Monday, February 25, 2013

Visiting Professor 6.3.13


Society for Endocrinology Visiting Professor
Endocrinology Clinical case meeting

Wednesday March 6
James Spence Lecture Theatre
Royal Victoria Infirmary


1.30-4.30. Interactive clinical case presentations
All students and staff welcome to what will be an interesting and enjoyable afternoon of interactive clinical case presentations focusing on diagnosis and management of endocrine disease.

5.00-6.00. SFE Visiting Professor Guest Lecture
Prof Lynette Nieman
NIH, USA
Perils & Pitfalls in the diagnosis of Cushing’s Disease



For information contact Dr. Steve Ball
s.g.ball@newcastle.ac.uk

Sunday, September 27, 2009

Endodiabology October 2009

ENDODIABOLOGY
Endodiabology.blogspot.com

NORTHEAST
NEWSLETTER
FOR SPRs AND BOSSES TRAPPED
IN THE NORTHERN DEANERY

OCTOBER 2009

Editors: Shaz Wahid , Petros Perros and 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 This e-mail address is being protected from spam bots, you need JavaScript enabled to view it
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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.

Tuesday, March 17, 2009

TOPDOC diabetes survey

Dear All,

May I request you all, on behalf of the topdocdiabetes (Trainees Own Perception of Delivery Of Care in Diabetes) survey team to help with this nationwide survey looking at the confidence levels among the junior doctors in management of diabetes. One of of our previous SpRs, now a consultant in Glsgow Royal Infirmary, Gerry Mckay leads the national steering committee. The study is sponsored by ABCD.

If you can forward this mail with the information below to all the juniors in your trust and encourage them to complete the online questionnaire, which will take not more than 5 minutes, will be very helpful. There are some prizes for the participants and also we may manage some grants for our CME fund. I particularly request my fellow SpRs to take an active interest and help with this project.

If any further information is needed, please let me know.

Sincere regards
Arut

Arutchelvam
Specialist registrar in Diabetes and Endocrinology
Northern Deanery

May I draw your attention to TOPDOC Diabetes-a national study of foundation and specialty trainees in all specialties looking at their confidence levels in management of diabetes. The study is available at www.topdocdiabetes.org and over 450 juniors have already responded.


This is a UK-wide survey of foundation doctors and specialist trainees from all specialities, looking at their confidence levels in the management of diabetes. The study is funded by Association of British Clinical Diabetologists and follows from a national pilot that showed a lack of confidence in managing aspects of diabetes care, including the management of diabetes emergencies.


All details are available at www.topdocdiabetes.org and the survey takes only 5 minutes to complete. On behalf of the national steering committee, I'll be most grateful if you would forward this email to foundation and specialty trainees in your hospital. -please encourage all your juniors to do this study.

Saturday, February 21, 2009

CPD diary for Specialist registrars

In case any of you is not aware, we the SpRs can also register for the CPD.

Training version of the CPD Diary is available for use by SpRs enrolled with JRCPTB. This training Diary looks and operates the same way as the Consultant's Diary.

The SpR version of the CPD Diary is available free to all SpRs who are enrolled with JRCPTB, and who have confirmed CCT dates. The SpR Diary is not available to LATS, or SpRs not enrolled with JRCPTB. This is because the CPD Diary is only available to those who contribute to the RCP by paying subscription fees to the college or to JRCPTB.
Once you receive your CCTs, you will need to complete the CPD Registration Form in order to change your status on the Federation CPD Scheme and update your details on our database. You will then be upgraded to the full, consultant version of the CPD Diary. Your Online CPD Diary login details will remain the same and you will be able to continue using the diary as normal to record your CPD. All activities recorded in the SpR Diary will be transferred into the consultant Diary when you upgrade to the full version. The Registration Form may be found on the CPD Registration Page.

How to Get an SpR Diary Password?

If you would like to get a password to be able to use the SpR CPD Diary, then please send an email to cpd@rcplondon.ac.uk, giving your GMC number and you will be issued with your unique login details for the CPD Diary.

Best wishes

Arut

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Monday, February 02, 2009

Endodiabology February 2009

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>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.





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