it has become an annual event).
Endodiabology:
• This is another unique opportunity in our region.
• You could start as an associate editor and you have the chance of becoming the senior editor.
• An excellent website remains functional. Being a web editor sharpens your IT skills as well.
PACES organising registrar:
• I got this opportunity when I was in James Cook University Hospital. Keep a watch as it is happening across the region as you are reading this.
Day with the Chief executive/ medical director
• Arrange to spend a day with the chief executive or medical director of the trust, attend meetings and learn practical management skills
All we need is initiative and enthusiasm to grasp these excellent opportunities provided by our region. All these experiences lead to satisfying achievements. To illustrate, with the CME when we received an average score of 4.4/ 5 on overall performances and demonstrated consistent improvement in attendance or when you register the increase in the endodiabology blog spot hit rate, trust me, it will all be very satisfying and rewarding. I have just outlined a few opportunities and there are plenty more available to fulfil our training needs and go beyond.
The Medical Leadership Competency Framework has been jointly developed by The Academy of Medical Royal Colleges and the NHS Institute for Innovation and Improvement, in conjunction with a wide range of stakeholders. This framework is built on the concept of shared leadership where leadership is not restricted to those who hold designated leadership roles, and where there is a shared sense of responsibility for the success of the organisation and its services. Acts of leadership can come from any individual in the organisation, as appropriate, at different times. Our region provide an opportunity to work with and improve on all these domains (figure 1). I suggest that we read more on these domains and each of its elements in the website http://www.institute.nhs.uk/assessment_tool/general/medical_leadership_competency_framework_-_homepage.html and continue to work on developing the relevant skills using the excellent opportunities available in the region..
Figure 1 The Medical Leadership Competency Framework

RECENT PUBLICATIONS FROM THE NORTHEAST
1. Randomised Controlled Trial to Assess the Impact of Continuous Glucose Monitoring on HbA1c in Insulin-Treated Diabetes (MITRE Study) D. Cooke, S.J. Hurel, A. Casbard, L. Steed, S. Walker, S. Meredith, A.J. Nunn, A.
Manca, M. Sculpher, M. Barnard, D. Kerr, J.U. Weaver, J. Ahlquist, S.P.
Newman Accepted Article Online: Diabetic Medicine Apr 4 2009.
2. Roycroft M, Fichna M, McDonald D, Owen K, Zurawek M, Gryczyńska M, Januszkiewicz-Lewandowska D, Fichna P, Cordell H, Donaldson P, Nowak J, Pearce S. The tryptophan 620 allele of the lymphoid tyrosine phosphatase (PTPN22 gene) predisposes to autoimmune Addison's disease. Clin Endocrinol (Oxf) 2009; 70: 358-362.
3. Owen CJ, Habeb A, Pearce SH, Wright M, Ichikawa S, Sorenson AH, Econs MJ, Cheetham TD. Discordance for X-linked hypophosphataemic rickets in identical twin girls. Horm Res. 2009;71:237-44.
4. Pearce SHS, Ed. Autoimmune Endocrine Disorders: Endocrinology and Metabolism Clinics of North America 2009; 38 (2).
5. Allahabadia A, Razvi S, Abraham P, Franklyn J. Diagnosis and treatment of primary hypothyroidism. BMJ. 2009 Mar 26;338:b725.
6. Magee G, Bilous RW, Cardwell CR,Hunter CJ,Kee F,Fogarty DG. Is hyperfiltration associated with the future risk of developing diabetic nephropathy? Diabetologia 2009 ; 52 ; 691 – 7.
7. Candesartan and Prevention of Microalbuminuria in Diabetes Effect of Candesartan on Microalbuminuria and Albumin Excretion Rate in Diabetes Three Randomized Trials (DIRECT – Renal) Rudy Bilous, MD; Nish Chaturvedi, MD; Anne Katrin Sjølie, MD; John Fuller, MD; Ronald Klein, MD; Trevor Orchard, MD; Massimo Porta, MD; and Hans-Henrik Parving, MD. Annals Internal Medicine 2009 ( in press).
8. Hill S, Arutchelvan V, Quinton R. 2009 Enclomiphene, an estrogen receptor antagonist for the treatment of testosterone deficiency in men. drugs. 12: 109-119.
9. Nicol M, Papacleovoulou G, Evans DB, Penning TM, Strachan MW, Advani A, Johnson SJ, Quinton R, Mason JI. 2009 Estrogen biosynthesis in human adrenocortical carcinoma cells. Molecular & Cellular Endocrinology. 300: 115-120.

RECENT PUBLICATIONS IN DIABETES & ENDOCRINOLOGY THAT HIT THE NEWS OR THAT MAY HAVE A SIGNIFICANT IMPACT ON MANAGEMENT
Defining polycystic ovary syndrome. Balen A, et al. BMJ 2009;338:426. Well worth a read and I would recommend that trainees bring it up on their PIU round to invoke debate/fisticuffs, rather like asking what is a normal short synacthen test.
Fatal thyrotoxic cardiomyopathy in a young man. Soh MC & Croxon M. BMJ 2009;338:476477. An excellent case report that you can hang thyrotoxic storm on, however I do manage it differently than discussed in the article.
HDL cholesterol and cardiovascular risk. Ghali WA & Rodondi N. BMJ 2009;338:488-489. I remember having to interpret a vignette from a paper discussing cholesterol transport and how raising HDL cholesterol may be beneficial in monkeys for my A-level biology exam. It is interesting to see how we have come full circle and the paradigm of raising HDL-c resulting in reduced cardiovascular disease has not come to fruition as eloquently discussed in this editorial.
Graves’ Ophthalmopathy. Bartalena L & Tanda ML. NEJM 2009;360:994-1001. A must read for trainees and those wishing a clinical practice update.
Dopamine agonists and hyperprolactinaemia. Martin N, et al. BMJ 2009;338:554-555. An excellent editorial with advice that I think is prudent: undertake an echo before starting cabergoline and then determine further echos depending on the cumulative dose. Worth a read.
Systemic management of diabetic retinopathy. Liew G, et al. BMJ 2009;338:612-613. An editorial discussing the ADVANCE, DIRECT and FIELD trials. Worth a read.
Thyroid eye disease. Perros P, Neoh C, Dickinson J. BMJ 2009;338:645-650. A practical update from a team of local Gurus in the field.
Investigating the thyroid nodule. Mehanna HM, et al. BMJ 2009;338:705-709 AND Rational Imaging: Incidental thyroid nodule. Patel CN, et al. BMJ 2009;338:713-715. Well worth a read of both articles that did lead to some controversy. I still say put 20 Endocrinologists in the same room……………………………………………………………………………………
An unusual cause of ventricular fibrillation. Gerritsen et al. Lancet 2009;373:1144. An excellent case report that gets you into topping up on the different causes of hypokalaemia and hyperkalaemia due to channelopathies.
Management of hirsutism. Koulouri O, Conway GS. BMJ 2009;338:823-826. AND Investigating hirsutism. Sathyapalan T, Atkin SL. BMJ 2009;338:1070-1072. 2 excellent practical articles well worth a read.
Late onset hypogonadism. Hugh Jones T. BMJ 2009;338:785-786. An editorial worthy of a read to guide further investigation of the literature.
The HRT controversy: observation studies and RCT fall in line. Vandenbroucke JP. Lancet 2009;373:1233-1235. An excellent editorial summarising the recent evidence on HRT and providing a wealth of references to aid further understanding.
Where are my testes? Kumar S, et al. Lancet 2009;373:1310. I write about this case report with a “smile”. It brings factor V leiden into the world of primary hypogonadism.
Practising safely in the foundation years. Long et al. BMJ 2009;338:887-890. A wonderful article that can be used as a teaching tool.
Prevention of Diabetic retinopathy. Anna Einarsdottir, Einar Stefansson. Lancet 2009;373:1316-1317. A review of the accompanying CALDIRET study with lessons to note.
Tight control of blood glucose in long standing type 2 diabetes. Richard Lehman. Lancet 2009;338:901-902. The view of QuOF on the reduction of target HbA1c from 7.5 to 7 %. I was expecting the howls of derision…………
Diagnosis and treatment of primary hypothyroidism. Amit Allahabadia, et al. BMJ 2009;338:1090-1091. The BTAs attempt to bring some semblance of control to the therapy of hypothyroidism.
Voglibose for prevention of type 2 diabetes mellitus. Andre J Scheen. Lancet 2009;373:1579-1580. An editorial that not only discusses the accompanying trial but also the issue of preventing diabetes using pharmacotherapy.
Genetics of Type 1A Diabetes. Patrick Concannon and Gerald Nepom. NEJM 2009;360:1646-1654. An excellent update on this important and ever expanding topic.
The Lancet 23-29th May 2009 volume 373 edition. A must read edition of the Lancet that is devoted to diabetes. 3 important trials on glitazones & hear disease, gestational diabetes and the Fenofibrate FIELD study are presented.
Zoledronic acid and risedronate in the prevention and treatment of glucocorticoid-induced osteoporosis (HORIZON): a multicentre, double-blind, double-dummy, randomised controlled trial. Reid DM,et al. Lancet. 2009 Apr 11;373(9671):1253-63. This 1-year randomised, double-blind, double-dummy, non-inferiority study of 54 centres around the world tested the effectiveness of 5 mg intravenous zoledronic acid versus 5 mg oral risedronate for prevention and treatment of glucocorticoid-induced osteoporosis. 833 patients were randomised 1:1 to receive zoledronic acid (n=416) or risedronate (n=417). Patients were stratified by sex, and allocated to prevention or treatment subgroups dependent on duration of glucocorticoid use immediately preceding the study. The treatment subgroup consisted of those treated for more than 3 months (272 patients on zoledronic acid and 273 on risedronate), and the prevention subgroup of those treated for less than 3 months (144 patients on each drug). The primary endpoint was percentage change from baseline in lumbar spine bone mineral density. Zoledronic acid was non-inferior and superior to risedronate for increase of lumbar spine bone mineral density in both the treatment ( mean difference 1.36% [95% CI 0.67-2.05], p=0.0001) and prevention (1.96% [1.04-2.88], p<0.0001) subgroups at 12 months. Adverse events were more frequent in patients given zoledronic acid than in those on risedronate, mainly because of transient symptoms during the first 3 days after infusion. Serious adverse events were worsening rheumatoid arthritis for the treatment subgroup and pyrexia for the prevention subgroup. This study has shown that a single 5 mg intravenous infusion of zoledronic acid is non-inferior, possibly more effective, and more patient friendly than is 5 mg of daily oral risedronate for the prevention and treatment of bone loss associated with glucocorticoid use. It is well worth reading the accompanying editorial by Luigi Gennari & John Belzezikian (Lancet 2009;373:1225-1226). Despite the clear evidence base for using annual zoledronic infusion in managing osteoporoses, I struggle to convince my Medical Director when I have asked for its use in certain individual circumstances. Because of cost I am pointed towards 6-monthly IV pamidronate.
Intensive versus conventional glucose control in critically ill patients. NICE-SUGAR Study Investigators. N Engl J Med. 2009 Mar 26;360(13):1283-97. In this trial 6104 adults within 24 hours after admission to an intensive care unit (ICU), who were expected to require treatment in the ICU on 3 or more consecutive days were randomly assigned to undergo either intensive glucose control (3054 patients), with a target blood glucose range of 4.5 to 6.0 mmol/l, or conventional glucose control (3050 patients), with a target of 10.0 mmol/l. The primary end point was death from any cause within 90 days after randomization. The two groups had similar characteristics at baseline. A total of 829 patients (27.5%) in the intensive-control group and 751 (24.9%) in the conventional-control group died (odds ratio for intensive control, 1.14 95%CI[1.02-1.28]; P=0.02). The treatment effect did not differ significantly between surgical and medical patients (odds ratio for death in the intensive-control group, 1.31 and 1.07, respectively; P=0.10). Severe hypoglycaemia (blood glucose level, < 2.3 mmol/l) was reported in 206 of 3016 patients(6.8%) in the intensive-control group and 15 of 3014 (0.5%) in the conventional-control group (P<0.001). There was no significant difference between the two treatment groups in the median number of days in the ICU (P=0.84) or hospital (P=0.86) or the median number of days of mechanical ventilation (P=0.56) or renal-replacement therapy (P=0.39). This trial found that intensive glucose control increased mortality among adults in the ICU: a blood glucose target of 10mmol/l or less had lower mortality than did a target of 4.5-6.0 mmol/l. A very important trial that I think outlines the important target of maintaining a blood glucose of 6-10 mmol/l in patients on an ICU. The accompanying editorial by Sylvio Inzucchi and Mark Siegel (NEJM 2009;360:1346-1349) is well worth a read. It is important that Intensivists do not go down the same route as many Cardiologists (following DIGAMI 2 and others) and abandon controlling hyperglycaemia, luckily “my crowd” still do mostly listen.
Catheter-based renal sympathetic denervation for resistant hypertension: a multicentre safety and proof-of-principle cohort study. Krum H, et al. Lancet. 2009 Apr 11;373(9671):1275-81. This proof-of-principle trial of therapeutic renal sympathetic denervation in 45-patients with resistant hypertension (ie, systolic blood pressure 159 mmHg on three or more antihypertensive medications, including a diuretic) assessed the latter procedures safety and blood-pressure reduction effectiveness. Patients received percutaneous radiofrequency catheter-based treatment between June, 2007 and November 2008, with follow-up to 1 year. The effectiveness of renal sympathetic denervation was assessed by measuring renal noradrenaline spillover in a subgroup of patients. Primary endpoints were office blood pressure and safety data before and at 1, 3, 6, 9, and 12 months after the procedure. Renal angiography was done before, immediately after, and 14-30 days after procedure, and magnetic resonance angiogram 6 months after procedure. In treated patients, baseline mean(SD) office blood pressure was 177/101(20/15) mmHg; mean 4.7 antihypertensive medications; mean(SD) eGFR was 81(23)ml/min; and mean reduction in renal noradrenaline spillover was 4795%CI 28-65)%. Office blood pressures after procedure were reduced by -14/-10, -21/-10, -22/-11, -24/-11, and -27/-17 mmHg at 1, 3, 6, 9, and 12 months, respectively. One intraprocedural renal artery dissection occurred before radiofrequency energy delivery, without further sequelae. There were no other renovascular complications. This preliminary trial has shown that catheter-based renal denervation causes substantial and sustained blood pressure reduction, without serious adverse events, in patients with resistant hypertension. However, prospective randomised clinical trials are needed. The accompanying editorial by Michael Doumas and Stella Douma is excellent (Lancet 2009;373:1228-1229).
Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. Sacks FM, et al. N Engl J Med. 2009 Feb 26;360(9):859-73. The authors randomly assigned 811 overweight adults to one of four diets where the targeted percentages of energy derived from fat, protein and carbohydrates in the four diets were 20, 15, and 65%; 20, 25, and 55%; 40, 15, and 45%; 40, 25, and 35%; and followed them up for 12-months. The diets consisted of similar foods and met guidelines for cardiovascular health. The participants were offered group and individual instructional sessions for 2 years. The primary outcome was the change in body weight after 2 years in two-by-two factorial comparisons of low fat versus high fat and average protein versus high protein and in the comparison of highest and lowest carbohydrate content. After 6-months participants assigned to each diet had lost an average of 6 kg, accounting for 7% of their initial weight; they began to regain weight after 12 months. By 2 years, weight loss remained similar in those who were assigned to a diet with 15% protein and those assigned to a diet with 25% protein (3.0 and 3.6 kg, respectively); in those assigned to a diet with 20% fat and those assigned to a diet with 40% fat (3.3 kg for both groups); and in those assigned to a diet with 65% carbohydrates and those assigned to a diet with 35% carbohydrates (2.9 and 3.4 kg, respectively) (P>0.20 for all comparisons). Among the 80% of participants who completed the trial, the average weight loss was 4 kg; 14 to 15% of the participants had a reduction of at least 10% of their initial body weight. Satiety, hunger, satisfaction with the diet, and attendance at group sessions were similar for all diets; attendance was strongly associated with weight loss (0.2 kg per session attended). The diets improved lipid-related risk factors and fasting insulin levels. The message from this study is to encourage calorie restriction to manage weight as weight loss occurred in this study regardless of which macronutrients they emphasised.

NEXT NEWSLETTER Due out beginning of October 2009 so keep the gossip coming.

Endodiabology February 2009

2009-02-02T00:14:00.000Z

ENDODIABOLOGY
Endodiabology.blogspot.com

NORTHEAST
NEWSLETTER
FOR SPRs AND BOSSES TRAPPED
IN THE NORTHERN DEANERY

FEBRUARY 2009
Editors: Shaz Wahid (shahid.wahid@sthct.nhs.uk) and
Petros Perros (petros.perros@ncl.ac.uk) and Arut Vijayaraman (riarut@aol.com )
Associate Editors: Shafie Kamarrudin, Ravi Erukulapati

SpR PLACEMENTS (NTN year of training from 1st October 2008)
• RVI- Shafie Kamarrudin (3), Beas Bhattacharya (5), Asgar Madathil (4), Kathryn Stewart (2), Rohanna Wright (1), Chandima Idampitiya (4), Preeti Rao (2)
• North Tyneside/Wansbeck- Ravi Erukalapati(4), Sudeep Manohar (2)
• South Tyneside- Sukesh Chandran(5)
• Gateshead- Arutchelvan Vijayaraman (5)
• Sunderland- Jeevan Mettayil (3), Sarah Steven (1)
• North Tees/Hartlepool- Khaled Mansur-Dukhan (5), Stuart Little (1)
• Middlesbrough- Anjali Santhakumar (2), Arif Ullah (2), Yahya Maghoub
• Carlisle- Naveen Siddaramaiha (1)
• Bishop Auckland Srikanth Mada(2)
• Durham-
• NGH/QEH- Freda Razvi (5)
• Research with numbers (supervisor)- Eelin Lim(5-Prof Taylor)

MEETINGS / LECTURES / ANNOUNCEMENTS
• 10th February 2009 SfE Clinical Cases meeting, London. Contact www.endocrinology.org .
• 11th-13th March 2009 DUK Annual Professional Conference, Birmingham. Contact www.diabetes.org.uk
• 16th – 19th March 2009 BES 2009, Harrogate. Contact www.endocrinology.org .
• 18th March 2009 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
• 23rd & 24th April 2009 Middlesbrough insulin pump course. Contact
• 29th April 2009 RCP Acute Medical Emergencies, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
• 30th April 2009 Novo Nordisk Symposium, Lumley Castle Hotel. Contact & see letters section.
• 7th-8th May 2009 ABCD Spring Meeting, Bristol, www.diabetologists.org.uk
• 11th May 2009 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
• 5th-9th June 2009 American Diabetes Association 69th Annual Scientific Sessions, New Orleans, USA. Contact meetings@diabetes.org .
• 10th-13th June 2009 ENDO 2009, Washington, USA. Contact endostaff@endo-societ.org or www.endo-society.org/scimeetings .
• 24th June 2009 Northern Endocrine & Diabetes Summer CME, Freeman Hospital. Contact
• 1st July 2009 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
• 10th September 2009 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
• 27th September-1st October 2009 45th EASD Annual meeting, Vienna, Austria. Contact www.easd.org
• 12th October 2009 Northern Endocrine & Diabetes Autumn CME, JCUH, Middlesbrough. Contact
• 2nd-4th November 2009 Society for Endocrinology Clinical Update 2009, venue TBC. Contact www.endocrinology.org
• 2nd November 2009 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
• 3rd November 2009 RCPL Medicine Update, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
• 25th November 2009 Northern Endocrine Region Research and Audit Group annual meeting, Lumley Castle, Durham 2pm-8pm. Contact shahid.wahid@sthct.nhs.uk
• 26th & 27th November 2009 Middlesbrough insulin pump course. Contact Rudy.Bilous@stees.nhs.uk

See www.worlddiabetescongress.org for the IDF world diabetes conference.
TRAINING ISSUES
NEW TPD See letters section for an introduction to our new TPD that also includes training advice.
ARCPs/RITAs/PYAs These are planned for Weds 13th May to Friday 15th May 2009. Nicky Leech will be distributing details. For those of you requiring a PYA keep Thurs 14th May 2009 free.
Acute Medicine Level 2 training for SpRs For this year’s ARCPs/RITAs any SpR who has not had their PYA will be expected to have 4 ACAT assessments and 4 Mini-CEXs/CbDs specifically in relation to Acute Medicine in their portfolio for the panel to review.
Acute Medicine Level 2 training for StRs Any trainee appointed after August 2007 will be considered a StR and for their ARCP they will be expected to have 4 ACAT assessments, 4 Mini-CEXs and 4 CbDs specifically in relation to Acute Medicine, a valid ALS qualification, evidence of achievement of all the procedures deemed necessary for Acute Medicine Level 2 training, Evidence of achievement of all emergency presentations to level 2, Evidence of achievement of 2/3rds top 20 presentations to level 2 and Evidence of ½ of other presentations to level 2. It is recommended to use the pages available from the Acute Medicine e-portfolio to collect the later evidence that CMT (ST1-ST2) trainees should already have. If you do not have access to this then contact your Post-Grad Education Centre Manager who should be able to get you access to the e-portfolio for CMTs.
DIABETES & ENDOCRINOLOGY PIMD WEBSITE Our specialty website is available on http://mypimd.ncl.ac.uk/PIMDDev . Click onto the specialty training tab then follow to Diabetes & Endocrinology. This site is essential reading, especially for ARCP preparation.
Registering with PMETB It is essential that all new SpRs/StRs (even LATs) register with the PMETB through the newly created Joint Royal Colleges of Physicians Training Board (formally the JCHMT) on www.jrcptb.org.uk although it is still possible to link with this site using the old www.jchmt.org.uk link. Not doing so means your training is not counted.
Log Book/Portfolio Documentation It is a trainee’s responsibility to make sure their portfolio/log book is prospectively completed and the necessary signatures obtained. Any experience that is not signed off by your educational supervisor at the time cannot be counted towards training.
Assessment tools Please see www.jrcptb.org.uk; it is the trainee’s responsibility to give all the appropriate forms to their Educational or Clinical Supervisor. It is the trainee’s responsibility to make sure that the appropriate assessment summaries are available in their portfolio for ARCP purposes, e.g. MSF Summary Form.
Acute Care Assessment Tool The ACAT is a tool that is commendable. It provides a method of assessing how Trainees managed their on-call period. It is recommended that at least one is available for ARCP purposes. It can be downloaded from the JRCPTB website.
Case Based Discussions (CbD) The pilot form is available from the JRCPTB website. It is a must for trainers to use as a tool to document feedback in clinic. This has always been done informally, but now there is a method to formally document it. I basically use it for when a SpR presents a new case to me in clinic.
Documenting CCU and ITU experience As of now it is essential that trainees document their CCU and ITU experience. This is best done by keeping a summary log of the cases seen on CCU and ITU and linking it with reflection or assessment. This should then be signed off by your Educational Supervisor to be of any use at the Acute Medicine PYAs.
Community Diabetes The curriculum is undergoing some slight revision to reflect the importance that trainees gain “practical” experience in issues around commissioning, service delivery with no “walls”, patient centred care in a district and other “political” issues/changes. That is, it is important to be prepared to utilise management skills around these areas upon attaining a CCT.
Training Committee Chair- Jola Weaver,; Regional Speciality Advisor- Shaz Wahid,; Programme Director- Nicky Leech; Consultant member (SAC rep)- Richard Quinton,; Consultant member-Jean MacLeod,; Consultant member (Research Advisor)-Simon Pearce; Consultant member-Simon Eaton,; SpR representative- Arutchelvan Vijayaraman ; SpR representative- Jeevan Mettayil
NEWS FROM THE NORTHEAST
• Congratulations to Nicky Leech as our new TPD, see her letter below.
• Shaz Wahid will be the new Regional Specialty Advisor (service delivery) with Richard Quinton still the regions rep on the national SAC committee (training matters).
• Richard Quinton attended the Endocrine Society of India annual congress, Cochin, Kerala, Dec 2008 as invited speaker on the Genetics of Idiopathic Hypogonadotrophic Hypogonadism. At the conference he met up with Dr V Suresh, who was Visiting Fellow at the RVI with us a few years back & is now Assistant Professor in Endocrinology at Department of Endocrinology at SVIMS, Tirupati, Andhra Pradesh & Dr Muthu Jayapaul, who has only just returned to India to join a newly-formed Endocrinology consortium in Madras (Chennai).
• Congratulations to Roy Taylor in obtaining a research grant from Diabetes UK. Effect of change in pancreas and liver fat content upon beta cell function and hepatic insulin action during weight loss in type 2 diabetes. £126,000. Taylor R., Mathers J, Hollingsworth K.
• Simon Eaton will Chair the Long Term Conditions Group for the SHA and would be very grateful for people to contact him if they are interested in contributing to the work of implementing the “Our Vision Our Future LTC” report.
• Simon Eaton will be relinquishing the NRDSAG chair and would be interested in hearing from someone who may want to take on this role.
• Sue Roberts was awarded CBE in the New Year Honours, congratulations!
• I am pleased to announce that Arut has agreed to become a Senior Editor on the ENDODIABOLOGY team and will continue this role through Consultant hood.
• Congratulations to Rohanna Wright on obtaining a place on the SPARROWS programme for the ADA. She will be joined by Bernadette Woodward a DSN at JCUH.
• Congratulations to John Parr on being asked by the ABCD to be their regional champion for the North East. See the letters section. Hopefully this may well lead to an ABCD meeting being held in the North East in the near future.
• We have appointed 2 NTNs from run-through, Catherine Napier & Atif Munir. Both of whom were excellent at interview. Interviews for vacancies will be held 3rd March 09 and June 09.

LETTERS
“United we stand, divided we fall”-Shaz Wahid
I remember reading about Mike Besser’s lecture at the ABCD several years ago with the above title, where he extolled the virtues of maintaining practice in both Diabetes & Endocrinology without bowing to external pressures and splitting the specialty. I could not agree more at the time and still remember whilst training as an SpR feeling rather puzzled when it was voiced that training in Diabetes & Endocrinology should be split by folk in the higher echelons of the then JCHMT and the DoH. Thankfully, matters have remained quiet in relation to the latter until recently when the PMETB have talked about issues such as credentialing and indeed there has been a comparison between our training curriculum and the Cardiology training curriculum with the intention to demonstrate that we should model training similar to Cardiology. That is, train in the basics (apparently mainly in primary care settings) but be able to choose time limited periods in more specialist areas (e.g. insulin pumps, reproductive endocrinology, obesity, etc) towards the senior years of training. Hence, rather like Cardiologists producing trainees specialised in such areas as electrophysiology we would produce trainees with a CCT in Diabetes & Endocrinology but credentialed in insulin pumps or gynea-fertility-endocrinology. This fills me with dread. Admittedly, when coming out at the other end I had an interest in renal diabetes but I did have enough of a grounding in the specialty and more importantly developed self-management and leadership skills to set up a diabetic foot service, further develop a transitional diabetes service and rubbed shoulders with the community via a number of initiatives without giving away the crown jewels! I remember sitting next to RT shortly after obtaining Consultant hood when he asked “Shaz did we prepare you”, “not for all eventualities, but I have had enough training to have developed the skills to manage all scenarios”, an answer RT was pleased with. It is not surprising Endocrinologists make good Acute Medicine Physicians as we are well versed in looking at disparate issues of patient care and bringing them together across a Trust or a community with the aim of delivering quality patient care. The current processes of care in the NHS do not lend themselves to remodelling training in Diabetes & Endocrinology along the lines of Cardiology so that we always produce “super specialists”. There are mechanisms within the specialty that already allow one to become a “super specialist” without having to reduce exposure to the basic groundings in the speciality that allow development of our unique specialist skills. In summary, going down the line of either splitting the sugar from hormones or compartmentalising the specialty to produce “super specialists” will only be to the detriment of delivering high quality patient care. Thankfully, our SAC thinks along similar lines as me……………………………………………………..

Thoughts of a New Trainee Programme Director. Life after 9/1/09. Dr Nicky Leech Diabetologists and Endocrinologists may be quiet and discerning but they whisper well. As a consequence I think you all know that I have now been officially appointed after a tough competitive interview!! As the only candidate I failed to convince the panel that I was wholly unsuitable as the Northern Deanery Training Programme Director for our specialty.
Why did we all take six paces backwards when Shaz declared his wish to step down? He has been exceptional and perhaps no one had the courage to follow such an act. Our thanks go to Shaz for steering us through the minefield of MMC and run-through training. He has kept engaged with a challenging system and pioneered the robust implementation of annual portfolio based assessment using the breadth of work-place based assessment tools. His excellent leadership is obvious. Look around you at the health of your diabetes and endocrinology training programme compared to equivalent specialities in the region.
Reflecting on the thoughts of a Guru, I will strive for private and public victory but don’t worry I wont forget to sharpen my sword! On a more personal note, thank you Shaz for your continued support and guidance as I try to take hold of the tiller and learn the ropes.
So what is looming on our horizon? I sense the excitement about the prospect of having another professional exam! This will need to have been achieved by PYA for all those entering speciality training after 2007. What about the rest of you? I would want to be “as qualified as the rest of them” wouldn’t you? When should you sit the exam? That is obviously your decision although it makes far more sense to me to sit very early in training. It will equip you with a wealth of knowledge which can then be applied, releases time for more personalised learning and if you fail (not that any of you will!) ensures you have time to resit without jeopardizing your career progression.
Some of you will have been surprised by the suggestion that they have inadequate evidence of GIM, ITU and cardiology at PYA. All trainees are doing enough but it is the documented evidence that counts. I refer you back to this and previous editions of Endodiabology. In summary; log your cases and ensure you have 4 ACATs, 4 Min-CEXs and 4 CbDs in General medicine including documented evidence of exposure in ITU and cardiology.
Now October and Christmas has passed all trainees should ensure they have sat with their supervisors and agreed their personal development plan (PDP) based on the training needs identified in the previous ARCP.
An old Chinese proverb says “if you don’t scale the mountain you cannot view the plain” so keep climbing as we work through the scree slope of change and if it is any comfort to you “today my mountain feels as steep as yours!”

Do you care for a person with diabetes who has problematic / unusual hypoglycaemia?
Would you like to discuss the case with world experts in hypoglycaemia?
You have the opportunity at this year’s NovoNordisk Symposium on Thursday 30 April 2009
To present, please submit an abstract of no more than 200 words, describing the clinical scenario, and indicating what you hope to achieve from the case discussion.
Submit to: Sally Marshall By 1 April 2009.
Northern Region NovoNordisk Symposium- Hypoglycaemia
Thursday 30 April 2009 Lumley Castle Hotel

Programme
1400 - 1430 Registration and Coffee
Chair Sally Marshall
1430 - 1515 Professor Stephanie Amiel, London
Hypoglycaemia and the Brain
1515 - 1600 Professor Brian Frier, Edinburgh
Hypoglycaemia and Life Issues
1600 – 1615 Tea
1615 - 1730 Dr James Shaw, Newcastle, Local Case Presenters and Expert Panel Discussion
Loss of awareness of hypoglycaemia: practical aspects
1730-1815 Dr Lotte Bjerre Knudsen
The Birth of a Molecule: from Conception to Delivery
1830 Close

ABCD-The best CPD in Diabetes? John Parr ABCD (The Association of British Clinical Diabetologists) is now 10 years old. I was sent by the NRDSAG to its inaugural meeting at Windsor to find out “what it was about”, particularly at the time there was great opposition to a potential rival organization from Diabetes UK. I actually found it an extremely beneficial, refreshing and vibrant meeting and have continued to attend meetings ever since.
For me it’s the best Diabetes CPD in town. Why? Firstly it provides twice-yearly specialist, up to date, timely and comprehensive programmes (see enclosed programmes) by expert speakers, directed to Specialist/Consultant Diabetologists, with enough time to question and debate the issues from the floor. Audience participation is one of its strengths and even the great and the good get questioned rigorously.
Secondly the programme addresses issues and challenges that we consultants face in daily practice, and in such a convivial setting talking to and supporting each other is the best psychotherapy around.
Thirdly its practical side; through country-wide collaboration, audits on triple oral therapy and glargine use in pregnancy have been undertaken and by achieving substantial numbers have made the results meaningful (current audits are on Charcot’s, Exubera, Osteomyelitis Management and Outcome); the Survey of Inpatient Services and through collaboration with Diabetes UK the UK Specialist Services Survey, have all been important. It submits to NICE and contributes to RCP groups. The organization represents consultants in diabetes and many are members.
Fourthly it encourages SpR membership, attendance and participation, through meetings (another venue for posters) and the audit programmes/awards. Indeed a meeting for SpRs follows on from the main meeting – making 2 days of good diabetes education and by taking in the splendid preceding British Thyroid Association meeting in November, extending to 3 days. Is it a meeting just for “old farts”? Not necessarily! It’s also for “young farts” (after all they eventually become “old-farts”) and specialists of all description. Further information is available from http://www.diabetologists-abcd.org.uk/ .

RECENT PUBLICATIONS FROM THE NORTHEAST
1. Langham S, Maggi M, Schulman C, Quinton R, Uhl-Hochgräber K. 2008 health-related quality of life instruments in studies of adult men with testosterone deficiency syndrome: a critical assessment. Journal of Sexual Medicine. 5: 2842-2852.
2. Nicol MR, Papacleovoulou G, Evans DB, Penning TM, Strachan MW, Advani A, Johnson SJ, Quinton R, Mason JI. Estrogen biosynthesis in human H295 adrenocortical carcinoma cells. Mol Cell Endocrinol. 2008 Nov 5. [Epub ahead of print].
3. Igreja S, Chahal HS, Akker SA, Gueorguiev M, Popovic V, Damjanovic S, Burman P, Wass JA, Quinton R, Grossman AB, Korbonits M. Assessment of p27 (cyclin-dependent kinase inhibitor 1B) and AIP (aryl hydrocarbon receptor-interacting protein) genes in MEN1 syndrome patients without any detectable MEN1 gene mutations. Clin Endocrinol (Oxf). 2008 Aug 15. [Epub ahead of print].
4. Ravikumar, B, Gerrard J, Dalla Man C, Firbank MJ, Lane A, English PT, Cobelli C, Taylor R. Pioglitazone decreases fasting and postprandial endogenous glucose production in proportion to decrease in hepatic triglyceride content. Diabetes 57: 2288-95, 2008.
5. Belch JJ, Macuish A, Campbell I, Cobbe S, Taylor R, Prescott R, Lee R, Bancroft J, MacEwan S, Shepherd J, Macfarlane P, Morris A, Jung R, Kelly C, Connacher A, Peden N, Jamieson A, Mathews D, Leese G, McKnight J, O’Brian I, Semple C, Petrie J , Gordon D, Pringle S, MacWalter R. The Prevention of Progression of Arterial Disease and Diabetes (POPADAD): a study of aspirin and antioxidants in patients with Diabetes and asymptomatic peripheral arterial disease. Brit Med J 337:a1840, 2008.
6. Arun CS, Al-Bermani A, Stannard KS, Taylor R. Long term impact of retinal screening upon significant diabetes related visual impairment in the working age population. Diabetic Medicine 2008 in press
7. Jovanovic A, Leverton E, Solanky B, Snaar JEM, Morris PEG, Taylor R. The second meal phenomenon is associated with enhanced muscle glycogen storage. Clin Sci 2008 in press
8. Al-Ozairi E, Waugh JJS, Taylor R. Termination is not the treatment of choice for severe hyperemesis gravidarum: Successful management using prednisolone. Obstetric Medicine 2008 in press
9. Chaturvedi N,Porta M, Klein R,Orchard T,Fuller J,Parving HH,Bilous R,Sjolie AK Effect of candesartan on prevention (DIRECT- Prevent1) and progression (DIRECT-Protect 1) of retinopathy in type 1 diabetes : randomised ,placebo controlled trials. Lancet 2008 372 1394 – 1402.
10. Sjolie AK, Klein R,Porta M, Klein R,Orchard T,Fuller J,Parving HH,Bilous R, Chaturvedi N Effect of candesartan on progression and regression of retinopathy in type 2 diabetes (DIRECT-Protect 2) : a randomised placebo controlled trial. Lancet 2008 372 1385 – 93.

RECENT PUBLICATIONS IN DIABETES & ENDOCRINOLOGY THAT HIT THE NEWS OR THAT MAY HAVE A SIGNIFICANT IMPACT ON MANAGEMENT
Rennekampff H-O, et al. Chronic wound care. Lancet 2008;372:1860-1862. An excellent editorial, well worth a read and provides useful references.

Spurling G and Walsh M. Aspirin type 2 diabetes: is there any evidence base? BMJ 2008;337:1163-1165. A wonderful summary of the evidence that I feel gives a resounding NO, do you agree? It also links in nicely with the POPADAD study below.

Lecky B and Sathasivam S. Statin induced myopathy. BMJ 2008;337:1159-1162. An essential read that provides practical advice.

Stevens P et al. Early identification and management of chronic kidney disease: summary of NICE guidelines. BMJ 2008;337:812-815. AND Haynes RJ & Landray MJ. Commentary: controversies in NICE guidance on chronic kidney disease. BMJ 2008;337:815-816. An excellent summary very pertinent to those involved in leading the diabetic renal service.

Miller jc et al. Definitive characterisation of adrenal lesions. BMJ 2009;338:233-236. An essential read providing a pragmatic update on adrenal imaging.

Belch j, et al. The prevention of progression of arterial disease and diabetes (POPADAD) trial: factorial randomised placebo controlled trial of aspirin and antioxidants in patients with diabetes and asymptomatic peripheral arterial disease. BMJ 2008;337:1030-1034. This multicentre, randomised, double blind, 2x2 factorial, placebo controlled trial recruited 1276 adults aged 40 or more with type 1 or type 2 diabetes and an ankle brachial pressure index of 0.99 or less but no symptomatic cardiovascular disease. Daily, 100 mg aspirin tablet plus antioxidant capsule (n=320), aspirin tablet plus placebo capsule (n=318), placebo tablet plus antioxidant capsule (n=320), or placebo tablet plus placebo capsule (n=318) were the different therapy arms in the trial. The end-points measured were: primary end points of death from coronary heart disease or stroke, non-fatal myocardial infarction or stroke, or amputation above the ankle for critical limb ischaemia; and death from coronary heart disease or stroke. 116 of 638 primary events occurred in the aspirin groups compared with 117 of 638 in the no aspirin groups (18.2% vs 18.3%): hazard ratio 0.98 (95% CI 0.76-1.26). Forty three deaths from coronary heart disease or stroke occurred in the aspirin groups compared with 35 in the no aspirin groups (6.7% vs 5.5%): 1.23 (0.79-1.93). Among the antioxidant groups 117 of 640 (18.3%) primary events occurred compared with 116 of 636 (18.2%) in the no antioxidant groups (1.03, 0.79 to 1.33). Forty two (6.6%) deaths from coronary heart disease or stroke occurred in the antioxidant groups compared with 36 (5.7%) in the no antioxidant groups (1.21, 0.78 to 1.89). A profound NO for the use of aspirin as primary prevention is provided by this trial, admittedly in this group of patients studied. However, adding the other 7 trials with similar results in relation to primary prevention of cardiovascular disease with aspirin into the mix has certainly resulted in a change in my practice. Do you agree…………..

Astrup A, et al. Effect of tesofensine on bodyweight loss, body composition, and quality of life in obese patients: a randomised, double-blind, placebo-controlled trial. Lancet 2008;372:1906-1913. This phase II, randomised, double-blind, placebo-controlled trial in five Danish obesity management centres assessed the efficacy and safety of tesofensine-an inhibitor of the presynaptic uptake of noradrenaline, dopamine, and serotonin-in patients with obesity (originally it was developed as anti-parkinson’s drug). After a 2 week run-in phase, 203 obese patients (BMI 30<
=40 kg/m2) were prescribed an energy restricted diet and randomly to treatment with tesofensine 0.25 mg (n=52), 0.5 mg (n=50), or 1.0 mg (n=49), or placebo (n=52) once daily for 24 weeks. The primary outcome was percentage change in bodyweight. Analysis was by modified intention to treat (all randomised patients with measurement after at least one dose of study drug or placebo). 161 (79%) participants completed the study. After 24 weeks, the mean weight loss produced by diet and placebo was 2.0% (SE 0.60). Tesofensine 0.25 mg, 0.5 mg, and 1.0 mg and diet induced a mean weight loss of 4.5% (0.87), 9.2% (0.91), and 10.6% (0.84), respectively, greater than diet and placebo (p<0.0001). The most common adverse events caused by tesofensine were dry mouth, nausea, constipation, hard stools, diarrhoea, and insomnia. After 24 weeks, tesofensine 0.25 mg and 0.5 mg showed no significant increases in systolic or diastolic blood pressure compared with placebo, whereas heart rate was increased by 7.4 bpm in the tesofensine 0.5 mg group (p=0.0001). This trial suggests that tesofensine 0.5 mg might have the potential to produce a weight loss twice that of currently approved drugs. However, further trials are awaited.

Drucker DJ, et al. Exenatide once weekly versus twice daily for the treatment of type 2 diabetes: a randomised, open-label, non-inferiority study. Lancet 2008;372:1240-1250. In this 30-week, randomised, non-inferiority study the authors compared a long-acting release formulation of exenatide 2 mg administered once weekly to 10 mcg exenatide administered twice a day, in 295 patients with type 2 diabetes (HbA1c 8.3% [SD 1.0], mean fasting plasma glucose 9 [SD 2] mmol/L, weight 102 [SD 20] kg, diabetes duration 6.7 [SD 5.0] years). The patients were naive to drug therapy, or on one or more oral antidiabetic agents. The primary endpoint was the change in HbA1c at 30 weeks. At 30 weeks, the patients given exenatide once a week had significantly greater changes in HbA1c than those given exenatide twice a day (-1.9 [SE 0.1%] vs -1.5 [0.1%], 95% CI -0.54% to -0.12%; p=0.0023). A significantly greater proportion of patients receiving treatment once a week versus twice a day achieved target HbA1c levels of 7.0% or less (77%vs 61% of evaluable patients, p=0.0039). Hence, exenatide once weekly resulted in significantly greater improvements in glycaemic control than exenatide given twice a day, with no increased risk of hypoglycaemia and similar reductions in bodyweight. Very interesting times in managing Type 2 diabetes with a plethora of new therapies that require careful evaluation and integration in care, obviously led by “specialists”.
Holman, RR, et al. Long-term follow-up after tight control of blood pressure in Type 2 diabetes. NEJM 2008;359:1565-1576. 1148 UKPDS patients with newly diagnosed type 2 DM and hypertension were randomly assigned, over a 4-year period beginning in 1987, to tight or less-tight blood-pressure control regimens. The 884 patients who underwent post-trial monitoring were asked to attend annual UKPDS clinics for the first 5 years, but no attempt was made to maintain their previously assigned therapies. Annual questionnaires completed by patients and general practitioners were used to follow patients who were unable to attend the clinic in years 1 through 5, and questionnaires were used for all patients in years 6 to 10. Seven prespecified aggregate clinical end points were examined on an intention-to-treat basis, according to the previous randomization categories. Differences in blood pressure between the two groups during the trial disappeared within 2 years after termination of the trial. Significant relative risk reductions found during the trial for any diabetes-related end point, diabetes-related death, microvascular disease, and stroke in the group receiving tight, as compared with less tight, blood-pressure control were not sustained during the post-trial follow-up. No risk reductions were seen during or after the trial for myocardial infarction or death from any cause, but a risk reduction for peripheral vascular disease associated with tight blood-pressure control became significant (P=0.02). This follow-up study has shown that the benefits of previously improved blood-pressure control were not sustained when between-group differences in blood pressure were lost. A seminal study that answers a question my patients often ask “Doc can I stop my BP tablets now that it is controlled?” “NO-and here is why UKPDS”.
Holman RR, et al. 10-Year follow-up of intensive glucose control in Type 2 diabetes. NEJM 2008;359:1577-1589. 4209 UKPDS patients with newly diagnosed type 2 diabetes were randomly assigned to receive either conventional therapy (dietary restriction) or intensive therapy (either sulphonylurea or insulin or, in overweight patients, metformin) for glucose control. In post-trial monitoring, 3277 patients were asked to attend annual UKPDS clinics for 5 years, but no attempts were made to maintain their previously assigned therapies. Annual questionnaires were used to follow patients who were unable to attend the clinics, and all patients in years 6 to 10 were assessed through questionnaires. Seven prespecified aggregate clinical outcomes from the UKPDS on an intention-to-treat basis, according to previous randomization categories, were examined. Between-group differences in HbA1c levels were lost after the first year. In the sulphonylurea-insulin group, relative reductions in risk persisted at 10 years for any diabetes-related end point (9%, P=0.04) and microvascular disease (24%, P=0.001), and risk reductions for MI (15%, P=0.01) and death from any cause (13%, P=0.007) emerged over time, as more events occurred. In the metformin group, significant risk reductions persisted for any diabetes-related end point (21%, P=0.01), MI (33%, P=0.005), and death from any cause (27%, P=0.002). This seminal study has shown that despite an early loss of glycaemic differences, a continued reduction in microvascular risk and emergent risk reductions for MI and death from any cause were observed during 10 years of post-trial follow-up. A continued benefit after metformin therapy was evident among overweight patients. In other words “in the long run improving glycaemic control matters for cardiovascular risk reduction and every little helps”-a true legacy effect in keeping with the follow-up of the seminal DCCT study.

Increased Prevalence of Tricuspid Regurgitation in Patients with Prolactinomas Chronically Treated with Cabergoline. Annamaria Colao et al,(JCEM 93: 3777–3784, 2008). Objective of this observational, case-control study was to evaluate prevalence of cardiac valve regurgitation in cabergoline-treated patients with prolactinomas. Fifty treated patients (44 women and six men) and 50 sex- and age-matched control subjects participated; 20 de novo patients were also studied. In the treated patients, the last cabergoline dose was 1.3 ± 1.3 mg/wk (<1 mg/wk in 44%, 1–3 mg/wk in 46%, and >3 mg/wk in 10%). Treatment duration was 12–60 months in 32% and more than 60 months in 68%. The cumulative (milligrams x months of treatment) dose of cabergoline ranged from 32–1938 mg (median 280 mg). In de novo patients, treated patients, and controls, the prevalence of mild regurgitation of mitral (35, 22, and 12%, P = 0.085), aortic (0, 4, and 2%, P = 0.59), tricuspid (55, 30, and 42%, P = 0.13) or pulmonary (20, 12, and 6%, P = 0.22) valves was similar. Conversely, the prevalence of moderate tricuspid regurgitation was higher in the treated patients (54%) than in de novo patients (0%) and controls (18%, P < 0.0001). Moderate tricuspid regurgitation was more frequent in patients receiving a cumulative dose above the median (72%) than in those receiving a lower dose (36%, P = 0.023). A higher systolic (P = 0.03) and diastolic blood pressure (P < 0.0001) was found in patients with than in those without moderate tricuspid regurgitation. Moderate tricuspid regurgitation is more frequent in patients taking cabergoline (at higher cumulative doses) than in de novo patients and control subjects, but the clinical significance of this finding has not been established. A complete echocardiographic assessment is indicated in patients treated long term with cabergoline, particularly in those requiring elevated doses.

NEXT NEWSLETTER Due out beginning of June 2009 so keep the gossip coming.

Endodiabology -October 2008

2008-09-29T23:50:00.000+01:00

ENDODIABOLOGY
Endodiabology.blogspot.com

NORTHEAST
NEWSLETTER
FOR SPRs AND BOSSES TRAPPED
IN THE NORTHERN DEANERY

OCTOBER 2008
Editors: Shaz Wahid and
Petros Perros (
Associate Editors: Arut Vijayaraman, Shafie Kamarrudin, Beas Bhattacharya, Ravi Erukulapati

SpR PLACEMENTS (NTN year of training from 1st October 2008)
· RVI- Shafie Kamarrudin (3), Beas Bhattacharya (5), Asgar Madathil (4), Kathryn Stewart (2), Rohanna Wright (1), Chandima Idampitiya (4), Preeti Rao (2)
· North Tyneside/Wansbeck- Ravi Erukalapati(4), Sudeep Manohar (2)
· South Tyneside- Sukesh Chandran(5)
· Gateshead- Arutchelvan Vijayaraman (5)
· Sunderland- Jeevan Mettayil (3), Sarah Steven (1)
· North Tees/Hartlepool- Khaled Mansur-Dukhan (5), Stuart Little (1)
· Middlesbrough- Anjali Santhakumar (2), Arif Ullah (2), Yahya Maghoub
· Carlisle- Naveen Siddaramaiha (1)
· Bishop Auckland Srikanth Mada(2)
· Durham- Ravikumar Balasubramanian (5)
· NGH/QEH- Freda Razvi (5)
· Research with numbers (supervisor)- Eelin Lim(5-Prof Taylor)

MEETINGS / LECTURES / ANNOUNCEMENTS
· 6-8th October 2008 Society for Endocrinology Clinical update, Bristol. Contact www.endocrinology.org
· 17th October 2008 DUK 2009 abstract deadline.
· 12th November 2008 North East Obesity Forum meeting. Obesogenic environment.
· 12th November 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 15th November 2008 BES 2009 abstract deadline.
· 26th November 2008 Northern Endocrine Regional Research and Audit Group (NERRAG) annual meeting, Lumley Castle, Durham. Contact
· 27th November 2008 58th British Thyroid Association Annual meeting, London, www.british-thyroid-association.org .
· 27th and 28th November 2008 (29th November 2008 is SpR meeting) ABCD Autumn Meeting, London, www.diabetologists.org.uk
· 27th and 28th November 2008Insulin Pump Course, James Cook University Hospital. Apply on line at www.conferencessouthtees.co.uk
· 10th December 2008 RCP Updates in G(I)M, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 14th January 2009 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 26th January 2009 Northern Endocrine & Diabetes Winter CME, Freeman Hospital.
· 10th February 2009 SfE Clinical Cases meeting, London. Contact www.endocrinology.org .
· 11th-13th March 2009 DUK Annual Professional Conference, Birmingham. Contact www.diabetes.org.uk
· 16th – 19th March 2009 BES 2009, Harrogate. Contact www.endocrinology.org .
· 18th March 2009 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 29th April 2009 RCP Acute Medical Emergencies, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 7th-8th May 2009 ABCD Spring Meeting, Bristol, www.diabetologists.org.uk
· 11th May 2009 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 24th June 2009 Northern Endocrine & Diabetes Summer CME, Freeman Hospital.
· 12th October 2009 Northern Endocrine & Diabetes Autumn CME, James Cook University Hospital

TRAINING ISSUES
Confusing paperwork The transitional period between SpR and StR training remains confusing and is especially hindered by the JRCPTBs poor communication and awful paperwork sent to the trainees. There will have to be separate instructions for the RITAs (old SpRs) and ARCPs (the new StR breed). As an example a new educational supervisor report was published by the JRCPTB the week before this years ARCPs/RITAs. The TPD now at least has some time to look at all the documents and ultimately produce separate instructions for regional use.
Acute Medicine Level 2 training for SpRs For next years ARCPs/RITAs any SpR who has not had their PYA will be expected to have 4 ACAT assessments and 4 Mini-CEXs specifically in relation to Acute Medicine in their portfolio for the panel to review.
Acute Medicine Level 2 training for StRs Any trainee appointed after August 2007 will be considered a StR and for their ARCP they will be expected to have 4 ACAT assessments, 4 Mini-CEXs specifically in relation to Acute Medicine, 4 CbDs in relation to Acute Medicine, a valid ALS qualification, evidence of achievement of all the procedures deemed necessary for Acute Medicine Level 2 training, Evidence of achievement of all emergency presentations to level 2, Evidence of achievement of 2/3rds top 20 presentations to level 2 and Evidence of ½ of other presentations to level 2. It is recommended to use the pages available from the Acute Medicine e-portfolio to collect the later evidence that CMT (ST1-ST2) trainees should already have. If you do not have access to this then contact your Post-Grad Education Centre Manager who should be able to get you access to the e-portfolio for CMTs.
DIABETES & ENDOCRINOLOGY PIMD WEBSITE Our specialty website is available on http://mypimd.ncl.ac.uk/PIMDDev . Click onto the specialty training tab then follow to Diabetes & Endocrinology. This site is essential reading, especially for ARCP preparation.
Registering with PMETB It is essential that all new SpRs/StRs (even LATs) register with the PMETB through the newly created Joint Royal Colleges of Physicians Training Board (formally the JCHMT) on www.jrcptb.org.uk although it is still possible to link with this site using the old www.jchmt.org.uk link. Not doing so means your training is not counted.
Log Book/Portfolio Documentation It is a trainee’s responsibility to make sure their portfolio/log book is prospectively completed and the necessary signatures obtained. Any experience that is not signed off by your educational supervisor at the time cannot be counted towards training.
Assessment tools Please see www.jrcptb.org.uk, It is the trainee’s responsibility to give all the appropriate forms to their Educational or Clinical Supervisor. It is the trainee’s responsibility to make sure that the appropriate assessment summaries are available in their portfolio for ARCP purposes, e.g. MSF Summary Form.
ANOTHER CURRICULUM Trainees who have been recently appointed now have a new curriculum for both the specialty, Acute Medicine to Level 2 and a generic curriculum. Essentially there is no difference other than the sections being reorganised into the subsections of OBJECTIVE/COMPETENCY, KNOWLEDGE, SKILLS, ATTITUDE. They are essential reading and can be accessed on www.jrcptb.org.uk .
The GOLD Guide This replaces the Orange guide, and is the definitive guide to all aspects of training in the UK. It can be accessed on http://www.jrcptb.org.uk/SiteCollectionDocuments/Gold%20Guide.pdf . A massive document that I delve into when the need arises, e.g. interdeanery transfers.
Acute Care Assessment Tool The ACAT is a tool that is commendable. It provides a method of assessing how Trainees managed their on-call period. It is recommended that at least one is available for ARCP purposes. It can be downloaded from the JRCPTB website.
Personal Development Plans (PDPs) Following the ARCPs all trainees will have their report. It is essential that this report is used to construct a PDP when starting your new post from 1st October. The format used should be standard template circulated by Shaz Wahid.
Case Based Discussions (CbD) The pilot form is available from the JRCPTB website. It is a must for trainers to use as a tool to document feedback in clinic. This has always been done informally, but now there is a method to formally document it. I basically use it for when a SpR presents a new case to me in clinic.
Documenting CCU and ITU experience As of now it is essential that trainees document their CCU and ITU experience. This is best done by keeping a summary log of the cases seen on CCU and ITU and linking it with reflection or assessment. This should then be signed off by your Educational Supervisor to be of any use at the Acute Medicine PYAs.
Training Committee Chair- Jola Weaver,; Regional Speciality Advisor- Richard Quinton, ; Programme Director- TBC ; Consultant member-Shaz Wahid,; Consultant member-Jean MacLeod,; Consultant member (Research Advisor)-Simon Pearce,; Consultant member-Simon Eaton,; Consultant member-Nicky Leech; SpR representative- Arutchelvan Vijayaraman ; SpR representative- Jeevan Mettayil

NEWS FROM THE NORTHEAST
· Congratulations to Simon Ashwell on his recent marriage to Amelia Lake.
· Akheel Syed has moved onto a Locum Consultant post in Salford.
· Welcome to Naveen Siddaramaiha (NTN) and Yayha Maghoub (LAT) onto the rotation.
· Shaz Wahid will be stepping down from 1st November 2008 as TPD having completed his tenure.
· Congratulations to Emma Peralta on winning the Prize for best SPARROWS presentation.

LETTERS
The 7 habits of highly effective people-personal change and management SHAZ WAHID. I recently undertook the latter course and have read the book by Stephen Covey. This is what “management” training should be. It relates to the importance of personal management before moving onto management of others/situations. The first 3 habits are about being “proactive”, “having the end in mind” and “putting first things first”-all add up to a private victory. Once mastered one can practice the habits of “think win-win”, “seek first to understand” and “synergise”-all adding up to an effective public victory. Of course in the NHS we need to know what PCT, PBR, PBC, Foundation Trust, etc stand for and work. But, true “management” is about practicing the 7-habits effectively so that we can fullfil our potential as leaders. The 7th habit is “sharpen the saw” and it is about refreshing ones heart, mind, body and soul on a regular basis so that the 1st 6-habits can be practiced effectively. I have been really impressed by this, to the point I have devised a training programme for the Acute Medicine StR that will be rotating through South Tyneside and not to forget the SpR/StR in DM&ENDO. I hope you are intrigued and will try the 7-habits. I have bought the 7-habits of highly effective teenagers book for my 15 year old daughter, of course, but whether she is one of the frogs who actually jumps off the log or simply chooses to remains to be seen.

Rescue of Addison’s Disease Study (RADS)-Simon Pearce RADS is a groundbreaking Newcastle University study, that has been funded by the Medical Research Council. RADS will examine the possibility that autoimmune Addison's disease (AAD) may be a curable condition, rather than a disease that is simply controlled by hormone replacement. Although we generally assume that the autoimmune attack inevitably destroys all the adrenal cortex in autoimmune Addison’s disease, it is possible that the autoimmune attack could be modified. A key feature of AAD is that it is often diagnosed at a stage when subjects have low but detectable serum cortisol. As adrenal tissue is highly plastic, the residual steroidogenic tissue may be sufficient to regenerate normal steroid secretion under the powerful ACTH drive, if the autoimmune process can be arrested.
RADS is a pilot study of rituximab (B lymphocyte depletion) therapy in an attempt to rescue adrenal steroidogenic capacity in ten subjects with early autoimmune Addison's disease: within 1 month of diagnosis. During the first twelve weeks of treatment, additional glucocorticoid therapy (prednisolone) will be given to ensure wellbeing and to rest the steroidogenic apparatus that is the target of the autoimmune attack. Glucocorticoids will be gradually withdrawn, in a controlled fashion, and adrenal function re-evaluated at 13, 26, 39 and 52 weeks. The primary endpoint will be restoration of steroidogenic function as judged by conventional endocrine indices of adrenocortical function. Additional outcomes; 21-hydroxylase autoantibody titres, B cell counts, adverse events and patient wellbeing will be assessed. B cell depletion may ameliorate the autoimmune attack against adrenal cells, potentially allowing a state of immune tolerance to be restored with subsequent regeneration of adrenal steroidiogenic capacity. The importance of this study lies in the possibility of informing the treatment of type 1 diabetes and other autoimmune endocrinopathies, as well as the potential benefit to the Addison’s participants.
All participant treatment and follow-up will be carried out at the Clinical Research Facility, Royal Victoria Infirmary, Newcastle. There will be no payment to participants, but travel expenses to the RVI will be reimbursed.
If you have a suitable potential participant, please discuss the study with them, let them have the patient information leaflet and contact Simon Pearce, 0191-2418674 (office), 07811-902282 (mob) or s.h.s.pearce@ncl.ac.uk

SPARROWS REPORT-EMMA PERALTA (DSN) PRIZE WINNER
Having the opportunity to be one of the 21,000 attendees at this years American Diabetes Association 68th Scientific Sessions in SanFrancisco created a mix of emotions. Being the only diabetes specialist nurse in the SPARROW group was, at first somewhat nerve-racking, however those feelings were soon replaced with exhilarating thoughts of having such a fantastic opportunity to attend a conference of this size and being able to learn about cutting edge clinical research and studies. The theme of this year’s conference was Type 2 diabetes and cardiovascular disease, with most sessions reflecting this. Although all sessions attended were equally as interesting as each other, one or two were memorable for various reasons. One such session being the Banting Memorial lecture, presented by Ralph DeFronzo, in which he highlighted the need to intervene earlier. He presented his rather controversial (and expensive!) intervention of lifestyle + TZD + Metformin + Exenatide to a crowd of mixed responses.
Another interesting session was that of self-monitoring blood glucose in which it was concluded that the success of this is dependant upon the interest of the patient as well as the interest/ time dedicated by the provider. We need to teach patients not only how to monitor blood glucose levels, but how to translate the results into action in terms of self-care.
Dr Gallen presented a marvellous session on Hypoglycaemia during exercise with practical tips to help manage insulin therapy and blood glucose levels both during and after exercise.
Although the education sessions were plentiful and interesting, opportunities to learn about the latest products serving diabetes were available in the exhibit hall. Being a keen pump enthusiast, I was interested to learn more about the OmniPod, an insulin delivery system launched in the USA in 2005 consisting of an integrated insulin reservoir, personal device manager and blood glucose meter. A system which looks both exciting and at the forefront of pump technology.
Attending the conference, as part of the SPARROW GROUP was a truly superb experience, an opportunity I would urge all DSN’s to take up in the future.

SPARROWS REPORT-Vijayaraman Arutchelvam (SpR)
When I made my itinerary for the scientific programme, I chose to attend the sessions discussing the glycaemic target in Type 2 Diabetes. ACCORD, ADVANCE and VADT were the three studies presented in ADA exploring the benefits (!) of tight glycaemic control.
ACCORD was a randomized controlled trial with a double 2 by 2 factorial design. All cause death rate was high in the intensive therapy group (HR 1.22) prompting the glycaemic arm to be stopped. ADVANCE a factorial randomized trial showed no significant reduction in CV outcome but reduction in nephropathy incidence. VADT, a prospective randomized trial showed increased CV death in the intensive therapy group.
Of the three big studies 2 demonstrated clear negative results with 1 being neutral in terms of macro vascular outcome. This modified my practice that I learn to be reassured with an HbA1c target of 7% rather than 6.5% in long standing type 2 diabetes. These studies also demonstrate the problem with weight gain and the importance of achieving a good glycaemic control early. Table: Three outcome studies in Type 2 diabetes-see appendix A
SPARROWS REPORT-Ravikumat Erukalapati
I am summarising my key learning points from some of the sessions that I attended.
A.) Great Protein Debate
I found the debate stimulating and thought provoking.
Problems with high protein intake in Diabetic patients:
· ↑ proteinuria
· ↑ RBF, GFR, intraglomerular pressure
· ↑ rate of progression of kidney failure
· Increases acid load on kidney
· Promotes osteoporosis (↑ calciuria)
· Induces anorexia
In favour of high protein diet are:
· Not ↑ plasma glucose
· ↑ Insulin response
· No need to ↑ CHO or fat in diet
· ↓ appetite, ↑ satiety
· ↑ weight loss, maintains lean mass
· ↓ Chol, LDL, Trigs
· ↓ BP
· ↓ CV events
My take-home message:
· High protein diet is not necessarily bad for Diabetic patients and might in fact be beneficial. RCTs are needed in this area.
· Protein requirements for patients with Diabetic Nephropathy cannot be generalised. Their protein requirements have to be dealt by a specialist dietician individually.
· Daily protein requirements are better expressed if ‘gm/kg body wt’ is used instead of ‘% of diet’.
B.) Pregnancy sessions
· Evidence available so far suggests that Insulin analogues are safe in pregnancy
Lispro- several Obs. Studies
Aspart- one large RCT
Glargine- Obs. Studies
Levemir- Ongoing RCT
· CI for Metformin- small fetus, severe preeclampsia, sepsis
C.) Newer classes of pharmacologic agents for treatment of Hyperglycaemia.
SGLT2 Inhibitors
· Sodium Glucose Cotransporter Type 2 Inhibitors
· Dopagliflozin, Remogliflozin, Phase 3 trials
· Mechanism of action- Glycosuria
· SE - Transient Hyperkalaemia, salt wasting, dehydration, energy deficit, wt↓, polyuria, polydipsia, recurrent UTIs
Glucokinase Activators
· Potential use in T2DM
· Mechanism of action- ↑ Hepatic glucose utilisation, ↑ Insulin secretion
· SE- Hypoglycaemia , Steatosis, Hepatic Glycogen deposition, weight gain
Glucagon receptor Antagonists
· Gluconeogenesis ( Alanine, Lactate, Pyruvate ) and Glycogenolysis contribute to plasma glucose
· Latest data suggests that 60% of glucose output is due to Gluconeogenesis
· Blocking glucagon action in rodents ↓hepatic glucose production
Sirtuins
· SIRT1 activating compounds
· Anti senility agents
· Resveratrol (GSK)
· Similar products in Red wine- if you can drink 1000 bottles/day !!
Due to space constrains, I have not detailed the other sessions and also my Alcatraz prison experience!

RECENT PUBLICATIONS FROM THE NORTHEAST
1. Taylor R. Pathogenesis of type 2 diabetes: Tracing the Reverse Route. Diabetologia 2008 Aug 26. [Epub ahead of print; Full text available under Open Access]

2. Arun CS, Taylor R. Influence of pregnancy on long-term progression of retinopathy in patients with type 1 diabetes. Diabetologia 2008. Jun;51(6):1041-1045. Epub 2008 Apr 8.

3. Trenell MI, Hollingsworth KG, Lim EL, Taylor R. Walking improves lipid oxidation independent of changes in mitochondrial ATP synthesis in people with Type 2 diabetes. Diabetes Care 2008; 31(8):1644-9. Epub 2008 May 16.

4. Ravikumar, B, Gerrard J, Dalla Man C, Firbank MJ, Lane A, English PT, Cobelli C, Taylor R. Pioglitazone decreases fasting and postprandial endogenous glucose production in proportion to decrease in hepatic triglyceride content. Diabetes 2008 Sep;57(9):2288-95. Epub 2008 Jun 5.

5. Simon G. Ashwell, Clare Bradley, James W. Stephens, Elke Witthaus, and Philip D. Home Treatment Satisfaction and Quality of Life With Insulin Glargine Plus Insulin Lispro Compared With NPH Insulin Plus Unmodified Human Insulin in Individuals With Type 1 Diabetes Diabetes Care 31: 1112-1117, June 2008.

6. Razvi S, Shakoor A, Vanderpump M, Weaver JU, Pearce SH. The influence of age on the relationship between subclinical hypothyroidism and ischemic heart disease: a metaanalysis. J Clin Endocrinol Metab. 2008 Aug;93(8):2998-3007.

7. Falardeau J, Chung WCJ, Beenken A, Raivio T, Plummer L, Sidis I, Jacobson-Dickman EE, Eliseenkova AV, Ma J, Dwyer AA, Quinton R, Na S, Hall JE, Huot C, Alois N, Pearce SHS, Cole LW, Hughes VA, Mohammadi M, Tsai P, Pitteloud N. 2008 Decreased FGF8 signaling causes deficiency of gonadotropin-releasing hormone in human and mice. Journal of Clinical Investigation. 118: 2832-2831.

8. Advani A, Vaikkakara S, Gill MS, Arun CS, Pearce SHS, Ball SG, James RA, Lennard TJW, Bliss RD, Quinton R, Johnson SJ. 2008 Impact of standardised reporting in adrenocortical carcinoma: a single centre clinicopathological review. Journal of Clinical Pathology. 61: 939-944.

9. Cole LW, Sidis I, Zhang CK, Quinton R, Plummer L, Pignatelli D, Hughes VA, Dwyer AA, Raivio T, Hayes FJ, Seminara SB, Huot C, Alos N, Speiser P, Takeshita A, van Vliet G, Pearce SHS, Crowley WF, Jr, Zhou QY, Pitteloud N. 2008 Mutations in Prokineticin 2 (PROK2) and PROK2-receptor (PROKR2) in human gonadotrophin-releasing hormone deficiency: molecular genetics and clinical spectrum. Journal of Clinical Endocrinology & Metabolism. 93: 3551-9.

10. Al-Ozairi E, Quinton R, Advani A. 2008 Therapeutic response to metformin in an underweight patient with polycystic ovarian syndrome. Fertility & Sterility. 2008 Jan 25. [Epub ahead of print].

11. Arutchelvam V & Quinton R. 2008 Anaemia in older patients can be secondary to testosterone deficiency. Geriatric Medicine. 38: 272-273.

12. Quinton R, Pearce SHS, Sievenpiper JL. 2008 Sun and melanoma: time to go to get your hat. BMJ. 337: 309.

13. Sievenpiper JL, McIntyre EA, Verrill M, Quinton R, Pearce SHS. 2008 Lesson of the Week: Unrecognised severe vitamins D deficiency. BMJ. 336: 1371-1374. [with Editorial Comment: Deficiency of sunlight and vitamin D: fortification of foods and advice on sensible sun exposure are urgently needed@, pp1318-1319]

14. Vaidya B, Pearce SHS. Management of hypothyroidism in adults. BMJ
2008;337: 284-89.

15. Skinningsrud B, Husebye ES, Pearce SH, McDonald DO, Brandal K, Boe Wolff A, Lovas K, Egeland T, Undlien DE. Polymorphisms in CLEC16A and CIITA at 16p13 are associated with primary adrenal insufficiency. J Clin Endocrinol Metab 2008; 93:3310-7.

16. Pearce SHS. Section VI. Hyperparathyroidism. In Davies TF. Case-based guide to Clinical Endocrinology. Integra Press, 2008 pp169-193.
Including case contributions from Drs. CS Arun, Ebaa Al Ozairi, Ee Lin Lim, Andy James, Muthy Korada, Reena Thomas & Tim Cheetham.

RECENT PUBLICATIONS IN DIABETES & ENDOCRINOLOGY THAT HIT THE NEWS OR THAT MAY HAVE A SIGNIFICANT IMPACT ON MANAGEMENT
Intensive glycaemic control and cardiovascular disease. Much has been said about this topic following publication of the ACCORD and ADVANCE trials. I would suggest reading Arut’s letter summarising the trials and read from there.
PTH Mutation with primary hyperthyroidism and undetectable intact PTH. Halpern et al. NEJM 2008;359:1182-1183. An interesting case report that should also be read in conjunction with a recent article on the same subject in Clinical Endocrinology.
Extracapsular haemorrhage from a parathyroid adenoma. MC Zillikens & A Wijbenga. NEJM 2008;359:1155. A good clinical picture.

Hypoparathyroidism. Dolores Shoback. NEJM 2008;359:391-403. An excellent practical review well worth a read.

Sievenpiper JL, McIntyre EA, Verrill M, Quinton R, Pearce SHS. 2008 Lesson of the Week: Unrecognised severe vitamins D deficiency. BMJ. 336: 1371-1374. [with Editorial Comment: Deficiency of sunlight and vitamin D: fortification of foods and advice on sensible sun exposure are urgently needed@, pp1318-1319]. An excellent local article that should serve as a reminder to consider vitamin D deficiency.

Precocious Puberty. JC Carel & J Leger. NEJM 2008;358:2366-2377. Essential reading for trainees.

Graves’ Disease. Gregory Brent. NEJM 2008;358:2594-2605. A good update.
A combined presentation of Graves’ disease and Miller-Fisher syndrome. Vetsch et al. NEJM 2008;371:1886. An excellent case report.

Risk assessment and lipid modification for primary and secondary prevention of cardiovascular disease: summary of NICE guidance (Angela Cooper&Norma O’Flynn) & the accompanying controversies report (Francesco Cappucio). BMJ 2008;336:1246-1249. An excellent summary with analysis.

The Addison’s disease dilemma-autoimmune or ALD? M-F Kong et al. Lancet 2008;371:1970. A very good case report that should act as a reminder that not all Addison’s is autoimmune.

Type 1 diabetes, hyperglycaemia, and the heart. Ravi Retnakaran & Bernard Zinman. Lancet 2008;371:1790-1809. A wonderful article reviewing the pathophysiology and possible treatment strategies of heart disease in Type 1 DM-NOT Type 2!

Management of type 2 diabetes; updated NICE guidance (Philip Home et al) & the accompanying controversies report (Stephen Atkin & Chris Walton). BMJ 2008;336:1306-1309. I just could not look at the electronic report hence bought the hard copy, tis big! This is an excellent summary of the guidance with some food for thought. Thankfully, because of my crystal ball gazing the local district guidelines do not need much rewriting.

Diagnosis and management of hypocalcaemia. Mark Cooper & Neil Gittoes. BMJ 2008;336:1298-1302. An excellent review and practical update.Can metabolic syndrome usefully predict cardiovascular disease and diabetes? Outcome data from two prospective studies. Sattar N, McConnachie A et al. Lancet 2008;371:1927-1935. The authors investigated to what extent metabolic syndrome and its individual components were related to risk for cardiovascular disease and diabetes in elderly populations, by relating metabolic syndrome (defined on the basis of criteria from the Third Report of the National Cholesterol Education Program) and its five individual components to the risk of events of incident cardiovascular disease and type 2 diabetes in 4812 non-diabetic individuals aged 70-82 years from the Prospective Study of Pravastatin in the Elderly at Risk (PROSPER); and, in a second prospective study (the British Regional Heart Study [BRHS]) of 2737 non-diabetic men aged 60-79 years. In PROSPER, 772 cases of incident cardiovascular disease and 287 of diabetes occurred over 3.2 years. Metabolic syndrome was not associated with increased risk of cardiovascular disease in those without baseline disease (hazard ratio 1.07 [95% CI 0.86-1.32]) but was associated with increased risk of diabetes (4.41 [3.33-5.84]) as was each of its components, particularly fasting glucose (18.4 [13.9-24.5]). Results were similar in participants with existing cardiovascular disease. In BRHS, 440 cases of incident cardiovascular disease and 105 of diabetes occurred over 7 years. Metabolic syndrome was modestly associated with incident cardiovascular disease (relative risk 1.27 [1.04-1.56]) despite strong association with diabetes (7.47 [4.90-11.46]). In both studies, body-mass index or waist circumference, triglyceride, and glucose cutoff points were not associated with risk of cardiovascular disease, but all five components were associated with risk of new-onset diabetes. The authors conclude that metabolic syndrome and its components are associated with type 2 diabetes but have weak or no association with vascular risk in elderly populations, and that clinical focus should remain on establishing optimum risk algorithms for each disease separately. This point is eloquently argued by Richard Kahn in the accompanying editorial (Lancet 2008;371:1892-1893) as “another nail in the coffin”.Effect of intensive insulin therapy on beta-cell function and glycaemic control in patients with newly diagnosed type 2 diabetes: a multicentre randomized parallel-group trial. Weng J, Li Y et al. Lancet 2008;371:1753-1760. In this multicentre, randomised trial to compare the effects of transient intensive insulin therapy(continuous subcutaneous insulin infusion[CSII] or multiple daily insulin injections [MDI]) with oral hypoglycaemic agents on beta-cell function and diabetes remission rate; 382 patients, aged 25-70 years, were enrolled from nine centres in China. The patients, with fasting plasma glucose of 7.0-16.7 mmol/L, were randomly assigned to therapy with insulin (CSII or MDI) or oral hypoglycaemic agents for initial rapid correction of hyperglycaemia. Treatment was stopped after normoglycaemia was maintained for 2 weeks. Patients were then followed-up on diet and exercise alone. Intravenous glucose tolerance tests were done and blood glucose, insulin, and proinsulin were measured before and after therapy withdrawal and at 1-year follow-up. The primary endpoint was time of glycaemic remission and remission rate at 1 year after short-term intensive therapy. More patients achieved target glycaemic control in the insulin groups (97.1% in CSII and 95.2%in MDI) in less time (4.0 days [SD 2.5] in CSII and 5.6 days [SD 3.8] in MDI) than those treated with oral hypoglycaemic agents (83.5% and 9.3 days [SD 5.3]). Remission rates after 1 year were significantly higher in the insulin groups (51.1% in CSII and 44.9% in MDI) than in the oral hypoglycaemic agents group (26.7%; p=0.0012). Beta-cell function measured by HOMA B and acute insulin response improved significantly after intensive interventions. The increase in acute insulin response was sustained in the insulin groups but significantly declined in the oral hypoglycaemic agents group at 1 year in all patients in the remission group. This study suggests that early intensive insulin therapy in patients with newly diagnosed type 2 diabetes has favourable outcomes on recovery and maintenance of beta-cell function and protracted glycaemic remission compared with treatment with oral hypoglycaemic agents. There are obvious limitations with extrapolating these results to our own patients, but I will not forget Andrew Advani thinking I was a “nut” when I used a similar approach in patients with clinical features of type 2 diabetes presenting with significant hyperglycaemia to the acute take. I think he changed his opinion when he saw the majority come off insulin and onto either oral agents or diet alone.Effect of financial incentives on inequalities in the delivery of primary clinical care in England: analysis of clinical activity indicators for the quality and outcomes framework. Doran T, Fullwood C, Kontopantelis E, Reeves D. Lancet 2008;372:728-736. The quality and outcomes framework (QuOF) has received much praise and some suggest it has done more for diabetes care than insulin! Make what you wish of it, but what is clear financial incentives have helped improved the processes and outcomes of care in the community allowing specialist teams to branch out into areas they can do justice to. Before you pure Endocrinologists switch off monitoring of thyroxine therapy is in the QuOF. However, incentive schemes can increase inequalities in the delivery of care if practices in affluent areas are more able to respond to the incentives than are those in deprived areas. The authors examined the relation between socioeconomic inequalities and delivered quality of clinical care in the first 3 years of QuOF by analyzing data extracted automatically from clinical computing systems for 7637 general practices in England, data from the UK census, and data for characteristics of practices and patients from the 2006 general medical statistics database. Practices were grouped into equal-sized quintiles on the basis of area deprivation in their locality. The overall levels of achievement, defined as the proportion of patients who were deemed eligible by the practices for whom the targets were achieved, for 48 clinical activity indicators during the first 3 years of QuOF were calculated. The median overall reported achievement was 85.1% (IQR 79.0-89.1) in year 1, 89.3% (86.0-91.5) in year 2, and 90.8% (88.5-92.6) in year 3. In year 1, area deprivation was associated with lower levels of achievement, with median achievement ranging from 86.8% (82.2-89.6) for quintile 1 (least deprived) to 82.8% (75.2-87.8) for quintile 5 (most deprived). Between years 1 and 3, median achievement increased by 4.4% for quintile 1 and by 7.6% for quintile 5, and the gap in median achievement narrowed from 4.0% to 0.8% during this period. Increase in achievement during this time was inversely associated with practice performance in previous years (p<0.0001), but was not associated with area deprivation (p=0.062). These results suggest that QuOF has made a substantial contribution to the reduction of inequalities in the delivery of clinical care related to area deprivation. Before, we put another leaf on QuOFs laurel it is essential to read the balanced accompanying editorial by Barbara Starfield (Lancet 2008;372:692-694) that states do these expensive financial incentive schemes truly reduce suffering? I guess my tune may change if HbA1c ever becomes a performance measure for specialists.

NEXT NEWSLETTER Due out beginning of February 2009 so keep the gossip coming.

Endodiabology June 2008

2008-05-27T22:51:00.000+01:00

ENDODIABOLOGY
Endodiabology.blogspot.com

NORTHEAST NEWSLETTER
FOR SPRs AND BOSSES TRAPPED
IN THE NORTHERN DEANERY

JUNE 2008
Editors: Shaz Wahid and Petros Perros
Associate Editors: Arut Vijayaraman, Shafie Kamarrudin, Beas Bhattacharya, Ravi Erukulapati

SpR PLACEMENTS (NTN year of training from 1st October 2007)
· RVI- Arutchelvan Vijayaraman (4), Jeevan Mettayil (3), Khaled Mansur-Dukhan (4)
· Freeman- Chandima Idampitiya (3), Ravikumar Balasubramanian (5)
· North Tyneside/Wansbeck- Akheel Syed(5), Sukesh Chandran(4)
· South Tyneside- Kathryn Stewart (1)
· Gateshead- Asgar Madathil (4)
· Sunderland- Shafie Kamarrudin (2),
· North Tees/Hartlepool- Beas Bhatacharya (4), Anjali Santhakumar (1)
· Middlesbrough- Srikanth Mada(1), Ravi Erukalapati(3), Preeti Rao
· Carlisle- Sudeep Manohar
· Bishop Auckland / Durham- , Arif Ullah (1)
· NGH/QEH- Freda Razvi (3)
· Research with numbers (supervisor)- Eelin Lim(4-Prof Taylor)

MEETINGS / LECTURES / ANNOUNCEMENTS
· 6th-10th June 2008 American Diabetes Association 68th Annual Scientific Sessions, San Francisco, USA. Contact meetings@diabetes.org .
· 15th-18th June 2008 ENDO 2008, San Francisco. Contact endostaff@endo-societ.org or www.endo-society.org/scimeetings .
· 17th June 2008 Management of Type 2 Diabetes (NICE GUIDELINES), Royal College of Physicians London. See RCPL website.
· 24th June 2008 Joint Trainers & Trainees meeting from 1600, University Hospital North Tees. This follows the STC meeting and the SPARROWS feedback meeting will begin from 1730.
· 3rd July 2008 Association of Physicians meeting, Freeman Hospital from 6pm.
· 9th July 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 16th July 2008 Northern Endocrine & Diabetes Summer CME, Freeman Hospital. Contact
· 3rd September 2008 Advanced insulin pump day, James Cook University Hospital. Contact Apply on line at www.conferencessouthtees.co.uk
· 7th-11th September 2008 44th EASD Annual meeting, Rome, Italy. Contact www.easd.org
· 15th September 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 8th October 2008 Northern Endocrine & Diabetes Autumn CME, James Cook University Hospital. Contact
· 12th November 2008 North East Obesity Forum meeting. Obesogenic environment. Contact
· 12th November 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 26th November 2008 Northern Endocrine Regional Research and Audit Group (NERRAG) annual meeting, Lumley Castle, Durham. 27th November 2007 58th British Thyroid Association Annual meeting, London, www.british-thyroid-association.org .
· 27th and 28th November 2008 (29th November 2008 is SpR meeting) ABCD Autumn Meeting, London, www.diabetologists.org.uk
· 27th and 28th November 2008Insulin Pump Course, James Cook University Hospital. Apply on line at www.conferencessouthtees.co.uk
· 10th December 2008 RCP Updates in G(I)M, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247

TRAINING ISSUES
IS THERE A CRISIS LOOMING Answers on a post card please. See the letter by Shaz Wahid in the letters section. The letter should stimulate discussion at the annual Trainers and Trainees meeting on the 24th June 2008.
QUALITY ASSURANCE Our specialty is undergoing a QA review by the PMETB. Richard Quinton is co-ordinating this and will be in touch with individual units shortly.
Information about the Pilot of Workplace-Based Assessments See the letters section.
Confusing paperwork The transitional period between SpR and StR training remains confusing and is especially hindered by the JRCPTBs poor communication and awful paperwork sent to the trainees. Despite the TPDs best attempts to try and reduce this confusion and introduce consistency it looks as though there will have to be separate instructions for the RITAs (old SpRs) and ARCPs (the new StR breed). As an example a new educational supervisor report was published by the JRCPTB the week before this years ARCPs/RITAs. The TPD now at least has some time to look at all the documents and ultimately produce separate instructions for regional use.
Acute Medicine Level 2 training for SpRs For next years ARCPs/RITAs any SpR who has not had their PYA will be expected to have 4 ACAT assessments and 4 Mini-CEXs specifically in relation to Acute Medicine in their portfolio for the panel to review.
Acute Medicine Level 2 training for StRs Any trainee appointed after August 2007 will be considered a StR and for their ARCP they will be expected to have 4 ACAT assessments, 4 Mini-CEXs specifically in relation to Acute Medicine, 4 CbDs in relation to Acute Medicine, a valid ALS qualification, evidence of achievement of all the procedures deemed necessary for Acute Medicine Level 2 training, Evidence of achievement of all emergency presentations to level 2, Evidence of achievement of 2/3rds top 20 presentations to level 2 and Evidence of ½ of other presentations to level 2. It is recommended to use the pages available from the Acute Medicine e-portfolio to collect the later evidence that CMT (ST1-ST2) trainees should already have. If you do not have access to this then contact your Post-Grad Education Centre Manager who should be able to get you access to the e-portfolio for CMTs.
DIABETES & ENDOCRINOLOGY PIMD WEBSITE Our specialty website is available on http://mypimd.ncl.ac.uk/PIMDDev . Click onto the specialty training tab then follow to Diabetes & Endocrinology. This site is essential reading, especially for ARCP preparation.
Registering with PMETB It is essential that all new SpRs/StRs (even LATs) register with the PMETB through the newly created Joint Royal Colleges of Physicians Training Board (formally the JCHMT) on www.jrcptb.org.uk although it is still possible to link with this site using the old www.jchmt.org.uk link. Not doing so means your training is not counted.
Log Book/Portfolio Documentation It is a trainee’s responsibility to make sure their portfolio/log book is prospectively completed and the necessary signatures obtained. Any experience that is not signed off by your educational supervisor at the time cannot be counted towards training.
Assessment tools Please see www.jrcptb.org.uk, It is the trainee’s responsibility to give all the appropriate forms to their Educational or Clinical Supervisor. It is the trainee’s responsibility to make sure that the appropriate assessment summaries are available in their portfolio for ARCP purposes, e.g. MSF Summary Form.
ANOTHER CURRICULUM Trainees who have been recently appointed now have a new curriculum for both the specialty, Acute Medicine to Level 2 and a generic curriculum. Essentially there is no difference other than the sections being reorganised into the subsections of OBJECTIVE/COMPETENCY, KNOWLEDGE, SKILLS, ATTITUDE. They are essential reading and can be accessed on www.jrcptb.org.uk .
The GOLD Guide This replaces the Orange guide, and is the definitive guide to all aspects of training in the UK. It can be accessed on http://www.jrcptb.org.uk/SiteCollectionDocuments/Gold%20Guide.pdf . A massive document that I delve into when the need arises, e.g. interdeanery transfers.
Acute Care Assessment Tool The ACAT is a tool that is commendable. It provides a method of assessing how Trainees managed their on-call period. It is recommended that at least one is available for ARCP purposes. It can be downloaded from the JRCPTB website.
Carbohydrate Counting Visit www.bdec-e-learning.com an essential resource that is free for now. Highly recommended for all caring for patients with Diabetes and something that could be considered mandatory for trainees.
Knowledge Based Assessments for Diabetes and Endocrinology will be rolled out by Spring 2009. The test will be compulsory for all SpRs who started on or after 1 August 2007. “Older” SpRs will also be encouraged to take it, but not compulsory for them. It will be administered by the RCP’s MRCP office and will look a lot like the written bits of MRCP parts 1 & 2. 2 sittings per year, starting in 2009. Cost £800. Not decided yet if this will be payable as a lump sum or in annual instalments added to the PMETB annual fee. Not decided yet if resits will mean paying the fee again. To be taken after SpR year 2 (=ST4) and passed before PYA Once passed, your MRCP UK will be amended to MRCP UK (Endocrinology & Diabetes).
Personal Development Plans (PDPs) Following the ARCPs all trainees will have their report. It is essential that this report is used to construct a PDP when starting your new post from 1st October. The format used should be standard template circulated by Shaz Wahid. This PDP should be completed by 26th November 2008 and a copy sent to Shaz Wahid for your training file. These PDPs are essential and compulsory from this year onwards.
Improving our links with Acute Medicine A number of Consultants in our specialty have a genuine interest in Acute Medicine (recently joined by Shaz Wahid). They do more than just the acute ward rounds, but are actively involved in designing the delivery of the emergency care of acute admissions. (a testament to the fact that Consultants in our specialty have a knack at service design across districts, regions and broad groups of health professionals). Several of the latter Consultants are closely involved with the training committees at the core and higher specialty level. Shaz Wahid is looking at improving the links with the latter STCs for the benefit of training in the specialty, recruitment to the specialty and careers counselling for the SpRs/StRs in preparation for a lukewarm Consultant job market.
Training Committee Chair- Jola Weaver, Regional Speciality Advisor- Richard Quinton, Programme Director- Shaz Wahid, Consultant member-Jean McLeod, Consultant member (Research Advisor)-Simon Pearce,; Consultant member-Simon Eaton,; Consultant member-Nicky Leech ; SpR representative- Arutchelvan Vijayaraman SpR representative- Jeevan Mettayil

NEWS FROM THE NORTHEAST
· Congratulations to Preethi Rao and Sudeep Manohar on obtaining their NTNs following the recent gruelling National interviews and will join as StRs.
· Welcome to Cecil Thomas as the 3rd Consultant at South Tyneside. He trained on the Mersey rotation and has an interest in the diabetic foot and cardiovascular diabetes.
· Welcome to Sarah Steven and Stuart Little as new StR3s joining us from 6th August 2008 through the CMT programme.
· Congratulations to all of those of you that presented at the recent BES and DUK conferences. The region had a strong presence at both national events. Jeevan Mettayil did particularly well presenting at the Cushings in pregnancy meet the professor session at the BES.
· Congratulations to Salman Razvi on his election to the British Thyroid Association Executive Committee.
· Andrew Advani and Muthukamaran Jayapaul have both got their CCTs and have moved to pastures new, Toronto for Andrew and India for Muthu.
· Reena Thomas will be getting married soon and moving to the USA.

LETTERS
The future of training in the specialty-Shaz Wahid
In recent times there are 2 worrying trends for our specialty. One is the lack of Consultant posts and indeed no real scope of further Consultant expansion given the government agenda. Hence, we will rely on retirements for future Consultant posts for the SpR/StRs. Not an issue, unless you look around at the current crop of Consultants and notice that the majority are at the beginning or prime of their careers. The second trend is the lack of “new” blood entering the specialty at training level coupled with the perceived poor popularity of the specialty. Having been involved with the national interviews we had 185 applications. I would say barely 30 were of good quality. We ended up short listing 48 and 38 turned up for interview. Of the 38 only 17 made the grade to be appointable to a NTN. Of the 24 NTNs available nationally we filled 14! The top 2 ranked candidates (one of whom had the Northern Deanery as their 1st choice) declined the offer as they must have been successful at their preferred specialty interview. Having said this, the way Preethi and Sudeep interviewed did my kudos with my fellow TPDs a world of good and they were an excellent advert for the region. Those of us at the national interviews discussed these trends in some detail, thankfully over a nice meal in the evening. We were a mix of the young (myself, Rob Andrews, Philip Weston and Marie-France Kong) and the learned well travelled ones (Ian Scobie, Steven Olczak and Andrew Johnson (who at some point in their career had some experience of the Northern Deanery)). We are pushing our SAC to progress three main issues:

1. To make sure that every region has Diabetes & Endocrinology contributing to core medical training. To our surprise there were 2 regions where our specialty was taken out of the CMT programme as it was felt the specialty was best suited to GP training!!!!! A major surprise given that the average on-call take admits 10-25% of patients with a metabolic problem.

2. We need to seriously think about cutting our training posts locally and nationally so as to try and make sure that we have quality entering the specialty. What we do not want to become is a specialty that only produces cannon fodder for Acute Medicine alone. We should reclaim ourselves as an elite specialty.

3. We need to make strides in improving our popularity within the ranks of the “young”. This can only be done by getting the F2s and CMTs to clinic. Despite my misgivings about run-through training I think our region has benefited. This year we have attracted 2 from the CMT programme and I know of at least 3 ST1s showing a serious interest in our specialty and are making active improvements to their CVs to reflect this. I need all trainers to seriously look at the F2 and CMT trainees that rotate through their units and actively try to get them to clinics so as to attract them to the specialty. I suppose I could introduce a prize for the training unit that attracts the most CMTs into the specialty to be presented at the annual Trainers & Trainees meeting.

I look forward to discussing these issues with yourselves in the near future.

Pilot of Workplace-Based assessments-Richard Quinton & Shaz Wahid
The RCP are launching a study to look at the above. The STC are meeting to discuss a local Study Co-ordinator within their own ranks. Once appointed the LSC will ask for volunteers from the trainees. For now the general information is provided below.
Information about the Pilot of Workplace-Based Assessments
In recent years the Royal Colleges of Physicians have promoted the use of workplace-based assessments (DOPS, mini-CEX and multi-source feedback) for trainees, having researched and piloted these techniques. In 2007 all specialties of medicine were required by the Postgraduate Medical Education and Training Board (PMETB) to define assessment strategies to be followed by all trainees entering the new run-through training programmes. For each speciality we now have an integrated assessment system which identifies the appropriate methods to be used to assess curricula competencies. These include combinations of workplace-based assessments, including “new” methods in addition to those mentioned above. Before introducing these new methods the Colleges are piloting them to investigate their reliability (provides reproducible results), validity (measures what it is supposed to) and feasibility in busy working environments.
The Methods to be Piloted
All 29 specialties and sub-specialties of medicine are participating in the project. The following assessment methods will be piloted, though not all of them may be relevant to all specialties. We will try to establish common formats which are acceptable to all or most specialties.
Case Based Discussion
A CbD assesses the performance of a trainee in the assessment and management of a patient to provide an indication of competence in areas such as clinical reasoning, decision-making and application of medical knowledge in relation to patient care.
Acute Care Assessment Tool
The ACAT is designed to assess and facilitate feedback on a doctor’s performance during a period practising on the Acute Medical Take. It is intended to help trainees show they are competent in managing the Acute Medical Take by assessing performance in areas such as prioritisation, communication, teamwork, patient assessment and decision-making over the course of a take period.
Audit Assessment
The Audit Assessment is designed to assess a trainee’s ability to conduct an audit by reviewing, against agreed criteria, an audit which the trainee has carried out.
Patient Survey
The Patient Survey is a method of giving patients the opportunity to give feedback on the performance of a doctor following an out-patient consultation. A number of patients are invited to provide feedback to build up a picture of a doctor’s performance in areas such as communication and professionalism.
Teaching Observation
The Teaching Observation is designed to provide a framework for assessors to provide structured feedback to a trainee. It is a formative tool only and does not have a numerical rating scale.
Local study set up
We will try to include all medical specialties and all regions of the UK in the pilot. For each specialty and participating hospital/centre there will be a nominated consultant in charge who will be the Local Study Coordinator. The Local Study Coordinator will be responsible for recruiting trainees, informing potential assessors (e.g. consultants, associate specialists, senior trainees) and distributing initial paperwork. Educational Supervisors will be asked to participate in order to provide feedback to the trainee on the Patient Survey outcome. Clearly in small units the Local Study Coordinator, Educational Supervisor and Assessor may often be the same person.

The Local Study Coordinator will give participating trainees a code, so that they remain anonymous to the College. They will then distribute information and paperwork to the trainees – this will also be available to download from www.jrcptb.org.uk. All participants will receive a detailed study handbook.

The trainees will be responsible for initiating all assessments, ensuring all paperwork is completed and returned to the Local Study Coordinator. The Local Study Coordinator will return any completed paperwork to the College in self-addressed/stamped envelopes (SAEs). They will also be the point of contact for the College in the event of any problems, incomplete or unreturned documents. The process for managing the Patient Survey will be different but the details of this are still to be defined.
Timescale
We are aiming to start the pilot in April 2008 and to allow 6 months for the completion of the assessments. We will then report findings in winter 2008/9.
Contact
For more information or to take part in the pilot contact:
Joe Booth
Education Projects Manager
Education Department
Royal College of Physicians
London NW1 4LE
joe.booth@rcplondon.ac.uk
020 7935 1174 xtn 541

RECENT PUBLICATIONS FROM THE NORTHEAST
1. Komajda M, Curtis P, Hanefeld M, Beck-Nielsen H, Pocock SJ, Zambanini A, Jones NP, Gomis R, Home PD, for The RECORD Study Group. Effect of the addition of rosiglitazone to metformin or sulfonylureas versus metformin/sulfonylurea combination therapy on ambulatory blood pressure in people with type 2 diabetes: a randomized controlled trial (the RECORD study). Cardiovascular Diabetology 2008; 7:10. doi:10.1186/1475-2840-7-10
2. McMillan C, Bradley C, Razvi S, Weaver J. Evaluation of new measures of the impact of hypothyroidism on quality of life and symptoms: the ThyDQoL and ThySRQ. Value Health. 2008 Mar-Apr;11(2):285-94.
3. Leontiou CA, Gueorguiev M, van der Spuy J, Quinton R, Lolli F, Hassan S, Chahal HS, Igreja SC, Jordan S, Rowe J, Stolbrink M, Christian HC, Wray J, Bishop-Bailey D, Berney DM, Wass JA, Popovic V, Ribeiro-Oliveira A Jr, Gadelha MR, Monson JP, Akker SA, Davis JR, Clayton RN, Yoshimoto K, Iwata T, Matsuno A, Eguchi K, Musat M, Flanagan D, Peters G, Bolger GB, Chapple JP, Frohman LA, Grossman AB, Korbonits M. THE ROLE OF THE AIP GENE IN FAMILIAL AND SPORADIC PITUITARY ADENOMAS. J Clin Endocrinol Metab. 2008 Apr 17. [Epub ahead of print]
4. Al-Ozairi E, Quinton R, Advani A.Therapeutic response to metformin in an underweight patient with polycystic ovarian syndrome.Fertil Steril. 2008 Jan 25. [Epub ahead of print]PMID: 18222436 [PubMed - as supplied by publisher]
5. Vaikkakara S, Al-Ozairi E, Lim E, Advani A, Ball SG, James RA, Quinton R. The investigation and management of severe hyperandrogenism pre- and postmenopause: non-tumor disease is strongly associated with metabolic syndrome and typically responds to insulin-sensitization with metformin. Gynecol Endocrinol. 2008 Feb;24(2):87-92.
6. Syed AA, Quinton R. Congenital radioulnar synostosis, azoospermia, and pseudodicentric Y chromosome. Fertil Steril. 2008 Jan 2. [Epub ahead of print]
7. Al-Ozairi E, Michael E, Quinton R. Insulin resistance causing severe postmenopausal hyperandrogenism. Int J Gynaecol Obstet. 2008 Mar;100(3):280-1. Epub 2007 Nov 19. No abstract available.
8. Young JM, Strey CH, George PM, Florkowski CM, Sies CW, Frampton CM, Scott RS. Effect of atorvastatin on plasma levels of asymmetric dimethylarginine in patients with non-ischaemic heart failure. Eur J Heart Fail. 2008 May;10(5):463-6. Epub 2008 Apr 21.

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

Diabetes in Pregnancy. Nice Clinical guideline 63. www.nice.org.uk. An essential read that brings together a number strands into succinct guidance that all services should use to review their practice. Of course there is controversy! Why go for 1 hour post-prandial monitoring and move away from the standard 2-hour post prandial monitoring? Why abandon the OGTT for post-natal screening? Read the following articles in the BMJ for an excellent overview on commentary on these guidelines: BMJ 2008;336:714-717 & BMJ 2008;336:717-718.
Careers in Diabetes and endocrinology. J Mettayil, R Quinton, S Wahid. BMJ Careers 1st March 2008, page 79. See BMJ vol 336 BMJ careers section. An interesting read and to be used as a recruitment tool.
Non-peptide arginine-vasopressin antagonists:the vaptans. Decauex G, et al. Lancet 2008;371:1624-1632. An excellent article summarising the basic science and trial evidence behind this new exciting class of drugs.
Osteoporosis in men. Peter Ebeling. NEJM 2008;358:1474-1482. An excellent clinical review well worth a read.
Non-surgical management of obesity in adults. Robert Eckel. NEJM 2008;358:1941-1950. An excellent practical review.
Assessment and management of medically unexplained symptoms. Hatcher S, Arroll B. BMJ 2008;336:1124-1128. A wonderful article that provides structure for managing this challenging group of patients.
Decision time for pancreatic islet-cell transplantation. Ruggenenti et al. The Lancet 2008;371:883-884. A thought provoking editorial well worth a read.
Should we dump the metabolic syndrome? Edwin Gale vs George Alberti and Paul Zimmet. BMJ 2008;336: 640-641. A wonderful debate, which still leaves me sceptical about the value of labelling some one as having the metabolic syndrome. But then others may well be on the other side.
Hyperthyroidism and pregnancy. Marx et al. BMJ 2008;336:663-666. An excellent clinical overview.
Lifelong learning at work. PW Teunissen and T Dornan. BMJ 2008;336:667-669. A wonderful read and an article I plan to hand out to all of the trainees I personally supervise.Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial. Davies MJ, et al. BMJ. 2008 Mar 1;336(7642):491-5. This Multicentre cluster randomized controlled trial in primary care (207 general practices in 13 primary care sites in the United Kingdom), randomized 824 adults (55% men, mean age 59.5 yrs) into either a structured group education programme for six hours delivered in the community by two trained healthcare professional educators or into usual care. After 12 months HbA1c levels had decreased by 1.49% in the intervention group compared with 1.21% in the control group. After adjusting for baseline and cluster, the difference was not significant: 0.05% (95% confidence interval -0.10% to 0.20%). The intervention group showed a greater weight loss: -2.98 kg (-3.54 to -2.41) compared with 1.86 kg (-2.44 to -1.28), P=0.027 at 12 months. The odds of not smoking were 3.56 (1.11 to 11.45), P=0.033 higher in the intervention group at 12 months. The intervention group showed significantly greater changes in illness belief scores (P=0.001); directions of change were positive indicating greater understanding of diabetes. The intervention group had a lower depression score at 12 months: mean difference was -0.50 (95% confidence interval -0.96 to -0.04); P=0.032. A positive association was found between change in perceived personal responsibility and weight loss at 12 months (P=0.008). The authors conclude that a structured group education programme for patients with newly diagnosed type 2 diabetes resulted in greater improvements in weight loss and smoking cessation and positive improvements in beliefs about illness but no difference in HbA1c levels up to 12 months after diagnosis. The accompanying editorial (BMJ 2008;336:459-460) is well worth a read.
Mutations in the iodotyrosine deiodinase gene and hypothyroidism. Moreno JC, et al. N Engl J Med. 2008 Apr 24;358(17):1811-8. DEHAL1 has been identified as the gene encoding iodotyrosine deiodinase in the thyroid, where it controls the reuse of iodide for thyroid hormone synthesis. The authors screened patients with hypothyroidism who had features suggestive of an iodotyrosine deiodinase defect for mutations in DEHAL1. Two missense mutations and a deletion of three base pairs were identified in four patients from three unrelated families; all the patients had a dramatic reduction of in vitro activity of iodotyrosine deiodinase. Patients had severe goitrous hypothyroidism, which was evident in infancy and childhood. Two patients had cognitive deficits due to late diagnosis and treatment. Thus, mutations in DEHAL1 led to a deficiency in iodotyrosine deiodinase in these patients. The significance of the study is that because infants with DEHAL1 defects may have normal thyroid function at birth, neonatal screening programs for congenital hypothyroidism might miss them. An excellent editorial by Peter Kopp (NEJM 2008;358:1856-1859) rounds off this article as a learning experience.Hyperglycemia and adverse pregnancy outcomes (HAPO). Metzger BE,et al. N Engl J Med. 2008 May 8;358(19):1991-2002. A total of 25,505 pregnant women at 15 centres in nine countries underwent 75-g oral glucose-tolerance testing at 24 to 32 weeks of gestation. Data remained blinded if the fasting plasma glucose level was 5.8 mmol/l or less and the 2-hour plasma glucose level was 11.1 mmol/l or less. For the 23,316 participants with blinded data, the adjusted odds ratios for adverse pregnancy outcomes associated with an increase in the fasting plasma glucose level of 1 SD (0.4 mmol/l), an increase in the 1-hour plasma glucose level of 1 SD (1.7 mmol/l), and an increase in the 2-hour plasma glucose level of 1 SD (1.3 mmol/l) were calculated. For birth weight above the 90th percentile, the odds ratios were 1.38 (95% confidence interval [CI], 1.32 to 1.44), 1.46 (1.39 to 1.53), and 1.38 (1.32 to 1.44), respectively; for cord-blood serum C-peptide level above the 90th percentile, 1.55 (95% CI, 1.47 to 1.64), 1.46 (1.38 to 1.54), and 1.37 (1.30 to 1.44); for primary caesarean delivery, 1.11 (95% CI, 1.06 to 1.15), 1.10 (1.06 to 1.15), and 1.08 (1.03 to 1.12); and for neonatal hypoglycaemia, 1.08 (95% CI, 0.98 to 1.19), 1.13 (1.03 to 1.26), and 1.10 (1.00 to 1.12). There were no obvious thresholds at which risks increased. These results indicate a strong, continuous association of maternal glucose levels below those diagnostic of diabetes with increased birth weight and increased cord-blood serum C-peptide levels (a proxy marker of foetal insulin resistance, with a higher level suggesting high foetal insulin levels). At South Tyneside we treat any 2 hour blood glucose post OGTT of 7.8-11.o mmol/l as GDM. Does HAPO change that. NO! It adds strength to it as a value and shifting the value lower than this is really not cost effective as argued by Jeffrey Ecker and Michael Greene in the accompanying editorial (NEJM 2008;358:2061-2063). However, does HAPO mean that we should screen all women for GDM instead of selective screening as most units do and recommended by NICE? Given that there is a continuum of risk with glucose it is attractive to suggest blanket screening, however again the cost-effectiveness of such an approach would nee careful examination.Metformin versus insulin for the treatment of gestational diabetes. Rowan JA,et al. N Engl J Med. 2008 May 8;358(19):2003-15. Metformin has been recommended by NICE as option to treat hyperglycaemia in GDM along with glibenclamide or insulin, hence this trial is timely. 751 women with gestational diabetes mellitus at 20 to 33 weeks of gestation were randomly assigned to open treatment with metformin (with supplemental insulin if required) or insulin. The primary outcome was a composite of neonatal hypoglycaemia, respiratory distress, need for phototherapy, birth trauma, 5-minute Apgar score less than 7, or prematurity. Secondary outcomes included neonatal anthropometric measurements, maternal glycaemic control, maternal hypertensive complications, postpartumglucose tolerance, and acceptability of treatment. Of the 363 women assigned to metformin, 92.6% continued to receive metformin until delivery and 46.3% received supplemental insulin. The rate of the primary composite outcome was 32.0% in the group assigned to metformin and 32.2% in the insulin group(relative risk, 1.00; 95% confidence interval, 0.90 to 1.10). More women in the metformin group than in the insulin group stated that they would choose to receive their assigned treatment again (76.6% vs. 27.2%, P<0.001). The rates of other secondary outcomes did not differ significantly between the groups. There were no serious adverse events associated with the use of metformin. This trial has shown that in women with gestational diabetes mellitus, metformin (alone or with supplemental insulin) is not associated with increased perinatal complications as compared with insulin and that not surprisingly metformin was preferred to insulin. Once-daily basal insulin glargine versus thrice-daily prandial insulin lispro in people with type 2 diabetes on oral hypoglycaemic agents(APOLLO): an open randomised controlled trial. Bretzel RG,et al. Lancet. 2008 Mar 29;371(9618):1073-84.In this 44-week, parallel, open study 418 patients with type 2 diabetes mellitus inadequately controlled by oral hypoglycaemic agents were randomly assigned to either once-daily insulin glargine taken at the same time every day or to insulin lispro administered three times per day with meals. 205 patients were randomly assigned to insulin glargine and 210 to insulin lispro. Mean HbA1c decrease in the insulin glargine group was -1.7% (from 8.7% [SD 1.0] to 7.0% [0.7]) and -1.9% in the insulin lispro group (from 8.7% [1.0] to 6.8% [0.9], a mean difference of 0.157 (95% CI -0.008 to 0.322). 57% patients reached HbA1c of 7% or less in the glargine group and 69% in the lispro group. In the glargine group, the fall in mean fasting blood glucose (-4.3 [SD 2.3] mmol/L vs -1.8 [2.3] mmol/L; p<0.0001) and nocturnal blood glucose (-3.3[2.8] mmol/L vs -2.6 [2.9] mmol/L; p=0.0041) was better than it was in the insulin lispro group, whereas insulin lispro better controlled postprandial blood glucose throughout the day (p<0.0001). The incidence of hypoglycaemic events was less with insulin glargine than with lispro (5.2 [95% CI 1.9-8.9] vs 24.0 [21-28] events per patient per year; p<0.0001). Respective mean weight gains were 3.01 (SD 4.33) kg and 3.54 (4.48) kg. The improvement of treatment satisfaction was greater for insulin glargine than for insulin lispro (mean difference 3.13; 95% CI 2.04-4.22). The authors conclude that insulin glargine provides a simple and effective option that is more satisfactory to patients than is lispro for early initiation of insulin therapy, since it was associated with a lower risk of hypoglycaemia, fewer injections, less blood glucose self monitoring, and greater patient satisfaction than was insulin lispro. Does this trial change my approach. No! I (Shaz) still individualise therapy. Once daily insulin may be better for certain patients, but in my experience the majority end up on more doses. Given the resource implications in my local district I prefer the once-two-three mixed insulin approach with metformin if tolerated. I try to emphasize approaches to reduce weight gain as well. Furthermore, the availability of exenatide adds more to the armourmentarium. The current therapies available for type 2 diabetes remind me a lot of the promulgumation of therapies available for chronic heart failure overnight, resulting in “heart failure nurses”. The difference in diabetes is that not one glove fits all and it is not all about titrating up the dose or adding more therapies. We have a major psychological barrier to mange in terms of weight and physical activity. Simvastatin with or without ezetimibe in familial hypercholesterolemia. Kastelein JJ,et al. N Engl J Med. 2008 Apr 3;358(14):1431-43. This double-blind, randomised, 24-month trial compared the effects of daily therapy with 80 mg of simvastatin either with placebo or with 10 mg of ezetimibe in 720 patients with familial hypercholesterolaemia. Patients underwent B mode ultrasonography to assess the intima-media thickness of the walls of the carotid and femoral arteries. The primary outcome measure was the change in the mean carotid-artery intima-media thickness. The primary outcome, the mean (SE) change in the carotid-artery intima-media thickness, was 0.0058(0.0037)mm in the simvastatin-only group and 0.0111(0.0038)mm in the combined-therapy group (P=0.29). At the end of the study, the mean (+/-SD) LDL cholesterol level was 4.98(1.56)mmol/l in the simvastatin group and 3.65(1.36)mmol/l in the combined-therapy group (a between-group difference of 16.5%, P<0.01). The differences between the two groups in reductions in levels of triglycerides and C-reactive protein were 6.6% and 25.7%, respectively, with greater reductions in the combined-therapy group (P<0.01 for both comparisons). Side-effect and safety profiles were similar in the two groups. In conclusion, in patients with familial hypercholesterolaemia, combined therapy with ezetimibe and simvastatin did not result in a significant difference in changes in intima-media thickness, as compared with simvastatin alone, despite decreases in levels of LDL cholesterol and C-reactive protein. A very interesting study with a surprising result. The accompanying editorials (Brown GB, Taylor AJ NEJM 2008;358:1504-1507 & Drazen JM et al NEJM 2008;358:1507-1508) are well worth a read as they try to pick through possible reasons for this surprising result.

NEXT NEWSLETTER Due out beginning of October 2008 so keep the gossip coming.

Endodiabology February 2008

2008-02-06T07:41:00.000Z

ENDODIABOLOGY
Endodiabology.blogspot.com

FEBRUARY 2008
Editors: Shaz Wahid
Associate Editors: Arut Vijayaraman, Shafie Kamarrudin, Beas Bhattacharya, Ravi Erukulapati

SpR PLACEMENTS (NTN year of training from 1st October 2007)
· RVI- Andrew Advani (5), Arutchelvan Vijayaraman (4), Jeevan Mettayil (3), Muthu Jayapaul(5), Khaled Mansur-Dukhan (4)
· Freeman- Chandima Idampitiya (3), Ravikumar Balasubramanian (5), Kerry Livingstone (2)
· North Tyneside/Wansbeck- Akheel Syed(5), Sukesh Chandran(4)
· South Tyneside- Kathryn Stewart (1)
· Gateshead- Asgar Madathil (4)
· Sunderland- Shafie Kamarrudin (2),
· North Tees/Hartlepool- Beas Bhatacharya (4), Anjali Santhakumar (1)
· Middlesbrough- Srikanth Mada(1), Ravi Erukalapati(3), Preeti Rao
· Carlisle- Sudeep Manohar
· Bishop Auckland / Durham- , Arif Ullah (1)
· NGH/QEH- Freda Razvi (3)
· Research with numbers (supervisor)- Eelin Lim(4-Prof Taylor)

MEETINGS / LECTURES / ANNOUNCEMENTS
· Endocrinology & Diabetes section of the RSM (www.rsm.ac.uk/endocrinology) offers the following meetings beginning at Wednesday 27 Feb 08: Diabetes in the Elderly (joint with ABCD) Wednesday 28 May 08: Evidence-based Endocrinology
· 26th February 2008 Clinical Cases Meeting, Society for Endocrinology, London. Contact http://www.endocrinology.org/
· 5th-7th March 2008 DUK Annual Professional Conference, Birmingham. Contact http://www.diabetes.org.uk/
· 8th March 2008 Association of Physicians meeting, University Hospital North Tyneside. Contact
· 17th March 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 7th-10th April 2008 BES 2008, Harrogate. Contact http://www.endocrinology.org/
· 10th-11th April 2008 ABCD Spring Meeting (follows straight after BES), Harrogate, http://www.diabetologists.org.uk/
· 17th April 2008 NovoNordisk Symposium 2008-Diabetes and the Liver, 1330-1800 Lumley Castle. Contact
· 30th April 2008 RCP Acute Medical Emergencies conference, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 6th May 2008 Northern Endocrine & Diabetes Summer CME, Freeman Hospital. Contact
· 14th May 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 16th-17th May 2008 21st European Diabetic Nephropathy Study Group meeting, Germany. Contact
· 22nd-23rd May 2008 RCP National Conference: General Medicine for the Physician, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 21st May 2008 North East Obesity Forum meeting. Wolfson Research Unit, Queens Campus, Thornaby from 4pm. Childhood obesity. Contact
· 6th-10th June 2008 American Diabetes Association 68th Annual Scientific Sessions, San Francisco, USA. Contact.
· 15th-18th June 2007 ENDO 2008, San Francisco. Contact endostaff@endo-societ.org or www.endo-society.org/scimeetings .
· 24th June 2008 Joint Trainers & Trainees meeting from 1600, University Hospital North Tees. This follows the STC meeting and the SPARROWS feedback meeting will begin from 1730. Contact
· 9th July 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 7th-11th September 2008 44th EASD Annual meeting, Rome, Italy. Contact http://www.easd.org/
· 15th September 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 8th October 2008 Northern Endocrine & Diabetes Autumn CME, James Cook University Hospital. Contact
· 12th November 2008 North East Obesity Forum meeting. Obesogenic environment. Contact
· 12th November 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 10th December 2008 RCP Updates in G(I)M, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247

TRAINING ISSUES
DIABETES & ENDOCRINOLOGY PIMD WEBSITE Our specialty website is available on http://mypimd.ncl.ac.uk/PIMDDev . Click onto the specialty training tab then follow to Diabetes & Endocrinology. This site is essential reading, especially for ARCP preparation.
Registering with PMETB It is essential that all new SpRs/StRs (even LATs) register with the PMETB through the newly created Joint Royal Colleges of Physicians Training Board (formally the JCHMT) on http://www.jrcptb.org.uk/ although it is still possible to link with this site using the old http://www.jchmt.org.uk/ link. Not doing so means your training is not counted.
Log Book/Portfolio Documentation It is a trainee’s responsibility to make sure their portfolio/log book is prospectively completed and the necessary signatures obtained. Any experience that is not signed off by your educational supervisor at the time cannot be counted towards training.
Assessment tools Please see http://www.jrcptb.org.uk/, It is the trainee’s responsibility to give all the appropriate forms to their Educational or Clinical Supervisor. It is the trainee’s responsibility to make sure that the appropriate assessment summaries are available in their portfolio for ARCP purposes, e.g. MSF Summary Form.
ANOTHER CURRICULUM Trainees who have been recently appointed now have a new curriculum for both the specialty, Acute Medicine to Level 2 and a generic curriculum. Essentially there is no difference other than the sections being reorganised into the subsections of OBJECTIVE/COMPETENCY, KNOWLEDGE, SKILLS, ATTITUDE. They are essential reading and can be accessed on http://www.jrcptb.org.uk/ .
The GOLD Guide This replaces the Orange guide, and is the definitive guide to all aspects of training in the UK. It can be accessed on http://www.jrcptb.org.uk/SiteCollectionDocuments/Gold%20Guide.pdf . A massive document that I delve into when the need arises, e.g. interdeanery transfers.
Acute Care Assessment Tool The ACAT is a tool that is commendable. It provides a method of assessing how Trainees managed their on-call period. It is recommended that at least one is available for ARCP purposes. It can be downloaded from the JRCPTB website.
Carbohydrate Counting Visit http://www.bdec-e-learning.com/ an essential resource that is free for now. Highly recommended for all caring for patients with Diabetes and something that could be considered mandatory for trainees.
ARCP (RITAs 2008) Will be held on Weds 14th, Thursday 15th and Friday 16th May 2008. The PYAS are planned for Thursday am 15th May 2008. Time tables and instructions have been circulated. Documents needed for the ARCP panel are:
1. Portfolio (If you have developed one)
2. Training Log Book (to include any assessments, e.g. MSF, Mini-CEX)
3. Three copies of an Educational Supervisor Report (appended electronically)
4. Three copies of an Annual Appraisal Record (appended electronically)
5. Structured CV (format appended electronically)
6. 4 mandatory Mini-CEXs (unless you have already had your PYA when they are optional)
7. A mandatory up to date MSF report (not seen in your last RITA), unless you have already had your PYA
8. Evidence in your folder/portfolio demonstrating competence in at least 6 Core Diabetes & Endocrinology Topics (not seen at your last RITA). If you are having a PYA you should have evidence of competence in your folder for at least 90% of the core topics
Recruitment & Selection for Diabetes & Endocrinology 2008
ROUND ONE-25th and 27th Feb 2008
Local selection of ST2s to try and fill 3 of our NTNs. Any that are not filled will go through to round 2. Those NTNs that are filled will be started ASAP to plug current gaps in the rotation ASAP. Shaz Wahid will be on the selection panel.
ROUND TWO-date to be confirmed
Will be led NATIONALLY by the Severn Deanery. We have 1 NTN in this round for definite with the option to carry NTNs through from round one. The fact that we have at least one of our NTNs accepted for this round is very good news for the LATs in the region and gives them a fighting chance. Shaz Wahid has been put forward by Nancy Redfern to help in the process if the Lead Dean wishes for external help.
ROUND THREE-Friday 13th June 2008
A local mopping up round to fill any LAT or NTN vacancies. NTN vacancies may arise because the ST2s who had accepted a post in round one may then have been successful in round 2, hence relinquishing their original offer which is acceptable under the current rules.
A School of Medicine The Northern Deanery has adopted a School of Medicine to oversee training in all medical specialties as well as core training in Medicine. Our STC will feed into the School of Medicine Board and the Head of School is Harriet Mitchison. From now on all Training Programme Directors will be interviewed by the Head of School.
Training Committee Chair- Jola Weaver,; Regional Speciality Advisor- Richard Quinton,; Programme Director- Shaz Wahid,; Consultant member-Jean McLeod,; Consultant member (Research Advisor)-Simon Pearce,; Consultant member-Simon Eaton, Consultant member-Nicky Leech ; SpR representative- Arutchelvan Vijayaraman ; SpR representative- Jeevan Mettayil

NEWS FROM THE NORTHEAST
· Beas Bhattacharya, Shafie Kamarrudin and Ravi Erukulapati have joined the ENDODIABOLOGY Editorial team.
· Shafie Kamaruddin has joined the NEDs CME committee.
· Congratulations to Latika Sibal & Prof Home AND John Parr & Team on having abstracts accepted for oral presentation at this years DUK APC.
· Ravi Erukalapati, Eelin Lim and Arut will be attending the ADA through the SPARROWS programme this year.
· Newcastle Diabetes Centre has entered into collaboration with Shanghai- the Newcastle Diabetes Centre Shanghai collaboration. Gillian Hawthorne visited Shanghai in November to see their diabetes service and to speak at a conference; she was accompanied by Deirdre Kyne the clinical nurse lead. The venture is supported by One NorthEast.
· Congratulations to Simon Ashwell on his engagement to Amelia Lake who is an Academic Nutritionist.
· Congratulations to Richard Quinton & Family on the birth of James Philip Richard Quinton born 13 Dec 2007.
· Congratulations to Jeevan Mettayil on his oral presentation for the Caledonian Society for Endocrinology in Nov 07. Also, Jeevan has joined the STC as the trainee rep in place of Andrew Advani.
· Congratulations to Akheel Syed on passing his PhD viva.
· Congratulations to Ibrahim on appointment to the Consultant post at University Hospital at North Durham.

LETTERS
The Addison's Disease Self-Help Group- Simon Pearce
Simon Pearce is a member of the advisory panel & visit http://www.addisons.org.uk/ for a useful set of patient/education materials on management of the Addison's patient. The core publications have been authored by a panel of the UK's leading adrenal specialists and cover:
1. Surgery and dentistry, glucocorticoid requirements
2. Emergency treatment of hypoadrenalism
3. The role of the GP
4. Information for newly-diagnosed Addison's patients
They can be download these from the website or they can send print copies, eg to a training event, if you can let them know how many and where.

Diabetes Year of Care Project-Northumbria Team
The Year of Care Project is a national pilot project across 3 sites funded and supported by the National Diabetes Support Team in partnership with Diabetes UK, the Department of Health and the Health Foundation. NHS North of Tyne, Northumbria Healthcare, North Tyneside PCT and Northumberland Care Trust have been selected as one of these sites.
The purpose of the project is essentially twofold. Firstly it will look at the opportunities and challenges of introducing a Care Planning approach across a diabetes network, based to a great extent on work that has been done in primary care in Northumberland and North Tyneside and in specialist clinics in North Tyneside. It also, and importantly, also looks at ways in which this can be linked to how services are commissioned across the network.
As a result Year of Care describes all the planned care, personal and network wide, that a person with diabetes should expect to receive, usually over the course of a year. Within the Care Planning process, patients will have a greater say in what planned services they would find helpful and this will be agreed within the Care Planning process. This will form the basis of a ‘menu’ of choices that patients can access that can develop with time as new opportunities and options arise. This menu will also inform the development of commissioning structures that support and guide the development of diabetes services, using the views and preferences of patients to provide services that best suit the needs of the local population. This means that for the first time, patient choices can directly influence not only their personal care, but the services that are available to them.
Each pilot site has been chosen to represent different types of community and bring different skills to the project. Our partners in Tower Hamlets and Kirklees & Calderdale will help us to see how these approaches can be used in densely populated populations with high proportions of ethnic minority groups and where English is frequently either not a first language or may not be spoken at all. So far the local contribution has focussed in large part on the development of consultation skills and care processes needed for Care Planning and the training for this in primary care is already under way. Alongside this a Care Planning Guide for Clinicians has been developed and will shortly be available via the NDST website. There are a number of other strands to the pilot including patient involvement, information and evaluation, commissioning and detailed examination of the challenges for clinicians and patients in moving to this new approach to care.
This project will be challenging and may change the way we all go about delivering diabetes care. It has already excited a good deal of national interest. For further enquiries contact our Project Officer, Rachel Turnbull, by e-mail or phone
Timing of Thyroxine ingestion, do we need to change our practices? Beas Bhattacharya
Hypothyroidism remains one of the commonest endocrine pathologies. Its physiology and replacement relatively simple compared to other endocrinopathies. Thyroxine replacement is taken to be straight forward and it remains one of the most prescribed medications. Patients are usually advised to take their thyroxine in the morning, half an hour before breakfast time. Other significant pointers brought into attention are its enteral absorption, particularly small bowel and interference by cholestyramine, resin, sucralphate, iron, food and herbal remedies. Fibre rich diet has been shown to have effect in absorption.
A recent article in Clinical Endocrinology draws our attention to the basic question of timing of Thyroxine replacement and bioavailability and as a consequence brings out some rather fascinating points regarding thyroid biochemistry. This original article, Effects of evening: morning thyroxine ingestion on serum Thyroid hormone profiles in hypothyroid patients (Clinical Endocrinology,66,43-48), is small study done with 12 patients studied on two occasions, once on stable thyroxine dose in the morning and two months after switching to night time with the same dose. It was noted that serum TSH levels decreased and T3 increased significantly after changing timings to bedtime. In the discussion it is mentioned that thyroid hormone profiles improve on changing the timings and practical benefits for patients are cited: it is well known breakfast may interfere with intestinal absorption of thyroxine even if eaten half an hour later and with bedtime ingestion this problem will not occur; night time bowel motility is slower and prolonged exposure of thyroxine to the intestinal mucosa may mean better uptake.
Physiological factors can also play a part in why bed time dosing effects thyroid hormone profiles: the deiodinases vary according to thyroid status and also maintain a circadian rhythm; inactivating pathways of T4 metabolism, such as glucuronidation and sulphation may vary during the day, and may have some influence in the greater bioavailability at night; bioavailability of TSH has a circadian variation with less bioactive and differently glycosylated TSH molecules secreted during the night.
Though a small study it makes interesting reading and proves rather thought provoking, dealing with what is almost bread and butter part of our speciality. We should reflect on this .

Motivational Interviewing Workshop-Jola Weaver
Clinical Psychology for non psychologists First regional workshop on techniques in Motivational Interviewing (sponsored by Sanofi ) was held in Gateshead. It attracted attendance from GP, SpRs, Nurse Practitioners in Diabetes, Practice Nurses and Hospital Consultants. Techniques for improved communication included rolling with resistance, supporting self efficiency, eliciting change talk, building motivation for change were practiced amongst many others. Further similar workshops are planned for future If interested please contact Jola Weaver
Selecting a Consultant Colleague-Shaz Wahid
This was new to me! It took some thought, but for the short-listing process I used the following scoring framework:
SPECIALIST (CLINIC) INTEREST
5-Excellent-supported with research, publications, audit, courses and service interaction
4-Good-supported with activity during training including courses, audit/publications
3-Standard as part of training
2-Poor
1-None evident
MDT & SERVICE MANAGEMENT EXPERIENCE
5-Excellent-MUST HAVE POTENTIAL TO DEVELOP SERVICE and supported with activity across a district & demonstrable evidence within application of an understanding of DISTRICT CARE or attempts to audit such care
4-Good- MUST HAVE POTENTIAL TO DEVELOP SERVICE and evidence within application of interaction with care across a district
3-Standard as part of training and MUST HAVE POTENTIAL TO DEVELOP SERVICE
2-Poor with no real potential to develop service
1-None evident
TEACHING EXPERIENCE
5-Excellent-formal qualification with regular teaching activities & Evidence of acting as an “educator in diabetes” & evidence of Managing Teaching
4-Good- formal qualification OR courses attended to enhance skills with regular teaching activities
3-Standard as part of training
2-Poor
1-None evident
GOVERNANCE EXPERIENCE
5-Excellent-demonstrable evidence of AUDIT that makes a difference, courses attended including Management course & activity contributing to governance
4-Good-demonstrable evidence of AUDIT that makes a difference, courses attended including Management course
3-Standard as part of training
2-Poor
1-None evident
RESEARCH EXPERIENCE
5-Excellent-formal qualification & peer reviewed publications
4-Good-peer reviewed publications with regional and international meeting presentations
3-Standard as part of training
2-Poor
1-None evident
GENERAL MEDICINE EXPERIENCE
5-Excellent-regular out-patient experience, regular Acute Medicine exposure, ALS or equivalent, have attended national/international courses AND have audits AND publications in relation to acute medicine.
4-Good- regular out-patient experience, regular Acute Medicine exposure, ALS or equivalent, have attended national/international courses OR have audits OR publications in relation to acute medicine.
3-Standard as part of training
2-Poor
1-None evident
COMMITMENT TO THIS POST
5-Excellent-Have visited STDH and discussed the post AND their special interest augments the service needs.
4-Good-Have visited STDH and discussed the post, but special interests are ambiguous
3-Reasonable-have verbally enquired about the job and stated an interest they would wish to develop at STNHSFT
2-Poor- have verbally enquired about the job, but special interests are ambiguous OR already catered for
1-None evident- have made no enquiry about the job
EXTRA-CURRICULAR ACTIVITIES
5-Excellent-have had direct responsibilities for a national AND regional role. Have evidence of effectiveness in this role.
4-Good-have had direct responsibilities for a national OR regional role. Have evidence of effectiveness in this role.
3-Reasonable- have had direct responsibilities for a national OR regional role.
2-Ok- have had indirect responsibilities for a national OR regional role.
1-None evident
Trainees applying for Consultant posts may find this useful.
Newcastle young persons service needs ……….An Enthusiastic, Committed and broad minded SpR in diabetes to add inspirational clinical skills to the team-Nicky Leech
An excellent opportunity has arisen for training in Adolescent Diabetes. Commitment: 4-7.30pm Thursday evenings about once per month for 3-6 months No previous experience of young persons clinics necessary – we train!!!! Feedback on consultation skills by clinical psychologist provided. Experience in working with young persons discussion groups in the clinic provided. As much opportunity to reflect and push the field of adolescent diabetes as you wish. Kathryn Stewart has taken up the 1st block of training and if you are interested in following her contact Dr Nicky Leech tel 01912820114.

RECENT PUBLICATIONS FROM THE NORTHEAST
1. Al-Ozairi E, Michael E, Quinton R. Insulin-resistance causing severe postmenopausal hyperandrogenism. Int. J. Gynaecol Obstet. 2007 Nov 13 [Epub ahead of print]. doi:10.1016/j.ijgo.2007.08.017
2. Syed AA & Quinton R. Congenital radioulnar synostosis, azoospermia, and pseudodicentric Y chromosome. Fertility & Sterility. 2008 Jan 2; [Epub ahead of print]
3. Wellcome Trust Case Control Consortium & The Australo-Anglo-American Spondylitis Consortium. 269 authors including Pearce SH. Association scan of 14,500 nonsynonymous SNPs in four diseases identifies autoimmunity variants. Nat Genet 2007; 39: 1329-1337.
4. Vaidya B, Abraham P, Williams GR, Pearce SHS. National survey of radioiodine use in benign thyroid disease. Clin Endocrinol 2007; (In press) PMID: 17973939
5. David R. Woods The Skeletal Muscle RAS in Health and Disease, chapter 11, Frontiers in Research of the Renin-Angiotensin System on Human Disease.
6. DR Woods, S Allen, TR Betts, D Gardiner, H Montgomery, JM Morgan, PR Roberts. High Altitude Arrhythmias. Cardiology, 2008, in press.
7. James Dunbar, Ben Cooper, Tim Hodgetts, Yskandar Halabi, Pieter van Thiel, Steve Whelan, Justin Taylor, David R Woods. An outbreak of human external ophthalmomyiasis due to Oestrus ovis in Southern Afghanistan. Clinical Infectious Diseases 2008, in press.

RECENT PUBLICATIONS IN DIABETES & ENDOCRINOLOGY THAT HIT THE NEWS OR THAT MAY HAVE A SIGNIFICANT IMPACT ON MANAGEMENT
Haemochromatosis. Paul C Adams, James C Barton. Lancet 2007;370:1855-60. An excellent update for trainers and trainees.
Management of Thyroid Dysfunction during Pregnancy and Postpartum: An Endocrine Society Clinical Practice Guideline. Essential reading that provides a compendium of all the evidence to try and inform clinical practice.
CETP INHIBITION is not dead! It is well worth reading the editorials by Patrick Duriez (Lancet 2007;370:1882-1883) and Daniel Rader (NEJM 2007;357:2180-2183) in relation to the future role of inhibiting CETP and hence raising HDL for cardiovascular risk protection.
Childhood Obesity-The Shape of Things to Come An excellent, thought provoking article by David Ludwig (NEJM 2007;357:2325-2327). Essential reading for trainees, including the accompanying articles in the same edition.
Metformin for the treatment of the polycystic ovary syndrome An enthusiast writes about this emotive topic (John E Nestler NEJM 2008;358:47-54) providing an evidence base well worth reading about.
Clinical Update: bariatric surgery An excellent update by Michael Korenkov & Stefan Sauerland (Lancet 2007;370:1988-1990). It illuminates an obvious service gap in the UK!
Glucocorticoid chronotherapy in rheumatoid arthritis An excellent editorial by Johannes Bijlsma and Johannes Jacobs (Lancet 2208;371:183-184) along with the accompanying paper ( Buttgereit F, et al. Lancet 2008;371:205-214). It has relevance to glucocorticoid replacement therapy and well worth a read.Addition of biphasic, prandial, or basal insulin to oral therapy in type 2 diabetes. Holman RR, Thorne KI, Farmer AJ et al. N Engl J Med. 2007;357:1716-30. This open-label, controlled, multicentre trial randomly assigned 708 patients with a suboptimal HbA1c (7.0 to 10.0%) who were receiving maximally tolerated doses of metformin and sulphonylurea to receive biphasic insulin aspart twice daily, prandial insulin aspart three times daily, or basal insulin detemir once daily (twice if required). At 1 year, mean HbA1c levels were similar in the biphasic group (7.3%) and the prandial group (7.2%) (P=0.08) but higher in the basal group (7.6%, P<0.001 for both comparisons). The respective proportions of patients with an HbA1c level of 6.5% or less were 17.0%, 23.9%, and 8.1%; respective mean numbers of hypoglycaemic events per patient per year were 5.7, 12.0, and 2.3; and respective mean weight gains were 4.7 kg, 5.7 kg, and 1.9 kg. Rates of adverse events were similar among the three groups. The authors conclude that a single analogue-insulin formulation added to metformin and sulphonylurea resulted in an HbA1c level of 6.5% or less in a minority of patients at 1 year. The addition of biphasic or prandial insulin aspart reduced levels more than the addition of basal insulin detemir but was associated with greater risks of hypoglycaemia and weight gain. For me personally, the message that I take from this trial is that it does not matter how you start insulin as long as it is started early instead of the average 5-yr “wait”. It also does not change my standard practice of individualizing as the main priority with the majority use of Novomix 30 twice-daily with metformin, followed by the addition of an extra dose at lunch time or a switch to basal bolus depending upon the individual’s eating practice. I am sure that there will be those of you who disagree! (Shaz)Effect of fenofibrate on the need for laser treatment for diabetic retinopathy (FIELD study): a randomised controlled trial. Keech AC, Mitchell P, Summanen PA et al. Lancet. 2007;370:1687-97. The Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study randomised 9795 patients aged 50-75 years with type 2 diabetes mellitus to receive fenofibrate 200 mg/day (n=4895) or matching placebo (n=4900) followed up for an average of 5-yrs. At each clinic visit, information concerning laser treatment for diabetic retinopathy was gathered. Adjudication by ophthalmologists masked to treatment allocation defined instances of laser treatment for macular oedema, proliferative retinopathy, or other eye conditions. In a substudy of 1012 patients, standardised retinal photography was done and photographs graded with Early Treatment Diabetic Retinopathy Study(TDRS) criteria to determine the cumulative incidence of diabetic retinopathy and its component lesions. Laser treatment was needed more frequently in participants with poorer glycaemic or blood pressure control than in those with good control of these factors, and in those with a greater burden of clinical microvascular disease, but the need for such treatment was not affected by plasma lipid concentrations. The requirement for first laser treatment for all retinopathy was significantly lower in the fenofibrate group than in the placebo group (3.4% patients on fenofibrate vs 4.9% on placebo; hazard ratio [HR] 0.69, 95% CI 0.56-0.84; p=0.0002). In the ophthalmology substudy, the primary endpoint of 2-step progression of retinopathy grade did not differ significantly between the two groups overall (9.6% patients on fenofibrate vs 12.3% on placebo; p=0.19) or in the subset of patients without pre-existing retinopathy (11.4% vs 11.7%; p=0.87). By contrast, in patients with pre-existing retinopathy, significantly fewer patients on fenofibrate had a 2-step progression than did those on placebo (3.1% patients vs 14.6%; p=0.004). An exploratory composite endpoint of 2-step progression of retinopathy grade, macular oedema, or laser treatments was significantly lower in the fenofibrate group than in the placebo group (HR 0.66, 95% CI 0.47-0.94; p=0.022). In conclusion, in this study treatment with fenofibrate in individuals with type 2 diabetes mellitus reduces the need for laser treatment for diabetic retinopathy and the mechanism of this effect does not seem to be related to plasma concentrations of lipids. A very interesting study that needs to be replicated in a group of patients at higher risk for retinopathy or in a study with a much longer follow-up period than 5-yrs. The weaknesses in the study include lack of baseline retinal photography as a routine, heterogeneous criteria between study centres defining the need for laser treatment and the small number of events in the substudy. Further clinical and experimental studies are needed before adding fenofibrate to the armamentarium to treat diabetic retinopathy.Zoledronic acid and clinical fractures and mortality after hip fracture. Lyles KW, Colón-Emeric CS, Magaziner JS et al. N Engl J Med. 2007;357:1799-809. This randomised, double-blind, placebo-controlled trial, assigned 1065 patients to receive yearly intravenous zoledronic acid (at a dose of 5 mg), and 1062 patients to receive placebo. The infusions were first administered within 90 days after surgical repair of a hip fracture. All patients (mean age, 74.5 years) received supplemental vitamin D and calcium. The median follow-up was 1.9 years. The primary end point was a new clinical fracture. The rates of any new clinical fracture were 8.6% in the zoledronic acid group and 13.9% in the placebo group, a 35% risk reduction with zoledronic acid (P=0.001); the respective rates of a new clinical vertebral fracture were 1.7% and 3.8% (P=0.02), and the respective rates of new nonvertebral fractures were 7.6% and 10.7% (P=0.03). In the safety analysis, 101 of 1054 patients in the zoledronic acid group (9.6%) and 141 of 1057 patients in the placebo group (13.3%) died, a reduction of 28% in deaths from any cause in the zoledronic acid group (P=0.01). The most frequent adverse events in patients receiving zoledronic acid were pyrexia, myalgia, and bone and musculoskeletal pain. No cases of osteonecrosis of the jaw were reported, and no adverse effects on the healing of fractures were noted. The rates of renal and cardiovascular adverse events, including atrial fibrillation and stroke, were similar in the two groups. This study suggests that an annual infusion of zoledronic acid within 90 days after repair of a low-trauma hip fracture was associated with a reduction in the rate of new clinical fractures and with improved survival. An interesting study that will produce plenty of hype from the drug company! I think that the important message here is that preventing further fractures by what ever means in patients presenting with a hip fracture is essential to help improve morbidity and mortality in this vulnerable group of patients. I do not find it surprising that preventing refractures in patients with hip fractures improves mortality. The first step would be for all orthogeriatric services to undertake a robust audit of secondary prevention and as evidence gathers in the field the consensus treatment, taking into account cost-effectiveness, can be used.Intensive insulin therapy and pentastarch resuscitation in severe sepsis. Brunkhorst FM, Engel C, N Engl J Med. 2008;358:125-39. In this multicentre, two-by-two factorial trial patients with severe sepsis were randomised to receive either intensive insulin therapy to maintain euglycaemia or conventional insulin therapy and either 10% pentastarch, a low-molecular-weight hydroxyethyl starch (HES 200/0.5), or modified Ringer's lactate for fluid resuscitation. The trial was stopped early for safety reasons. Among 537 patients who could be evaluated, the mean morning blood glucose level was lower in the intensive-therapy group (6.2 mmol/l) than in the conventional-therapy group (8.4 mmol/l], P<0.001). However, at 28 days, there was no significant difference between the two groups in the rate of death or the mean score for organ failure. The rate of severe hypoglycaemia (glucose level, < or = to 2.2 mmol/l) was higher in the intensive-therapy group than in the conventional-therapy group (17.0% vs. 4.1%, P<0.001), as was the rate of serious adverse events (10.9% vs. 5.2%, P=0.01). HES therapy was associated with higher rates of acute renal failure and renal-replacement therapy than was Ringer's lactate. In this trial the use of intensive insulin therapy placed critically ill patients with sepsis at increased risk for serious adverse events related to hypoglycaemia and HES was harmful, and its toxicity increased with accumulating doses. I (Shaz) am an enthusiast for the appropriate management of hyperglycaemia in acute illness. This trial confirms the concerns of increased hypo risk from another large trial of medical patients on ITU. I suppose what we should be looking at is what is the optimum range to maintain blood glucose in ITU patients. It certainly should not be 10-20 mmol/l as suggested by an intensivist I recently chatted to!

NEXT NEWSLETTER Due out beginning of February 2008 so keep the gossip coming.

Endodiabology 2007; Issue 3 (October)

2007-10-14T23:53:00.000+01:00

ENDODIABOLOGY
Endodiabology.blogspot.com

NORTHEAST NEWSLETTER FOR SPRs AND BOSSES TRAPPED IN THE NORTHERN DEANERY
OCTOBER 2007

Editors: Shaz Wahid and Petros Perros
Associate Editors: Freda Razvi, Akheel Syed, Arut Vijayaraman

SpR PLACEMENTS (NTN year of training from 1^st October 2007)

RVI- Andrew Advani (5), Arutchelvan Vijayaraman (4), Jeevan Mettayil (3), Muthu Jayapaul(5), Khaled Mansur-Dukhan (4)
Freeman- Chandima Idampitiya (3), Ravikumar Balasubramanian (5), Kerry Livingstone (2)
North Tyneside/Wansbeck- Akheel Syed(5), Sukesh Chandran(4)
South Tyneside- Kathryn Stewart (1)
Gateshead- Asgar Madathil (4)
Sunderland- Shafie Kamarrudin (2), LAT
North Tees/Hartlepool- Beas Bhatacharya (4), Anjali Santhakumar (1)
Middlesbrough- Srikanth Mada(1), Ravi Erukalapati(3), Preeti Rao
Carlisle- Sudeep Manohar
Bishop Auckland / Durham- Sony Anthony (5), Arif Ullah (1)
NGH/QEH- Freda Razvi (3)
Research with numbers (supervisor)- Eelin Lim(4-Prof Taylor)

MEETINGS / LECTURES / ANNOUNCEMENTS
8^th October 2007 Northern Endocrine & Diabetes Autumn CME, James Cook University Hospital. Contact Arut V.
16^th October 2007 Regional Diabetes Audit Group meeting, preceded by NRDSAG. Contacts Dr K Narayanan or Simon Eaton
19^th October 2007 Deadline for submission of abstracts to DUK for APC in March 2008.
31^st October 2007 National Training Scheme for the use of radioiodine in benign thyroid disease, Birmingham. Contact Helen Flood
1^st November 2007 57^th British Thyroid Association Annual meeting, London, BTA website .
1^st-2^nd November 2007 (3^rd November is SpR meeting) ABCD Autumn Meeting, London, ABCD website
3^rd November 2007 Association of Physicians meeting, Freeman Hospital. Contact Clive Kelly
5^th-7^th November 2007 Society for Endocrinology Clinical Update 2007, Manchester. Contact SFE website
15^th November 2007 Deadline for submission of abstracts to Society for Endocrinology for BES conference in April 2008
21^st November 2007 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
28^th November 2007 Northern Endocrine Region Research and Audit Group annual meeting, Lumley Castle, Durham 2pm-8pm. Contact Shaz Wahid
3^rd December 2007 UK Neuroendocrine Tumour Society Conference, London. Contact Rebecca Hannah
4^th December 2007 RCP Update in Medicine, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
14^th January 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
29^th January 2008 Northern Endocrine & Diabetes Winter CME, Freeman Hospital. Contact Arut V
26^th February 2008 Clinical Cases Meeting, Society for Endocrinology, London. Contact SFE website
5^th-7^th March 2008 DUK Annual Professional Conference, Birmingham. Contact DUK website
17^th March 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
7^th-10^th April 2008 BES 2008, Harrogate. Contact SFE website
10^th-11^th April 2008 ABCD Spring Meeting (follows straight after BES), Harrogate, ABCD website
16^th April 2008 RCP Acute Medical Emergencies conference, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
6^th May 2008 Northern Endocrine & Diabetes Summer CME, Freeman Hospital. Contact Arut V
8^th October 2008 Northern Endocrine & Diabetes Autumn CME, James Cook University Hospital. Contact Arut V
Endocrinology & Diabetes section of the RSM website offers the following meetings beginning at 9am: Thursday 1 Nov 07: Diabetes for Hospital Doctors. Wednesday 23 Jan 08: Adolescent Endocrinology (joint with Paed/Child Health) Wednesday 27 Feb 08: Diabetes in the Elderly (joint with ABCD) Wednesday 28 May 08: Evidence-based Endocrinology

TRAINING ISSUES
DIABETES & ENDOCRINOLOGY PIMD WEBSITE Our specialty website has been redesigned and is now available on PIMD website . Click onto the specialty training tab then follow to Diabetes & Endocrinology. This site is essential reading, especially for RITA preparation.
Registering with PMETB It is essential that all new SpRs/StRs (even LATs) register with the PMETB through the newly created Joint Royal Colleges of Physicians Training Board (formally the JCHMT) on JRCPTB website. Not doing so means your training is not counted.
Log Book/Portfolio Documentation It is a trainee’s responsibility to make sure their portfolio/log book is prospectively completed and the necessary signatures obtained. Any experience that is not signed off by your educational supervisor at the time cannot be counted towards training.
Assessment tools Please see JRCPTB website. It is the trainee’s responsibility to give all the appropriate forms to their Educational or Clinical Supervisor. It is the trainee’s responsibility to make sure that the appropriate assessment summaries are available in their portfolio for RITA purposes, e.g. MSF Summary Form.
Laboratory Training Following SpR feedback, the STC has prepared a document providing guidance for training units and SpRs on the minimum training to be provided in relation to this important subject. It can be accessed on PIMD website.
ANOTHER CURRICULUM!!! Trainees who have been recently appointed now have a new curriculum for both the specialty, Acute Medicine to Level 2 and a generic curriculum. Essentially there is no difference other than the sections being reorganised into the subsections of OBJECTIVE/COMPETENCY, KNOWLEDGE, SKILLS, ATTITUDE. They are essential reading and can be accessed on JRCPTB website.
The GOLD Guide This replaces the Orange guide, and is the definitive guide to all aspects of training in the UK. It can be accessed on JRCPTB Gold Guide . A massive document that I delve into when the need arises, e.g. interdeanery transfers.
REPLACING RITA MMC/PMETB/JRCPTB has produced new guidance on assessing trainees’ progression. The RITA will be replaced with the Annual Review of Competence Progression. ARCP for short. Our region already fulfils the majority of the guidance as the RITAs were revamped 2-yrs ago. Further guidance will be issued in early 2008, once the TPD has been on the course!
ARCP (RITAs 2008) Next year they will be held on Weds 14^th, Thursday 15^th and Friday 16^th May 2008. The PYAS are planned for Thursday am 15^th May 2008. An early timetable has been circulated with initial guidance to trainees. Please reply to Shaz Wahid ASAP.
PERSONAL DEVELOPMENT PLANS One of the recommendations of the new Gold Guide is for each trainee to document a PDP at the beginning of each new post. This is something the STC will provide future guidance on, but it would do no harm for trainees to develop one at the start of their current training unit. A suggested template: What development needs have I? How will I address them? Date by which I plan to achieve development goal? Outcome? Completed? Another suggested template: What do I need to learn? How am I going to learn this? What resources do I need to achieve the learning? How will I measure when I have achieved this? How long will this take?
Training Committee Chair – Jola Weaver; Regional Speciality Advisor – Richard Quinton; Programme Director – Shaz Wahid; Consultant members – Jean Macleod, Simon Pearce (Research Advisor), Simon Eaton, and Nicky Leech ; SpR representatives – Arutchelvam Vijayaraman and Andrew Advani.

NEW FACES ON THE SCENE
Welcome to Kathryn Stewart, Anjali Santhakumar, Arif Ullah and Sudeep Manohar as new SpRs (now called StRs (Specialty Trainees) to the region.
Welcome to Chris Strey as Consultant Endocrinologist at Wansbeck. Since graduation from medical school in Munich, Germany, Chris has been practicing medicine in England for eleven years; interrupted by a three year - PhD programme in New Zealand. He has been working in diabetes and endocrinology for the last eight years completing his specialty training at Addenbrooke’s Hospital, Cambridge University. His research interests focus on endothelial dysfunction in health and disease and endothelial hormones.

NEWS FROM THE NORTHEAST
It may be a little early to officially announce, but unofficially then!, congratulations to Professor Simon Pearce on his Chair.
Congratulations to Peter Carey on obtaining the Consultant post at Sunderland Royal. Also, our congratulations to Pete and family on the birth of his daughter Maebh which occurred just after the last newsletter was published.
Congratulations to Salman Razvi on obtaining the Consultant post at Gateshead.
Congratulations to Sony Anthony on obtaining the Consultant post at Hartlepool, he plans to act up before his CCT date.
Reena Thomas will be undertaking a Locum Consultant post at Rochdale from October 2007.
Congratulations to Srikanth Mada on obtaining his NTN at the recent interviews.
Nicky Leech has joined the STC as a Consultant member.
Our best wishes to Ebaa Al-Ozairi as she returns to Kuwait.
Freda Razvi has returned from her period of career break in a part-time capacity.
Richard Quinton has joined the Specialist Advisory Committee for Diabetes & Endocrinology, representing the Northern Deanery.
Kerry Livingstone has joined the NED CME committee with Arut.
Congratulations to Arut on his recent oral presentation at EASD titled “changes in plasma glucose following exercice:comparison of three basal insulins, V. Arutchelvam , T. Heise, S. Dellweg, B. Elbroend, I. Minns, P. D. Home”.
Congratulations to Simon Eaton on being selected as Lead Clinician for Care Planning in Diabetes leading the national engagement and implementation of Care Planning with the National Diabetes Support Team and the Department of Health.

LETTERS

Contributions for this section can include meeting reports, research experiences, book reviews, experiences abroad, and anything else you feel may benefit trainees and trainers around the region. The success of this section really does depend on YOU.

Is Management for me?-Shaz Wahid

Having been a Consultant for 4-years I am now asked whether I would like to develop “formal” management skills by a number of individuals at the Trust and attend some regional/national events. Basically, it is a “code” for do you want to join “The Management”? There are 2 courses I could attend, the Kings Fund Development Programme for Diabetologists or the regional NHS course supported by the StHA and the PIMD (I was nominated by Nancy Redfern and my MD). Having looked at the course objectives both of them have a number of objectives which I have already obtained. This is backed up in my portfolio with reflection and via the BMJ Learning website with completed modules and practical examples from my working practice. My activities over the last 4-yrs in relation to Programme Director, Specialty service redesign and more recently Leading the clinical input into redesigning Acute Medicine at the Trust have required obvious managerial skills. If it had not been for this activity I certainly would have booked up on either of the latter courses for my own professional development. However, I personally at this point in time can not see myself wishing to reduce my clinical activities in the future to take on a formal management role. I still enjoy the “coal” face both when delivering a clinical service or an educational “service”. Joining “Management” at the moment is not right for me. My advice to those Consultants recently appointed is that trying to get onto a formal management course (the Kings Fund Course is probably the best one) would be worthwhile for professional development and is certainly a stepping stone to joining “The Management” in the future.

Laboratory Training-Shaz Wahid

As specialists we are frequently asked to comment on investigation that seems out of the “box”, e.g. funny TFTs. Having a working knowledge as to what the Labs do” is therefore essential and helps in test interpretation. It is part of being a specialist! Following SpR feedback the STC have produced the following guidance:

It is important to arrange exposure to laboratory medicine during each unit attachment backed up by background reading. It is important to cover the following topics:

HbA1c assay measurement, cv, standardisation

Glucose measurements in the lab and meters with causes of errors

Hormone assay methods

Immunometric; RIA, ELISA

Chromatography

Reasons for variability+errors, eg hook effect, protein binding

Pitfalls in autoAb measuring, e.g. TBII, thyroid, adrenal

Pitfalls in measuring or assessing the following hormones or endocrine axis

TSH, fT4, fT4, thyroglobulin, total thyroid hormones

Prolactin

Cortisol, ACTH

PTH, calcitonin, calcium, vitamin D

Water & electrolyte handling; electrolytes, osmolality, ADH

GH, IGF1

LH, FSH, Testosterone, SHBG, E2

Renin, aldosterone, PRA

Catecholamines

The domains of a Consultant Diabetologist/Endocrinologist-Shaz Wahid

“A review of job satisfaction and current practice of consultant diabetologists in England-barriers and successes, MacLeod K, et al. Diabetic Medicine September 2007;24:946-954” is essential reading for ALL, including Endocrinologists! It is a wonderful collection of thoughts on what a Consultant in Diabetes&Endocrinology truly is in practice. There are 3 basic overlapping domains to being a specialist in our specialty: clinical specialist skills, leadership skills across boundaries and clinical education skills. Each of the domains overlap and pertain to clinical activity, management activity, research activity, governance activity, etc. It is essential for trainees to develop these domains during their training. We far too often concentrate on the clinical skills development that is guided by the curriculum, but it is important to bear in mind that there is ample opportunity for the development of subspecialty skills (diabetic foot, transitional care, etc). It is important to develop leadership skills (eminently demonstrated by Simon Eaton in the letter below) and to undertake activity during training demonstrating these skills, e.g. rota leader, audit resulting in service change that is implemented by the trainee. It is important to demonstrate effective activity as a clinical educator of patients, students, junior Drs, allied health professionals, peers in the hospital and community. When undertaking PYAs one can get a sense of which domains have been developed by the trainee. I highly recommend reading this important piece of work.

The Diabetes Year of Care Pilot Project-Simon Eaton

Year of Care is about people with diabetes taking charge of their condition and working in partnership with healthcare professionals to plan their care. Year of Care describes all the planned care that a person with diabetes should expect to receive, usually over the course of a year. This includes support for self management in line with national standards and, where appropriate, planned specialist referrals.

This national pilot project, backed by Diabetes UK, the Department of Health and the National Diabetes Support Team, aims to find out how this will work in practice. The annual review appointment will become a care planning discussion where the person with diabetes is on equal footing with the healthcare professional. They will jointly decide on the right options for them. The plan they arrive at will form the basis of their individual Year of Care, which will have implications for commissioning. The pilot will test whether it is feasible for the system to work around individual needs in this way.

North Tyneside has been selected as a pilot site, along with Calderdale and Kirklees and Tower Hamlets. Please contact me if you would like any further information on Simon Eaton .

RECENT PUBLICATIONS FROM THE NORTHEAST

Please send us your recent publication for inclusion in the next newsletter.

Dashora UK, Sibal L, Ashwell SG, Home PD. Insulin glargine in combination with nateglinide in people with Type 2 diabetes: a randomised placebo-controlled trial. Diabetic Medicine 2007; 24(4):344-9.

Al-Ozairi E, Sibal L, Home PD. Counterpoint: ADOPT; good for sulfonylureas? Diabetes Care 2007; Jun;30(6):1677-80.

Advani A, Kelly DJ, Advani SL, Cox AJ, Thai K, Zhang Y, White KE, Gow RM, Marshall SM, Steer BM, Marsden PA, Gilbert RE (2007) Role of VEGF in maintaining renal structure and function under normotensive and hypertensive conditions. Proc Natl Acad Sci USA 104, 14448-14453.

Raivio T, Falardeau J, Dwyer AA, Quinton R, Hayes FJ, Hughes VA, Cole LW, Pearce SHS, Lee H, Boepple P, Crowley WF, Jr, Pitteloud N. 2007 Reversal of congenital idiopathic hypogonadotropic hypogonadism. New England Journal of Medicine. 357: 863-873. 457-463. [with Editorial Comment: “Experiments of nature -a glimpse into the mysteries of the pubertal clock”, pp929-932].

Maggi M, Schulman C, Quinton R, Langham S, Uhl-Hochgräber K. 2007 The burden of testosterone deficiency in adult men: economic and quality-of-life impact. Journal of Sexual Medicine. 4: 1056-1069.

Rossor AM, Pearce SH, Adams PC. Left ventricular apical ballooning (takotsubo cardiomyopathy) in thyrotoxicosis. Thyroid. 2007; 17:181-2.

Fanciulli M, Norsworthy PJ, Petretto E, Dong R, Harper L, Kamesh L, Heward JM, Gough SC, Froguel P, Owen CJ, Pearce SHS, Teixeira L, Guillevin L, Cunningham Graham DS, Pusey CD, Cook HT, Vyse TJ, Aitman TJ. FCGR3B copy number variation is associated with susceptibility to systemic but not organ-specific autoimmunity. Nature Genetics. 2007; 39: 721-3.

Donaldson P, Veeramani S, Baragiotta A, Floreani A, Venturi C, Pearce S, Wilson V, Jones D, James O, Taylor J, Newton J, Bassendine M. Cytotoxic T-Lymphocyte-Associated Antigen-4 Single Nucleotide Polymorphisms and Haplotypes in Primary Biliary Cirrhosis. Clin Gastroenterol Hepatol. 2007; 5: 755-60.

Sutherland A, Davies J, Owen CJ, Vaikkakara S, Cheetham TD, James RA, Perros P, Cordell HJ, Donaldson PT, Quinton R, Pearce SHS. Genomic polymorphism at the interferon-induced helicase (IFIH1) locus is associated with Graves’ disease. J Clin Endocrinol Metab 2007: 92(8):3338-41.

Razvi S, Pearce SHS. Do antithyroid drugs influence outcome after radioiodine therapy for hyperthyroidism? Nat Clin Pract Endocrinol Metab 2007; 3: 628-9.

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

Clinical update:adverse effects of antiretroviral therapy. Calmy A, et al. Lancet 2007;370:12-14. An excellent article summarising the metabolic problems associated with antiretroviral therapy. Essential reading for trainees.

Vitamin D Deficiency. Michael Holick. NEJM 2007;357:266-281. An excellent review and essential reading for trainees.

Clinical update: new treatments for hot flushes. Vered Stearns. Lancet 2007;369:2062-2064. A symptom we often come across as Endocrinologists which can be very difficult to treat. This update is well worth a read.

Polycystic Ovary Syndrome. Norman RJ, et al. Lancet 2007;370:685-697. An excellent review discussing pathophysiology, epidemiology, diagnosis and management. Well worth a read for an update.

Diagnosis and management of chronic fatigue syndrome or myalgic encephalomyelitis (or encephalopathy); Summary of NICE guidance. Baker R, Shaw EJ. BMJ 2007;335:446-448. Editorial White P, et al. BMJ 2007:411-412. Well worth a read for those of you have to deal with the common referral of “lethargy”.

Hypertriglyceridaemia. John Brunzell. NEJM 2007;357:1009-1017. An excellent practical review.

Gynecomastia. Glenn Braunstein. NEJM 2007;357:1229-1237. Mandatory reading for trainees. An excellent practical account. After reading it, I had a referral in clinic the next day. I had found this article useful.

Reversal of idiopathic hypogonadotropic hypogonadism. Raivio T, Falardeau J, Dwyer A, Quinton R, Hayes FJ, Hughes VA, Cole LW, Pearce SH, et al. N Engl J Med. 2007 Aug 30;357(9):863-73. The authors describe 15 men in whom reversal of idiopathic hypogonadotropic hypogonadism was sustained after discontinuation of hormonal therapy. Sustained reversal of idiopathic hypogonadotropic hypogonadism was defined as the presence of normal adult testosterone levels after hormonal therapy was discontinued. Ten sustained reversals were identified retrospectively. Five sustained reversal were identified prospectively among 50 men with idiopathic hypogonadotropic hypogonadism after a mean (+/-SD) duration of treatment interruption of 6+/-3 weeks. Of the 15 men who had a sustained reversal, 4 had anosmia. At initial evaluation, 6 men had absent puberty, 9 had partial puberty, and all had abnormal secretion of GnRH-induced luteinising hormone. All 15 men had received previous hormonal therapy. Among those whose hypogonadism was reversed, the mean serum level of endogenous testosterone increased from 1.9+/-1.0 nmol/l to 13.4+/-3.2 nmol/l (P less than 0.001), the luteinising hormone level increased from 2.7+/-2.0 to 8.5+/-4.6 IU/L (P less than 0.001), the level of follicle-stimulating hormone increased from 2.5+/-1.7 to 9.5+/-12.2 IU/L (P less than 0.01), and testicular volume increased from 8+/-5 to 16+/-7 ml (P less than 0.001).This study has shown sustained reversal of normosmic idiopathic hypogonadotropic hypogonadism and the Kallmann syndrome after discontinuation of treatment in about 10% of patients with either absent or partial puberty. The authors hypothesise the cause of this reversal as improved plasticity of the neuronal system with time, whilst the accompanying editorial by Shalender Bhasin (NEJM 2007;357:929-932) favours the pubertal clock hypothesis (delayed activation of the GnRH pulse generator) and uses the study by Adriano Lorano-Porto, et al (NEJM 2007;357:897-904) in the same issue to back this up. Whatever the hypothesized mechanism, this study has certainly influenced my own clinical practice.

Efficacy and safety of combined use of aliskiren and valsartan in patients with hypertension: a randomised, double-blind trial. Oparil S, Yarows SA, et al. Lancet 2007;370:221-229. This double-blind study assessed dual renin system intervention with the maximum recommended doses of aliskiren and valsartan, compared with each drug alone in patients with hypertension. 1797 patients with hypertension (mean sitting diastolic blood pressure 95-109 mm Hg and 8-h daytime ambulatory diastolic blood pressure > or =90 mm Hg) were randomly assigned to receive once-daily aliskiren 150 mg (n=437), valsartan 160 mg (455), a combination of aliskiren 150 mg and valsartan 160 mg (446), or placebo (459) for 4 weeks, followed by forced titration to double the dose to the maximum recommended dose for another 4 weeks. The primary endpoint was change in mean sitting diastolic blood pressure from baseline to week 8 endpoint. Analyses were done by intention to treat. 196 (11%) patients discontinued study treatment before the end of the trial (63 in the placebo group, 53 in the aliskiren group, 43 in the valsartan group, and 37 in the aliskiren/valsartan group), mainly due to lack of therapeutic effect. At week 8 endpoint, the combination of aliskiren 300 mg and valsartan 320 mg lowered mean sitting diastolic blood pressure from baseline by 12.2 mm Hg, significantly more than either monotherapy (aliskiren 300 mg 9.0 mm Hg decrease, p less than 0.0001; valsartan 320 mg, 9.7 mm Hg decrease, p less than 0.0001), or with placebo (4.1 mm Hg decrease, p less than 0.0001). Rates of adverse events and laboratory abnormalities were similar in all groups. In conclusion, the combination of aliskiren and valsartan at maximum recommended doses provides significantly greater reductions in blood pressure than does monotherapy with either agent in patients with hypertension, with a tolerability profile similar to that with aliskiren and valsartan alone. This study uses a new class of antihypertensive drugs that are active oral inhibitors of rennin. The accompanying editorial provides an excellent summary (Birkenhager W, Staessen JA Lancet 2007;320:195-196).

Impact of self monitoring of blood glucose in the management of patients with non-insulin treated diabetes: open parallel group randomised trial. Farmer A, et al. BMJ 2007;335:132-136. This Three arm, open, parallel group randomised trial set in 48 general practices in Oxfordshire and South Yorkshire recruited 453 patients with non-insulin treated type 2 diabetes (mean age 65.7 years) for a median duration of three years and a mean HbA1c level of 7.5%. The patients were randomized into either of the following 3 treatments arms: standardised usual care with measurements of HbA1c every three months as the control group (n=152); blood glucose self monitoring with advice for patients to contact their doctor for interpretation of results, in addition to usual care (n=150); blood glucose self monitoring with additional training of patients in interpretation and application of the results to enhance motivation and maintain adherence to a healthy lifestyle (n=151). At 12 months the differences in HbA1c level between the three groups (adjusted for baseline HbA1c level) were not statistically significant (P=0.12). The difference in unadjusted mean change in HbA1c level from baseline to 12 months between the control and less intensive self monitoring groups was -0.14% (95% confidence interval -0.35% to 0.07%) and between the control and more intensive self monitoring groups was -0.17% (-0.37% to 0.03%). This trial’s evidence is not convincing of an effect of self monitoring blood glucose, with or without instruction in incorporating findings into self care, in improving glycaemic control compared with usual care in reasonably well controlled non-insulin treated patients with type 2 diabetes. This is a very emotive subject and Simon Heller’s accompanying editorial (BMJ 2007;335:105-106) provides excellent “advice”. The bottom line is that we as clinicians should discuss the value of blood monitoring in our patients and only advocate its use and continued use in patients who utilize the results to self-manage their diabetes. However, this fact is lost in primary care with Type 2 Diabetic patients on insulin being advised to test twice a week if that! Furthermore, the special group of pregnant diabetic patients often need to jump through hoops to get glucose monitoring strips. Who said type 2 diabetes is easy!

Estrogen therapy and coronary-artery calcification. Manson JE, Allison MA, et al. NEJM 2007;356:2591-2602. This sub study of the Women's Health Initiative trial of conjugated equine oestrogens (0.625 mg per day) as compared with placebo in women who had undergone hysterectomy, computed tomography of the heart was performed in 1064 women aged 50 to 59 years at randomisation. Imaging was conducted at 28 of 40 centres after a mean of 7.4 years of treatment and 1.3 years after the trial was completed (8.7years after randomization). Coronary-artery calcium (or Agatston) scores were measured at a central reading centre without knowledge of randomization status. The mean coronary-artery calcium score after trial completion was lower among women receiving oestrogen (83.1) than among those receiving placebo (123.1) (P=0.02 by rank test). After adjustment for coronary risk factors, the multivariate odds ratios for coronary-artery calcium scores of more than 0, 10 or more, and 100 or more in the group receiving oestrogen as compared with placebo were 0.78 (95% confidence interval, 0.58 to 1.04), 0.74 (0.55 to 0.99), and 0.69 (0.48 to 0.98), respectively. The corresponding odds ratios among women with at least 80% adherence to the study oestrogen or placebo were 0.64 (P=0.01), 0.55 (P less than 0.001), and 0.46 (P=0.001). For coronary-artery calcium scores of more than 300 (vs. less than 10), the multivariate odds ratio was 0.58 (P=0.03) in an intention-to-treat analysis and 0.39 (P=0.004) among women with at least 80% adherence. In conclusion, among women 50 to 59 years old at enrolment, the calcified-plaque burden in the coronary arteries after trial completion was lower in women assigned to oestrogen than in those assigned to placebo. This study lends support to the timing hypothesis that oestrogen has differing effects on blood vessels in younger women than in women long after the menopause.

Main morbidities recorded in the women's international study of long duration oestrogen after menopause (WISDOM): a randomised controlled trial of hormone replacement therapy in postmenopausal women. Vickers MR, MacLennan AH, et al. BMJ 2007;335:239-244. This multicentre, randomised, placebo controlled, double blind trial assessed the long term risks and benefits of hormone replacement therapy (combined hormone therapy versus placebo, and oestrogen alone versus combined hormone) by recruiting postmenopausal women aged 50-69 years from General practices in the UK (384), Australia (91), and New Zealand (24). At early closure of the trial, 56,583 had been screened, 8980 entered run-in, and 5692 (26% of target of 22,300) started treatment. The trial was prematurely closed during recruitment, after a median follow-up of 11.9 months (interquartile range 7.1-19.6, total 6498 women years) in those enrolled, after the publication of early results from the women's health initiative study. The mean age of randomised women was 62.8 (SD 4.8) years. When combined hormone therapy (n=2196) was compared with placebo (n=2189), there was a significant increase in the number of major cardiovascular events (7 v 0, P=0.016) and venous thromboembolisms (22 v 3, hazard ratio 7.36 (95% CI 2.20 to 24.60)). There were no statistically significant differences in numbers of breast or other cancers (22 v 25, hazard ratio 0.88 (0.49 to 1.56)), cerebrovascular events (14 v 19, 0.73 (0.37 to 1.46)), fractures (40 v 58, 0.69 (0.46 to 1.03)), and overall deaths (8 v 5, 1.60 (0.52 to 4.89)). Comparison of combined hormone therapy (n=815) versus oestrogen therapy (n=826) outcomes revealed no significant differences. The results of this trial are consistent with the findings of the women's health initiative study and secondary prevention studies in that hormone replacement therapy increases cardiovascular and thromboembolic risk when started many years after the menopause. The Kronos Early Estrogen Prevention Study (KEEPS) and the Early Versus Late Intervention Trial with Estradiol (ELITE) trials should answer whether the effect HRT is different early in the menopause than later on.

Incidence of new-onset diabetes and impaired fasting glucose in patients with recent myocardial infarction and the effect of clinical and lifestyle risk factors. Mozaffarian D, et al. Lancet. 2007 Aug 25;370(9588):667-75. The authors prospectively obtained data for 8291 Italian patients with a myocardial infarction within the previous 3 months, who were free of diabetes(determined by medication use, a physician-reported diagnosis, or fasting glucose > or =7 mmol/L) at baseline. Incidence of new-onset diabetes (new diabetes medication or fasting glucose > or =7 mmol/L) and impaired fasting glucose (fasting glucose > or =6.1 mmol/L and less than 7 mmol/L) were assessed at follow-up at 0.5, 1.0, 1.5, 2.5, and 3.5 years. Baseline data for body-mass index (BMI), other risk factors, dietary habits, and medications were updated during follow-up. A Mediterranean diet score was assigned according to consumption of cooked and raw vegetables, fruit, fish, and olive oil. Associations of demographic, clinical, and lifestyle risk-factors with incidence of diabetes and impaired fasting glucose were assessed with multivariable Cox proportional hazards. During 26 795 person-years (mean follow-up 3.2 years [SD 0.9]), 998 individuals (12%) developed new-onset diabetes. Of the 7533 without impaired fasting glucose at baseline, 2514 (33%) developed new-onset impaired fasting glucose or diabetes rising to 3859 (62%) of 6229 with the lower cut-off for impaired fasting glucose of 5.6 mmol/L. Independent risk factors for new-onset diabetes or impaired fasting glucose included older age, hypertension, use of beta-blockers, lipid-lowering medications (protective), and diuretic use. Independent lifestyle risk-factors included higher BMI, greater BMI gain during follow-up, current smoking, a lower Mediterranean dietary score, and wine consumption of more than 1 L/day. Data for physical activity were unavailable, but inability to perform exercise testing was associated with higher incidence of diabetes and impaired fasting glucose. In conclusion, this study has shown that compared with population-based cohorts, patients with a recent myocardial infarction had a higher annual incidence rate of impaired fasting glucose (1.8 vs 27.5%) and diabetes (0.8-1.6% compared with 3.7%). Thus, indicating that myocardial infarction could be a prediabetes risk equivalent. This makes the case for screening all patients who have had an MI for dysglycaemia. Each service should develop local protocols. The questions to answer are: fasting glucose vs OGTT and frequency of screening. As an example it would not be unreasonable to undertake an OGTT on all patients 6-weeks post MI initially followed by fasting blood glucose on annual basis via their GP. Any one disagree?

ROSIGLITAZONE Do not moan! As Rudy Bilous aptly stated in his excellent editorial in Diabetic Medicine on the issue of Rosiglitazone and MI risk “you must have been practicing Diabetes in Mars if have not heard about this”.

NEXT NEWSLETTER Due out beginning of February 2008 so keep the gossip coming.

Endodiabology - the North-East of England Endocrinology and Diabetes Newsletter

2005-10-01T12:53:00.000+01:00

Welcome to the Endodiabology blog!

This site has been developed for trainees and trainers in Diabetes and Endocrinology in north-east England. Its express purpose is to enable posting of information of interest, sharing of ideas, and to serve as an informal portal of communication. We invite comments, suggestions, etc. via the link below the article(s). Please sign your posts with your name or initials. Alternatively, you may write to us via Email. Matters of wider interest to the group will be re-posted as articles on the site.

Web Editor