Endodiabology 2005; Issue 3 (October)

ENDODIABOLOGY

NORTHEAST NEWSLETTER
FOR SPRs AND BOSSES TRAPPED IN THE NORTHERN DEANERY

October 2005

Editors: Shahid Wahid and Petros Perros
Associate Editors: Freda Razvi, Akheel Syed and Ebaa Al-Ozairi

SpR PLACEMENTS (NTN/VTN year of training from 1st October 2005)
RVI- Arun(5), Salman Razvi (3), Akheel Syed (4), Andrew Advani (3/4), Suresh Vaikkakara (visiting SpR)
Freeman- Eelin Lim(3), Reena Thomas (4), Vishmawitra Sharma
North Tyneside/Wansbeck- Muthu Jayapaul (3) /Chandima Idampitiya (1)
South Tyneside- Ibrahim M Ibrahim (4)
Gateshead- Ravi Erukalapati(1)
Sunderland-Isha Malik(1), Subir Ray (2)
North Tees/Hartlepool- Sony Anthony(4)/ Peter Carey(3)
Middlesbrough- Simon Ashwell(5), Sukesh Chandran (2), Asgar Madathil (2)
Carlisle- Khaled Mansur-Dukhan (2)
Bishop Auckland / Durham- Beas Bhatacharya (3)/Jeevan Metayil (1)
NGH/QEH- Yasir Elkhatim
Research with numbers (supervisor)- Latika Sibal (Prof Home), Arutchelvan Vijayaraman (Prof Home), Ravikumar Balasubramanian (Prof Taylor), Ebaa Al-Ozairi (USA-Prof Home)
Acting up David Woods (5)

MEETINGS / LECTURES / ANNOUNCEMENTS
10th-11th October 2005 Controversy or Consensus in the Diabetic Foot Conference, London. Contact SB Communications Group
21ST October 2005 Deadline for BES abstract submission. See www.ece2006.com
25th October 2005 55th Meeting of British Thyroid Association, London. Contact Mark Vanderpump
26th-27th October 2005 ABCD Autumn meeting, London. Contact www.diabetologists.org.uk
26thOctober 2005 Northern Endocrine & Diabetes Autumn CME,James Cook University Hospital. Contact Simon Ashwell .
3rd November 2005 RCP Update in Medicine, Freeman Hospital. Contact Lorraine Waugh
7th-9th November 2005 196th Meeting of the Society for Endocrinology, London. Contact www.endocrinology.org
9th November 2005 North East Obesity Forum, Freeman Hospital 1600-1800, “the Liver in Obesity”. Contact Karen Blackburn or Nigel Unwin
12th November 2005 Association of Physicians meeting,South Tyneside District Hospital. Contact Roy Taylor .
14th November 2005 Regional Neuroendocrine Tumour Meeting, Freeman Hospital 1730-2030, Contact Beverley Ashton
14th-16th November 2005 3rd National MED REG conference, London. Contact www.mahealthcareevents.co.uk or Mark Allen Group
25th November 2005 Abstract Deadline for DUK APC Birmingham March 2006.
30th November 2005 Northern Endocrine Regional Research and Audit Group (NERRAG) meeting, Lumley Castle, Chester-le-street, Durham. Contact Shahid Wahid
14th December 2005 GIM training ½ day-Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine Waugh
15th December 2005 SpR Assessment methods training workshop, James Cook University Hospital 1230-1700. Contact Helen Scales
15th February 2006 Society for Endocrinology Clinical Cases meeting, London. Contact Ann Lloyd


TRAINING ISSUES
Registering with JCHMT/PMETB It is essential that all new SpRs (even LATs) register with the PMETB (used to be JCHMT). Not doing so means your training is not counted and you cannot have a RITA.
SpR Feedback Recently feedback forms for training posts have been circulated to all SpRs. Please complete one form for each training post you have been to in the region as an SpR and return electronically to Shaz Wahid. The results for each individual unit will be sent to them along with a regional summary for comparison. This will allow individual units to improve training. The summary results and examples of practice will be discussed at the annual Trainers meeting. The process will be completed every 3-yrs (to coincide with planned Programme Director change over) so to maintain SpR anonymity.
SpR Database The STC are building an updated database of trainees. Could all SpRs with a number forward their NTN details and CCT date ASAP to Shaz Wahid.
Log Book/Portfolio Documentation It is a trainees 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 Run Through Grade-An update from Shaz Wahid and John Parr As of August 2007 all SHO posts in the region “will” join the PIMD school of medicine, with Basic Specialist Training in Medicine provided in 2-year rotations based around 4 geographical areas with associated hospitals: Wearside (Sunderland Royal, South Tyneside); Newcastle (FRH, FRH, QEH, Northumbria); Durham (UHND, Bishop Auckland, Darlington); Teeside (JCUH, Friaridge, North Tees, Hartlepool). The rotations will be governed by the PIMD. Although floated in a discussion document initially, at a recent GIM STC meeting Nancy Redfern has confirmed that the deanery will be adapting this model. A lot of groundwork is required (an understatement) and the following preliminary timetable was sketched out for our region:
1. By Jan 06
All the "Ology" Specialty programme directors/committees will be consulted and asked what they want of the BST programme for people acceptable to their specialty training programmes, and how do they want to be represented; this will also include the likes of Radiology where medical SHOs also currently go to (the current estimate is that only 40% SHOs go onto medical specialty training programmes so other routes of specialization also need to be catered for in a Basic Medical Specialty Training Programme.
How many non-F2 SHOs (approved posts; Trust doctors; Clinical Fellows etc) do we have in the region?
What posts do we have within the "obvious base units" and are there enough posts to provide suitable rotations?
Who will be the local Trust doctor charged with doing the donkey work within each Trust?
Workforce Planning issues to be sorted out with SHA.
2. By March 06
A draft working plan/document to be produced and presented.
Trusts' Managers to be approached formally.
Final document/plan to be agreed.
3. Between April and Dec 06.
Appoint Programme Directors;
Produce Rotation Specifications; Means of Assessment etc
Assess individual posts to ensure they can provide what the rotations need - (?Trainers may need to produce their own portfolio!).
Means of appointment (?National or Regional); Employment issues - e.g. Trust or Regional Contracts etc.
4. Feb 07
Advertise Posts for appointment for 1st August 2007
There are many outstanding issues which the PIMD will need to take on board; for example;
a) Role of current Royal College approval visits
b) Role of MRCP if the SHOs get their CCST in Acute Medicine at the end of the 2 year BST programme (the inference here is they may even be eligible as a Consultant in Acute Medicine after only 4 years training!).
c) What becomes of the "slow" trainee - will a 3rd year be needed?
d) How will the needs of Radiology, Dermatology, Anaesthesia etc be accommodated within the BST programme.
The STC is considering the implications of the above for our Training Programme. The PIMD are already setting up work-shops to prepare STCs for the Run through grade
Academic SpR rotation The STC are developing a post for an SpR to fill who is academically inclined. The details are still embryonic, but the attributes of future applicants should be:
-Wants an academic (eg. University, not NHS) career
-Already has a good first research degree (MD/PhD)
-Has already a significant publication record (eg. 4 rated papers for
the purposes of research assessment exercise [IF>5], or close to this)
-Has clear and independent research plans that will lead to an
application for a Clinician-scientist fellowship post within 12 months
of starting
-Has strong backing both from an Academic supervisor and a second
Clinical supervisor
-Has already been successful in obtaining some independent research
grant support
Obviously this is a tall order, and the post won't always be filled. An Academic SpR post will be a significantly different experience to a regular SpR post and not just a bland alternate designation with the same training expectations and experiences. Watch this space!
Community Diabetes Training/exposure in this area should consist of the following:
-Attendance at GP diabetes Clinics in the community to view process of care
-Participation in educational activities involving primary care health professionals
-Interaction with local Diabetes UK patient groups
-Attendance at a Diabetes Clinical Network or other management activity involving primary and secondary care interaction
-Participation with Diabetes Specialist Nurses in the community, e.g. home visit
Evidence may comprise reflective accounts, case based discussions, minutes of meetings, programme of events or feedback forms. These are the minimum training standards. Trainees keen to pursue a career in Community Diabetes will need a different slant to their rotation (cv academic rotation), which will require more extensive exposure to community diabetes and SOLID management training. The STC may have to look at this issue in due course.
SpR adverts for NTNs/LATs New PIMD regulations mean that each specialty will be allowed only 2 advertisements per year for Numbers/LAT appointments. The adverts for DM/Endo will be scheduled for end of September (this year 24th September) and Middle of April (next year 14th April). We therefore will only have 2 appointment panels per year for SpRs with a limited window. This has major implications:
1. All SpRs wishing to undertake an out of programme experience (formal research/travel abroad/acting up) or leave the rotation in 2006 are to give Shaz Wahid notice of the exact dates of absence(in writing) by the 1st March 2006. This will then allow the appropriate advertisement to be placed in April 2006 with an appointments panel convened in May/June 2006. Be warned that once SpRs have gave formal notice and the interviews have taken place with a replacement appointed for the period of absence from the rotation there is no going back. Any SpR missing this deadline will not be allowed to come off the rotation until the next appointments panel in October/November 2006 can appoint a replacement.
2. For SpRs with CCSTs due in 2006, the appointments panel in May/June 2006 will automatically appoint a replacement to start 6-months after their CCST date. This may be sooner, if the CCST holder accrues a post earlier than their 6-month grace and enough notice has been given to the appointments panel.
Inevitably a gap may arise in the rotation. The PIMD will post an advert for a LAS that does not require an appointments panel.
New Assessment tools Please see the following website. As of October 2005 Multisource feedback (MSF) and Directly Observed Procedural Skills (DOPS) will be formally introduced and Mini Clinical Evaluation Exercise (Mini-CEX) will go live from October 2006. Also read Ebaa’s excellent thought provoking letter below.
Training Committee Committee Chair- Jola Weaver; Regional Speciality Advisor- Richard Quinton; Programme Director- Shahid Wahid; Consultant member- Jean Macleod; Consultant member (Research Advisor)-Simon Pearce; Consultant member- Simon Eaton; Consultant member- Ronan Canavan; SpR representative- Simon Ashwell; SpR representative- Andrew Advani.

NEW FACES ON THE SCENE
Welcome to Chandima Idampitiya. She joins us as a new NTN beginning at Northumbria.
Welcome to Suresh Vaikkakara. He is a visiting SpR from India based at the RVI.
OLD FACES ON THE GO
Congratulations to Kamal Abouglila on appointment to the post of Consultant in Diabetes and Endocrinology at University Hospital of North Durham.
NEWS FROM THE NORTHEAST
Congratulations to Jeevan Matayil and Ravi Erukulapati on their NTNs.
Congratulations to Richard Quinton and Family on the birth of Baby Oliver.
Congratulations to Akheel Syed and family on the birth of baby boy sunain.
The Programme Director Change has been brought forward, with Shaz Wahid taking over from Richard Quinton on 1st October 2005.

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.

The Death of General Medicine as a dual speciality is nigh
Shaz Wahid
Some may think I am mad, but throughout my training as both an SpR and SHO I thoroughly enjoyed GIM in both its acute medicine and out-patient varieties. My career choices have been coloured by Physicians such as David Carr, Rudy Bilous and Jean MacLeod to name but a few who have (had) established GIM out-patient clinics when I was on their team. This exposure I believe has contributed to my development. It was with a heavy heart that I have recently had to stop taking GIM out-patient referrals from GP colleagues and now run a mainly endocrine clinic with a spattering of ward follow-up patients. The reason for this is the ever-increasing specialist work-load and pressures such as choose and book to name a few. Once Acute Medicine becomes an entrenched speciality and there are enough Acute Physicians, even the acute medicine will disappear into the horizon and I will probably be writing a similar piece in ENDODIABOLOGY. What does this trend hold for future training programmes? I believe that the writing is on the wall for dual speciality training between GIM and DM&Endo. When this may occur is any ones guess, but the split may well be traumatic.

RCP Assessment Tools: Grading the Graders- The missing link!!!
Ebaa Al-ozairi
Assessment is an essential element of all educational systems and to be useful it must be viewed as an integral rather than series of events. Royal College of Physicians (RCP) has recently released new assessment tools for SpRs. Many of the tools have been widely used in the USA and Canada; however can they be applied to the UK system???? In my one year of experience in the USA at Harvard with the remodelling of postgraduate training in the UK has fuelled me to explore discrepancy in the training system and the impact towards a better training system
With the development of modernizing medical careers, it has come to my attention that the onus is on the trainee themselves including evaluation, continuing assessment and examination with huge issue not being addressed: GRADING THE GRADERS- The missing link!!!!!
Mini-Cex: While this method is certainly widely used in USA for the medical students it is hardly used at the fellow stages (equivalent to the SpR stage). Both the American Board of Internal medicine and the fellowship exams are solely based on MCQ with no clinical components. In Canada twice a year mini-cex evaluation takes place in the residency program to prepare the interns for the clinical component of internal medicine exams. Both USA and Canadian systems do not allow interns or fellows to see any in-patient consultation or outpatient without individual discussion of the plan in the presence of the attending (Consultant) who needs to see every single case both at the inpatient and the Outpatient and this is regarded as continuing educational process and mimic the Mini Cex for the later stages. This certainly can not be applied to UK training due to the number of patients seen.
MSF and Raters: I strongly believe in team work and the concept is very appealing. However this method may be useful as an assessment tool after foundation year and may be in the initial stages of higher training but certainly neither in the last 2 years when SpR should be looked at as a senior figure nor at foundation year 1 (F1). Why should doctors get assessed by the allied health professional when they are not assessed by SpR and junior doctors???? Junior doctors in the UK are under so much pressure by the nursing staff and in my opinion the majority of the house officers have enough stress at this stage.
In both the USA and the Canadian system an essential part of the assessment is the complete evaluation of the residents and fellows by their staff (consultant). This is a detailed evaluation of availability, patient care, teaching, communication skills and system based practice. I strongly believe this is a powerful tool that has been missed out at the postgraduate stage although it is widely emphasized in the UK undergraduate system
Similarly the attending evaluates the residents/fellow however it is the duty of the of the attending to take the lead in arranging the evaluation dates and discussing all the evaluations with the resident/fellow rather than resident/fellow running around making appointments.
I strongly believe in assessment as a tool to validate educational effort. Without adequate summative assessment we can not fulfil our obligation to society to assure physicians training meets the higher state of knowledge, competence and professionalism. The UK has been well known for the quality of trained physicians but the time came to polish up to excellence level.

RECENT PUBLICATIONS FROM THE NORTHEAST
Please send us your recent publication for inclusion in the next newsletter.

1. Brook, Clayton and Brown: Clinical Paediatric Endocrinology (5e), which will be launched this month at the European Society of Paediatric Endocrinology meeting with a chapter "Polyglandular Syndromes" by Owen CJ, Cheetham TD and Pearce SH.
2. Carey PE, Gerrard J, Cline GW, Dalla Man C, English PT, Firbank MJ, Cobelli C, Taylor R. ACUTE INHIBITION OF LIPOLYSIS DOES NOT AFFECT POST-PRANDIAL SUPPRESSION OFENDOGENOUS GLUCOSE PRODUCTION. Am J Physiol Endocrinol Metab. 2005 Jul 5; [Epub ahead of print]
3. Hart RH, Kendall-Taylor P, Crombie A, Perros P. Early response to intravenous glucocorticoids for severe thyroid-associated ophthalmopathy predicts treatment outcome. J Ocul Pharmacol Ther. 2005 Aug;21(4):328-36.
4. Home PD, Home EM. International textbook of diabetes mellitus. Diabet Med. 2005 Oct;22(10):1460.
5. Home PD, Hallgren P, Usadel KH, Sane T, Faber J, Grill V, Friberg HH. Pre-meal insulin aspart compared with pre-meal soluble human insulin in type 1 diabetes. Diabetes Res Clin Pract. 2005 Jul 26; [Epub ahead of print]
6. Home PD, Pocock SJ, Beck-Nielsen H, Gomis R, Hanefeld M, Dargie H, Komajda M, Gubb J, Biswas N, Jones NP. Rosiglitazone Evaluated for Cardiac Outcomes and Regulation of Glycaemia in Diabetes (RECORD): study design and protocol. Diabetologia. 2005 Sep;48(9):1726-35. Epub 2005 Jul 16.
7. Home PD, Rosskamp R, Forjanic-Klapproth J, Dressler A. A randomized multicentre trial of insulin glargine compared with NPH insulin in people with type 1 diabetes. Diabetes Metab Res Rev. 2005 Jul 15; [Epub ahead of print]
8. Jennings CE, Owen CJ, Wilson V, Pearce SHS. A haplotype of the CYP27B1 promoter is associated with autoimmune Addison’s disease but not with Graves’ disease in a UK population. J Mol Endo 2005; 34: 859-863.
9. MacColl G & Quinton R. 2005 Kallmann's syndrome: bridging the gaps. Journal of Paediatric Endocrinology & Metabolism. 18: 541-543.
10. Perros P. A 69-year-old female with tiredness and a persistent tan. PLoS Med. 2005 Aug;2(8):e229. Epub 2005 Aug 30.
11. Perros P, Kendall-Taylor P, Neoh C, Frewin S, Dickinson J. A prospective study of the effects of radioiodine therapy for hyperthyroidism in patients with minimally active graves' ophthalmopathy. J Clin Endocrinol Metab. 2005 Sep;90(9):5321-3. Epub 2005 Jun 28.
12. Putta-Manohar S, Syed AA, Parr JH. Cutaneous lesions on the legs. J Postgrad Med 2005; 51(2):127-30.
13. Quinton R & Brownrigg H. The Riots in Kandy. In: More Tales from the Travellers. Editor: Chris Bonnington, Martin Tomkinson Publications, 22 June 2005, ISBN: 0905500741.
14. Roglic G, Unwin N, Bennett PH, Mathers C, Tuomilehto J, Nag S, Connolly V, King H. The burden of mortality attributable to diabetes: realistic estimates for the year 2000. Diabetes Care. 2005 Sep;28(9):2130-5.
15. Sibal L, Ball SG, Connolly V, James RA, Kane P, Kelly WF, Kendall-Taylor P, Mathias D, Perros P, Quinton R, Vaidya B. Pituitary Apoplexy: A Review of Clinical Presentation, Management and Outcome in 45 Cases. Pituitary. 2005 Jul 11; [Epub ahead of print]
16. Sjolie AK, Porta M, Parving HH, Bilous R, Klein R; The DIRECT Programme Study Group. The DIabetic REtinopathy Candesartan Trials (DIRECT) Programme: baseline characteristics. J Renin Angiotensin Aldosterone Syst. 2005 Mar;6(1):25-32.
17. Syed AA, Weaver JU. Glucocorticoid sensitivity: the hypothalamic-pituitary-adrenal-tissue axis. Obes Res. 2005 Jul;13(7):1131-3.
18. Weaver JU. Obesity, cytokines and the search for beauty. Clin Endocrinol (Oxf). 2005 Sep;63(3):251-2.
19. Walker M, Taylor RW, Turnbull DM. Mitochondrial diabetes. Diabet Med. 2005 Sep;22 Suppl 4:18-20.

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

Reid IR, Miller P, Lyles K, Fraser W, Brown JP, Saidi Y, Mesenbrink P, Su G, Pak J, Zelenakas K, Luchi M, Richardson P,Hosking D. Comparison of a single infusion of zoledronic acid with risedronate for Paget's disease. NEJM 2005;353:872-5.
Two identical, randomized, double-blind, actively controlled trials of 6 months' duration compared one 15-minute infusion of 5 mg of zoledronic acid with 60 days of oral risedronate (30 mg per day). The primary efficacy end point was the rate of therapeutic response at six months, defined as a normalisation of alkaline phosphatase levels or a reduction of at least 75% in the total alkaline phosphatase excess. The results of the studies were pooled. RESULTS: At six months, 96% of patients receiving zoledronic acid had a therapeutic response as compared with 74.3% of patients receiving risedronate (p less than 0.001). Alkaline phosphatase levels normalised in 88.6% of patients in the zoledronic acid group and 57.9% of patients in the risedronate group (p less than 0.001). Zoledronic acid was associated with a shorter median time to a first therapeutic response (64 vs. 89 days, p less than 0.001). Higher response rates in the zoledronic acid group were consistent across all demographic, disease-severity, and treatment-history subgroups and with changes in other bone-turnover markers. The physical-component summary score of the Medical Outcomes Study 36-item Short-Form General Health Survey, a measure of the quality of life, increased significantly from baseline at both three and six months in the zoledronic acid group and differed significantly from those in the risedronate group at 3-months. Pain scores improved in both groups. During post-trial follow-up (median, 190 days), 21 of 82 patients in the risedronate group had a loss of therapeutic response, as compared with 1 of 113 patients in the zoledronic acid group (p less than 0.001). In conclusion a single infusion of zoledronic acid produces more rapid, more complete, and more sustained responses in Paget's disease than does daily treatment with risedronate.

Cundy T, Davidson J, Rutland MD, Stewart C, DePaoli AM. Recombinant osteoprotegerin for juvenile Paget's disease. NEJM 2005;353:918-23.
Juvenile Paget's disease, a genetic bone disease characterized by accelerated bone turnover, results from inactivating mutations in the gene encoding osteoprotegerin--a key regulator of osteoclastogenesis. The effects of recombinant osteoprotegerin were investigated in two adult siblings with juvenile Paget's disease. Bone resorption (assessed by N-telopeptide excretion) was suppressed by once-weekly subcutaneous doses of 0.3 to 0.4 mg per kilogram of body weight. After 15 months of treatment, radial bone mass increased in one patient by 9 percent and in the other by 30 percent, skeletal bisphosphonate retention decreased by 37 percent and 55 percent, respectively, and there was radiographic improvement. Apart from mild hypocalcaemia and hypophosphataemia, no apparent adverse events occurred. Read the accompanying perspectives article by Deftos LJ, NEJM 2005;353:872-875, relating to these 2 articles. It is excellent.

Ehrmann DA. Polycystic Ovary Syndrome. NEJM 2005;352:1223-1236.
An excellent review article that is of practical and intellectual value.

Watanabe D, Suzuma K, Matsui S, Kurimoto M, Kiryu J, Kita M, Suzuma I, Ohashi H, Ojima T, Murakami T, Kobayashi T, Masuda S, Nagao M, Yoshimura N, Takagi H. Erythropoietin as a retinal angiogenic factor in proliferative diabetic retinopathy. NEJM 2005;353:782-92.
The investigators measured both erythropoietin and VEGF levels in the vitreous fluid of 144 patients with the use of radioimmunoassay and enzyme-linked immunosorbent assay. Vitreous proliferative potential was measured according to the growth of retinal endothelial cells in vitro and with soluble erythropoietin receptor. In addition, a murine model of ischemia-induced retinal neovascularization was used to evaluate erythropoietin expression and regulation in vivo. RESULTS: The median vitreous erythropoietin level in 73 patients with proliferative diabetic retinopathy was significantly higher than that in 71 patients without diabetes (464.0 vs. 36.5 mIU per milliliter, p less than 0.001). The median VEGF level in patients with retinopathy was also significantly higher than that in patients without diabetes (345.0 vs. 3.9 pg per milliliter, p less than 0.001). Multivariate logistic-regression analyses indicated that erythropoietin and VEGF were independently associated with proliferative diabetic retinopathy and that erythropoietin was more strongly associated with the presence of proliferative diabetic retinopathy than was VEGF. Erythropoietin and VEGF gene-expression levels are up-regulated in the murine ischaemic retina, and the blockade of erythropoietin inhibits retinal neovascularization in vivo and endothelial-cell proliferation in the vitreous of patients with diabetic retinopathy in vitro. This study suggests that erythropoietin is a potent ischemia-induced angiogenic factor that acts independently of VEGF during retinal angiogenesis in proliferative diabetic retinopathy. Any therapy that is in the pipeline relating to erythropoietin blockade is probably best delivered locally because of its uncertain systemic effects.

Lenders JWM, Eisenhofer G, Mannelli M, Pacak K. Phaeochromocytoma. Lancet 2005;366:665-675. A review article that is a good revision aid.Matsumoto S, Okitsu T, Iwanaga Y, Noguchi H, Nagata H, Yonekawa Y, Yamada Y, Fukuda K, Tsukiyama K, Suzuki H, Kawasaki Y, Shimodaira M, Matsuoka K, Shibata T, Kasai Y, Maekawa T, Shapiro J, Tanaka K. Insulin independence after living-donor distal pancreatectomy and islet allotransplantation. Lancet 2005;365:1642-4.
Rising demand for islet transplantation will lead to severe donor shortage in the near future, especially in countries where cadaveric organ donation is scarce. The investigators undertook a successful transplantation of living-donor islets for unstable diabetes. The recipient was a 27-year-old woman who had had brittle, insulin-dependent diabetes mellitus for 12 years. The donor, who was a healthy 56-year-old woman and mother of the recipient, underwent a distal pancreatectomy. After isolation, 408 114 islet equivalents were transplanted immediately. The transplants functioned immediately and the recipient became insulin-independent 22 days after the operation. The donor had no complications and both women showed healthy glucose tolerance. Transplantation of living-donor islets from the distal pancreas can be sufficient to reverse brittle diabetes.

Feenstra J, de Herder WW, ten Have SM, van den Beld AW, Feelders RA, Janssen JA, van der Lely AJ. Combined therapy with somatostatin analogues and weekly pegvisomant in active acromegaly. Lancet 2005;365:1644-6.
Pegvisomant monotherapy once daily returns concentrations of insulin-like growthfactor I (IGF-I) to normal in most patients with acromegaly, but is very costly. In a 42-week dose-finding study, the investigators assessed the efficacy of the combination of long-acting somatostatin analogues once monthly and pegvisomant once weekly in 26 patients with active acromegaly. Dose of pegvisomant was increased until IGF-I concentration became normal or until a weekly dose of 80 mg was reached. IGF-I reached normal concentrations in 18 of 19 (95%) patients who completed 42 weeks of treatment, with a median weekly dose of 60 mg pegvisomant (range 40-80). No signs of pituitary tumour growth were noted, but mild increases in liver enzymes were observed in ten patients (38%). This combined treatment is effective, might increase compliance, and could greatly reduce the costs of medical treatment for acromegaly in some patients.

IDF First Global guidelines for management of type 2 diabetes
On 13th Sept at Athens the EASD congress the IDF release of the first global guidelines for the management of T2DM. The guidelines call for more aggressive treatment of type 2 diabetes across the globe with detailed 3 level care approach. For full version check www.idf.org

The metabolic syndrome: time for a critical appraisal.
An excellent review article from the joint statement of ADA and EASD published in Diabetes Care. 2005 Sep;28(9):2289-304. Definitely worth reading!!

Dahlof B, Sever PS, Poulter NR, Wedel H, Beevers DG, Caulfield M, Collins R, Kjeldsen SE, Kristinsson A, McInnes GT, Mehlsen J, Nieminen M, O'Brien E, Ostergren J; ASCOT Investigators. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial. Lancet. 2005;366:895-906.
This multicentre, prospective, randomised controlled trial compare the effect on non-fatal MI and fatal CHD of combinations of atenolol with a thiazide versus amlodipine with perindopril in 19 257 patients with hypertension who were aged 40-79 years and had at least three other cardiovascular risk factors. Patients were assigned either amlodipine 5-10 mg adding perindopril 4-8 mg as required (amlodipine-based regimen; n=9639) or atenolol 50-100 mg adding bendroflumethiazide 1.25-2.5 mg and potassium as required (atenolol-based regimen; n=9618). The primary endpoint was non-fatal MI (including silent MI) and fatal CHD. Analysis was by intention to treat. The study was stopped prematurely after 5.5 years' median follow-up and accumulated in total 106 153 patient-years of observation. Though not significant, compared with the atenolol-based regimen, fewer individuals on the amlodipine-based regimen had a primary endpoint (429 vs 474; unadjusted HR 0.90, 95% CI 0.79-1.02, p=0.1052), fatal and non-fatal stroke (327 vs 422; 0.77, 0.66-0.89, p=0.0003), total cardiovascular events and procedures (1362 vs 1602; 0.84, 0.78-0.90, p less than 0.0001), and all-cause mortality (738 vs 820; 0.89, 0.81-0.99, p=0.025). The incidence of developing diabetes was less on the amlodipine-based regimen (567 vs 799; 0.70, 0.63-0.78, p less than 0.0001). In conclusion the amlodipine-based regimen prevented more major cardiovascular events and induced less diabetes than the atenolol-based regimen. The authors state that these results have implications with respect to optimum combinations of antihypertensive agents. From a personal point of view this trial does not change my own clinical practice of perindopril followed by bendrofluamethazide followed by amlodipine followed by doxazosin followed by atenolol when managing hypertension. This practice is certainly not written in stone and I do individualise treatment. ASCOT simply shows that there is little to choose between older and newer agents. The provocative accompanying editorial argues that the 2.7mmHg difference in systolic BP between the amlodipine/perindopril vs BFZ/atenolol arm can account for the difference between the regimens. A lot of marketing pressure is going to be applied to Drs over coming months in relation to the results of ASCOT. My advice will be to be consistent as advised by one of my trainers whilst I was towards the end of my training. If you prefer to use lisinopril or methyldopa stick to it, but strive to achieve target blood pressures. Even in ASCOT only 32.2% of diabetic and 60% of non-diabetic patients were well controlled.

Ashen MD, Blumenthal RS. Clinical practice. Low HDL cholesterol levels. N Engl J Med. 2005 Sep 22;353(12):1252-60.
This is an excellent review article which discusses the scientific basis behind lowering HDL and relates to clinical practice. A worthwhile read.

NEXT NEWSLETTER Due out beginning of February 2006, so keep the gossip coming.

Endodiabology 2005; Issue 2 (June)

ENDODIABOLOGY

NORTHEAST NEWSLETTER
FOR SPRs AND BOSSES TRAPPED IN THE NORTHERN DEANERY

FEBRUARY 2005

Editors: Shahid Wahid and Petros Perros
Associate Editors: Freda Razvi, Akheel Syed and Ebaa Al-Ozairi


SpR PLACEMENTS (NTN/VTN year of training from 1st October 2004)
RVI- Eelin Lim(2), Simon Ashwell(4), Ibrahim M Ibrahim (4), Reena Thomas (3), Freda Razvi (3/4)
Freeman- David Woods(5), Arun(4), Arutchelvan Vijayaraman (3), Salman Razvi (3)
North Tyneside/Wansbeck- Vishmawitra Sharma/ Jaysri Ranjani
South Tyneside- Akheel Syed (3)
Gateshead- Jeevan Metayil
Sunderland- Asghar Madathil (1), Khaled Mansur-Dukhan (1)
North Tees/Hartlepool- Stella Kaddis(5) / Sukesh Chandran (1)
Middlesbrough- Peter Carey(3), Beas Bhatacharya (2), Dr Erulapati
Carlisle- Isabelle Howat (1)
Bishop Auckland / Durham- Yasir Elkhatim/ Sony Anthony(3),
NGH/QEH- Subir Ray (1)
Research with numbers (supervisor)- Latika Sibal (Prof Home), B Ravikumar (Prof Taylor), Mutu Jayapaul (Prof Walker), Ebaa El Ozairi (USA-Prof Home), Andrew Advani (Australia)

MEETINGS / LECTURES / ANNOUNCEMENTS
4th-7th June 2005 ENDO 2005, San Diego, USA. Contact ENDO email or ENDO website .
10th-14th June 2005 American Diabetes Association 65th Annual Scientific Sessions, San Diego, USA. Contact ADA email .
1st July 2005 Association of Physicians meeting, University Hospital of North Durham. Contact Roy Taylor .
4th-8th July 2005 The Society For Endocrinology Summer School, Durham. Contact Simon Pearce or Ann Lloyd
6th July 2005 SpR GIM training ½ day-Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
10th-15th September 2005 41st Annual EASD meeting, Athens. Contact EASD website
12th September 2005 SpR GIM training ½ day- Sunderland Royal Hospital. Contact Lorraine Waugh 0191 223 1247
13th-14th September 2005 Oxford Advanced Endocrinology seminar. Contact Juliet Need
10th-11th October 2005 Controversy or Consensus in the Diabetic Foot Conference, London. Contact SB Communications Group
25th October 2005 55th Meeting of British Thyroid Association, London. Contact Mark Vanderpump
26th-27th October 2005 ABCD Autumn meeting, London. Contact ABCD website
3rd November 2005 RCP Update in Medicine, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
7th-9th November 2005 196th Meeting of the Society for Endocrinology, London. Contact Society for Endocrinology website
12th November 2005 Association of Physicians meeting,South Tyneside District Hospital. Contact Roy Taylor .
14th-16th November 2005 3rd National MED REG conference, London. Contact website or email
30th November 2005 Northern Endocrine Regional Research and Audit Group (NERRAG) meeting, Lumley Castle, Chester-le-street, Durham. Contact Shahid Wahid
14th December 2005 GIM training ½ day-Freeman Hospital. Contact Lorraine Waugh 0191 223 1247


TRAINING ISSUES
Record of Internal Training Assessments These are once more all change from May 2006. These changes will comply with national guidance set down by the PMETB and which the Deanery is obliged to follow. The main messages are:
-an interview/presentation will no longer be acceptable alone in the place of assessment
-the region will adopt a paper based RITA with the panel made up of all Consultant members of the RITA, a PIMD representative, an External Speciality assessor and a member of the regional GIM STC
-the Evidence of Achievement (EoA) form, structured CV and training portfolio will need to arrive at the PIMD 14-days before the RITA date.
-the EoA and structured CV will be sent to the allocated assessors at least 7 days before the RITA date
-the whole RITA panel will meet for a full day to gather the assessors recommendations and sample evidence from the training portfolio so as to allocate a RITA grade (C-satisfactory progress; F-out of training experience; G-satisfactory completion of training for CCST; D-requires targeted training for the next year with a review RITA; E-needs to repeat training with a review RITA)
-Trainees receiving a RITA C or F will be sent a written summary of strengths/weaknesses to discuss with their educational supervisor
-A separate date will be arranged to meet with trainees receiving a RITA D or E
-Trainees not submitting the required documentation before the deadlines can not have a RITA. Deadlines have to be adhered to.
Assessment methods From October 2005 methods of formal assessment will be utilised to assess a trainees progress. These will include mini-Clinical Exercise (mini-CEX), 360 degree appraisal questionnaires, case based discussions and patient satisfaction questionnaires. The redesigned EoA form will reflect this. Further details will be provided at the joint trainers/trainees meeting.
Joint Trainers/Trainees meeting the traditional annual get-together will be on Mon 20th June 2005 at the Education Centre, University Hospital of Hartlepool.
AUDIT As part of a trainees appraisal and what future RITA panels will be examining is not whether an audit was undertaken, but whether the loop was closed. It is essential that an audit is completed and presented regionally or nationally. There is ample opportunity to present audits regionally (NERRAG every November and NORDAG in May and October) and nationally (DUK or BES). Furthermore, the inclusion of one general audit during training which examines a particular process of care in the NHS will be encouraged.
Teaching The comment “I regularly teach medical students” in a portfolio will no longer suffice for RITA purposes. It is essential that a trainee has his/her teaching skills appraised in the form of feedback from teaching sessions, therefore collect evidence of feedback. The other method to satisfy the RITA is to attend a training course (check out the PIMD website).
Change of circumstances It is essential that all trainees inform the STC via the programme director well in advance of any intentions such as resignation, maternity leave, undertake research, request for an interdeanery transfer, etc. Over the years the STC has been very understanding and bent over backwards to accommodate requests, however with the recent worrying trend that the STC is usually told last, the STC may have to adapt a hard nose approach and apply the 3 month rule or more if applicable.
Log Book/Portfolio Documentation It is a trainees 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 can not be counted towards training.
Restructured rotation As of October 2005 the rotation is split into Northern and Southern with the RVI as the common link. Trainees can expect to spend 1-yr at the RVI and 1-yr at either Freeman or JCUH and rotate around the linked DGHs. Rotation allocation will depend on training needs, e.g. trainees will not automatically be allocated a DGH in their final year. Trainees will be allotted training units over 2 years so as to aid planning of learning and assessment.
Training Committee Regional Speciality Advisor & Programme Director - Richard Quinton; Committee Chairman- Jola Weaver; Consultant member (Programme Director Elect from Jan 2006)- Shahid Wahid; Consultant member- Jean Macleod; Consultant member (Research Advisor)- Simon Pearce; Consultant member- Simon Eaton; Consultant member- Ronan Canavan; SpR representatives- Simon Ashwell & Andrew Advani

Training post review: South Tyneside District Hospital
This is a new feature that gives trainees’ perspectives on training posts in the Northern region with the express objective of aiding other trainees in choosing their next appointments. It is also hoped that it will be of benefit to trainers in recommending/ organising rotations tailored to the individual needs of the trainees. Each issue will feature one training post, starting with South Tyneside District Hospital in the current issue. We invite reviews of 300 words or less from other centres for the next issue due out in October.

Training post: South Tyneside District Hospital (STDH)
Address: Harton Lane, South Shields NE34 0PL
Consultants: Dr John Parr & Dr Shahid Wahid
Current SpR: Dr Akheel Syed (reviewer)

STDH is a 627-bedded DGH serving a district of population 152,785 (Census 2001). It is situated on the coast 13 mi. approx. from Newcastle, well connected by road (Tyne tunnel toll £ 1.00 for cars) and metro-rail. The department of medicine has three gastroenterologists, three cardiologists, two respiratory physicians and three COTE/Stroke physicians apart from the two consultants in diabetes/endocrinology.
Training opportunities:
Diabetes: Includes weekly diabetes and joint antenatal clinics, and monthly pre-conception, young persons’, joint renal-diabetes, and optional community and paediatric clinics; there are also regular retinopathy and foot clinic sessions. There is ample opportunity to see a wide variety of patients ranging from the newly diagnosed to the challenging heart-sinks!
Endocrinology: Includes weekly endocrine clinic, monthly radioiodine clinic, and optional osteoporosis and infertility clinics. There is an Endocrine Day Unit staffed by a very experienced, helpful senior nurse. The range of conditions is typical of the usual DGH spectrum i.e. thyroid, calcium and water and electrolyte disorders but abundant training and experience in managing thyroid nodules, and interpretation of thyroid imaging.
GIM: Outpatient experience includes two clinics per week with generous prospects for seeing new patients. On-call rota is shared by 9 registrars/Senior SHOs and includes day-shifts and weeks of nights. Solid DGH experience with busy unselected general medical intake via an Acute Medical Admissions Unit or A&E, direct responsibility for 6-bedded CCU out-of-hours (Registrar rounds during weekends), referrals from non-medical wards/specialities and cover for ITU/HDU. Well-supported by radiology, biochemistry, haematology and microbiology. Ample opportunities for procedures such as central line insertion, lumbar puncture, paracentesis, pleural drain insertion, BIPAP ventilation, and advanced life support. Sufficient experience in ethical issues such as end-of-life decisions.
Study/Research: There are two regular lunch-time meetings and an excellent radiology meeting every week. There is a half-day for personal study/research.
Consultants: Two of the best clinicians in the region. They each have a distinct style and approach and you can expect to benefit hugely from their experience as well as their enthusiasm.
Assessment/Appraisal: As of October 2005 STDH will be actively utilising competence assessment/appraisal in the form of mini-CEX, 360 degree appraisals, patient satisfaction questionnaires and case based discussions.
Verdict: Excellent post for Year 1/2 or those looking to consolidate DGH experience in their final year.

FLEXIBLE TRAINING
From June a new £14 million deal will make it easier for doctors to train flexibly. It is believed that this will boost the NHS workforce by doubling the numbers of flexible trainees over the next three to five years. Access to flexible training has been poor during the past few years. Only one in 20 junior doctors train flexibly, but around half say they would like to at some stage. Junior doctors will be able to apply for flexible training for a wider range of reasons split into two.
Those in category one will have priority and include doctors in training with:
Disability or ill health (this may include those on IVF programmes)
Carer responsibility for children, relatives or other dependents
Category two doctors include those with:
Opportunities for their own personal or professional development such as training for big sporting events
Religious commitment
Non-medical professional development such as diploma in complementary therapies, fine art courses or law courses.

Flexible Careers Scheme
The Flexible Careers Scheme (FCS) is a response to the Improved Working Lives Initiative, which aims to make the NHS a better place to work. It has been developed to give hospital doctors more opportunities to work flexibly in their careers and so enable doctors who would otherwise leave the service or have already left to use their skills and experience gained in the NHS to benefit the NHS. The Scheme is designed to enable doctors to fulfil the revalidation requirements of their speciality, keep up their practice, receive advice and have access to appraisal.
Who is the FCS for?
Doctors in training grades who wish to take a managed break from training in the NHS, working 19 hours a week or less but still maintaining their clinical skills.
The nature of Flexible Careers Posts
In each case the scheme will be adapted to individual circumstances, but have the following features.
To be time limited to two years for trainee grades at the onset, but with the possibility of extension later (including extension to cover maternity leave where appropriate).
Specialist Registrars are eligible to retain their National Training Number for the duration of the period on the scheme.
To provide sufficient medical/ clinical practice for revalidation purposes.
Because posts are usually less than half time minimum required for training they will not normally count towards training and are considered time out of training.
Each doctor will meet regularly with a clinical and educational supervisor.
Each post will contain an educational CPD element.
Access to the NHS pension scheme will be available.
Doctors on the scheme have access to the same range of employment benefits as other colleagues such as sickness, annual leave, maternity rights.
Doctors on the scheme will be entitled to study leave on a pro-rata basis.

NEW FACES ON THE SCENE
One NTN will be advertised for October 2005 and possibly 2 LAT posts.
OLD FACES ON THE GO
Olivia Pereira has arranged an interdeanery transfer to Grampian region.
Isabel Howwat will be leaving for Scotland in October 2005 after arranging an interdeanery transfer.
Terry Asprey has accepted the post of Diabetes and COTE Physician at Sunderland Royal Hospital.
Kamal Abouglila has taken up the post of Locum Consultant in Diabetes and Endocrinology at University Hospital of North Durham.
Stella Kadis has been awarded her CCST and plans to undertake a locum post at Northumbria from October 2005.
NEWS FROM THE NORTHEAST
Simon Eaton and Ronan Canavan have joined the STC.
Congratulations to Professor Roy Taylor on an excellent Arnold Bloom Lecture at DUK. It is the best one I(Shaz) have heard and sticks in the memory in the same way as the message he conveyed several years ago “ simplify, simplify, simplify”.
Congratulations to Sath Nag on his appointment as Acute Physician with a specialist interest in Diabetes & Endocrinology at James Cook University Hospital.
Shaz Wahid will be Programme Director from January 2006 with an interim period from October 2005.
Congratulations to Simon Ashwell on obtaining his MD.
Congratulations to Alison Gallagher on obtaining her MD.
Congratulations to Stella Kadis and family on the birth of baby Zoe.
Nigel Unwin, who many of you will know, holds the Chair of Epidemiology at Newcastle University.
Congratulations to Simon Eaton and family on the birth of baby Euan.
Akheel Syed and Ebaa Al-Ozairi have joined the Editorial team of ENDODIABOLOGY.
Congratulation to Sath Nag and the team from Middlesbrough in their award for best YDF presentation at DUK in April.
Congratulations to Latika Sibal, Beas Bhattacharya, and Ravi on successful oral presentations at DUK.
Freda Razvi will be joining the Retainer Scheme from 31st July 2005.
Kemal Abouglila is undertaking a Locum at University Hospital of North Durham.
Professor Taylor will be taking the lead role in managing the MR center that is being constructed in Newcastle. This will have a huge impact on research in the region.

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.

NORDAG meeting 4th May 2005.-Jola Weaver
This meeting was attended by 30 Consultants, Specialist Registrars, Medical Students and PCT representatives. During the course of the meeting five very interesting audits were presented. Laura Hannon, medical student from Newcastle University, won the Novo Nordisk Audit Prize for the best audit presentation. The meeting was approved for 2 CPD credit points. I am looking for a successor to chair the next meeting which is due to take place on 5th October, 2005. Please forward nominations to my email address at your earliest opportunity Jola Weaver (Uni) or Jola Weaver (QEH).

Scrambled or Benedict: How would you like your nutritional guidelines served?-Ebaa Al-Ozairi
Nearly 80% of type 2 diabetics are overweight or obese. Clinical research over the last few years has shown that healthy life style measures are much more effective than any medications. The key is to find a logical and easy-to-use plan for people to follow, supported by strong evidence. This was Dr Hamdy (Obesity Clinic Director at JDC) basis for the new guidelines.
Joslin Diabetes Center (JDC) has crafted new lifestyle guidelines targeting people with type 2 diabetes or prediabetes who are overweight or obese. In the new recommendations, 40% of daily calories come from carbohydrates; 20% to 30% from protein (except in the presence of renal disease); 30% to 35% from fat, (mostly mono- and polyunsaturated fats); and the diet consists of a minimum of 20 to 35 g of fibre. By reducing daily caloric intake by 250 to 500 calories, individuals should be able to lose one pound every one to two weeks. Total daily caloric intake should be at least 1,000 to 1,200 for women and 1,200 to 1,600 for men. To maintain or increase lean body mass, the guidelines recommend a target of 60 to 90 minutes of moderate intensity physical activity, including cardiovascular, stretching, and resistance activities most days of the week, with a minimum of 150 to 175 minutes weekly.
At least 50% of the references included in these guidelines are between July 2003 and February 2005, so the guidelines reflect the cutting-edge knowledge in this field. These guidelines differ from those of other national organizations in some respects:
First, these guidelines are directed to overweight and obese subjects and are not directed to all diabetic patients. Secondly, the guidelines extend to cover the overweight and obese prediabetes population. Thirdly, the lower carbohydrate (CHO) content 40% of daily calories which is lower than in previous recommendations.
The rationale of the lower CHO comes from the wealth of evidence over the past 2 years from experimental studies and randomised controlled clinical trials in humans that support the concept that reducing energy intake from carbohydrates and increasing it from protein is effective in controlling diabetes, improving insulin sensitivity, reducing visceral fat, improving lipid profile and helping people to lose weight. Many recent studies also have shown that postprandial hyperglycemia and hypertriglyceridemia are significantly improved with the percentage of carbohydrates around 40%.
For full version of the guideline please visit website. The only limiting factor is that specific guidelines for the Asian population were not included.

Painting the landscape for prevention-Ebaa Al-Ozairi
A new worldwide definition of the metabolic syndrome in attempt to halt the cardiovascular time bomb. International Diabetes Federation press release on 16th April a new guidelines which include new, clinical easily applicable guidelines including gender and ethnic specific cut points for central obesity. These guidelines are well timed. With a prevalence of 25% for metabolic syndrome there is the huge demand for a single unified definition.
According to the new IDF definition, for a person to be defined as having the metabolic
syndrome they must have:
Central obesity (defined as waist circumference ≥ 94cm for Europid men and ≥ 80cm for Europid women, with ethnicity specific values for other groups)
Plus any two of the following four factors:
raised TG level: more than 150 mg/dL (1.7 mmol/L), or specific treatment for this
lipid abnormality
reduced HDL cholesterol: less than 40 mg/dL (1.03 mmol/L*) in males and less than 50
mg/dL (1.29 mmol/L*) in females, or specific treatment for this lipid
abnormality
raised blood pressure: systolic BP ≥130 or diastolic BP≥ 85 mm Hg, or
treatment of previously diagnosed hypertension
raised fasting plasma glucose (FPG) ≥100 mg/dL (5.6 mmol/L), or
previously diagnosed type 2 diabetes
If above 5.6 mmol/L or 100 mg/dL, OGTT is strongly recommended but is not
necessary to define presence of the syndrome.
For full details of guidelines please check website
Also check the metabolic syndrome seminar in lancet,16 April 16,1415-1428 which provides easy excellent summary with wealth of information.

RECENT PUBLICATIONS FROM THE NORTHEAST
Please send us your recent publication for inclusion in the next newsletter.

1. Gilroy JJ, James RA. Optimising somatostatin analog therapy in acromegaly: long-acting formulations. Treat Endocrinol. 2002;1(3):149-54. Review.
2. Jennings CE, Owen CJ, Wilson V, Pearce SH. No association of the codon 55 methionine to valine polymorphism in the SUMO4 gene with Graves' disease. Clin Endocrinol (Oxf). 2005 Mar;62(3):362-5.
3. Luster M, Lippi F, Jarzab B, Perros P, Lassmann M, Reiners C, Pacini F. rhTSH-aided radioiodine ablation and treatment of differentiated thyroid carcinoma: a comprehensive review. Endocr Relat Cancer. 2005 Mar;12(1):49-64.
4. Marshall SM. Management of diabetic nephropathy. Diabet Med. 2005 May;22(5):668-9.
Quinton R. 2005 Delayed puberty: if in doubt procrastinate? British Medical Journal. 330: 789.
5. Solomon Tesfaye, Nish Chaturvedi, Simon Eaton, John D. Ward, Christos Manes, Constantin Ionescu-Tirgoviste, Daniel R. Witte, and John H. Fuller, for the EURODIAB Prospective Complications Study Group. Vascular Risk Factors and Diabetic Neuropathy. NEJM 352 (4) p 341-350.
6. Wang Y, Marshall SM, Thompson MG, Hoenich NA. Cardiovascular risk in patients with end-stage renal disease: a potential role for advanced glycation end products. Contrib Nephrol. 2005;149:168-74.
7. Wilkinson A, Davidson J, Dotta F, Home PD, Keown P, Kiberd B, Jardine A,Levitt N, Marchetti P, Markell M, Naicker S, O'connell P, Schnitzler M, Standl E, Torregosa JV, Uchida K, Valantine H, Villamil F, Vincenti F, Wissing M. Guidelines for the treatment and management of new-onset diabetes after transplantation. Clin Transplant. 2005 Jun;19(3):291-8.
8. Wilson MO, Scougall KT, Ratanamart J, McIntyre EA, Shaw JA. Tetracycline-regulated secretion of human (pro)insulin following plasmid-mediated transfection of human muscle. J Mol Endocrinolgy (2005) 34: 391-403

RECENT PUBLICATIONS IN DIABETES & ENDOCRINOLOGY THAT HIT THE NEWS OR THAT MAY HAVE A SIGNIFICANT IMPACT ON MANAGEMENT
Cooper DS. Antithyroid Drugs. NEJM 2005; 352: 905-917.
An excellent review of the drug treatment for thyrotoxicosis which is full of practical advice. I highly recommend it as compulsory reading for all trainees.
Buttgereit F, et al. Optimised glucocorticoid therapy: the sharpening of an old spear. Lancet 2005; 365: 801-803.
An excellent review of the negative and positive effects of glucocorticoids with an emphasis on pathophysiology which provides an excellent framework on which to base clinical practice.
Sjoholm A, Nystrom T. Endothelial inflammation in insulin resistance. Lancet 2005; 365: 610-612.
An excellent overview of the pathophysiology linking cardiovascular risk and insulin resistance. This is a topical subject at the moment and this review is timely.
Ehrmann DA. Polycystic Ovary Syndrome. NEJM 2005; 352: 1223-1236.
A good practical overview of PCOS with an American style. Recommended reading for trainees.
Van Gaal LF, Rissanen AM, Scheen AJ, Ziegler O, Rossner S; RIO-Europe Study Group.Effects of the cannabinoid-1 receptor blocker rimonabant on weight reduction and cardiovascular risk factors in overweight patients: 1-year experience from the RIO-Europe study. Lancet. 2005 Apr;365:1389-97.
Van Gall et al assessed the effect of rimonabant, a selective cannabinoid-1 receptor blocker, on bodyweight and cardiovascular risk factors in overweight or obese patients. 1507 patients with BMI more than 29.9 kg/m2 or more than than 26.9 kg/m2 with treated or untreated dyslipidaemia, hypertension, or both, were randomised to receive double-blind treatment with placebo, 5 mg rimonabant, or 20 mg rimonabant once daily in addition to a mild hypocaloric diet (600 kcal/day deficit). The primary endpoint was weight change from baseline after 1 year of treatment in the intention-to-treat population. Weight loss at 1 year was significantly greater in patients treated with rimonabant 5 mg (mean -3.4 kg [SD 5.7]; p=0.002 vs placebo) and 20 mg (-6.6 kg [7.2]; p less than 0.001 vs placebo) compared with placebo (-1.8 kg [6.4]). Significantly more patients treated with rimonabant 20 mg than placebo achieved weight loss of 5% or greater (p less than 0.001) and 10% or greater (p less than 0.001). Rimonabant 20 mg produced significantly greater improvements than placebo in waist circumference, HDL-cholesterol, triglycerides, and insulin resistance, and prevalence of the metabolic syndrome. The effects of rimonabant 5 mg were of less clinical significance. Rimonabant was generally well tolerated with mild and transient side effects. There was an approximate 40% drop out in all arms, with psychological symptoms being relatively common in the treatment arms. In conclusion, CB1 blockade with rimonabant 20 mg, combined with a hypocaloric diet over 1 year, promoted significant decrease of bodyweight and waist circumference, and improvement in cardiovascular risk factors. However, the high drop out rate and relative increased rate of psychological symptoms with rimonabant detracts from the study.
LaRosa JC, Grundy SM, Waters DD, Shear C, Barter P, Fruchart JC, Gotto AM, Greten H, Kastelein JJ, Shepherd J, Wenger NK; Treating to New Targets (TNT) Investigators. Intensive lipid lowering with atorvastatin in patients with stable coronary disease. N Engl J Med. 2005 ;352:1425-35.
LaRosa et al prospectively assessed the efficacy and safety of lowering LDL cholesterol levels below 2.6 mmol/l in patients with stable coronary heart disease (CHD). A total of 10,001 patients with clinically evident CHD and LDL cholesterol levels less than 3.4 mmol/l were randomly assigned to double-blind therapy and received either 10 mg or 80 mg of atorvastatin per day. Patients were followed for a median of 4.9 years. The primary end point was the occurrence of a first major cardiovascular event, defined as death from CHD, nonfatal non-procedure-related myocardial infarction, and resuscitation after cardiac arrest, or fatal or nonfatal stroke. The mean LDL cholesterol levels were 2.0 mmol/l during treatment with 80 mg of atorvastatin and 2.6 mmol/l during treatment with 10 mg of atorvastatin. The incidence of persistent elevations in liver aminotransferase levels was 0.2 percent in the group given 10 mg of atorvastatin and 1.2 percent in the group given 80 mg of atorvastatin (P less than 0.001). A primary event occurred in 434 patients (8.7%) receiving 80 mg of atorvastatin, as compared with 548 patients (10.9%) receiving 10 mg of atorvastatin, representing an absolute reduction in the rate of major cardiovascular events of 2.2% and a 22% relative reduction in risk (hazard ratio, 0.78; 95% confidence interval, 0.69 to 0.89; P less than 0.001). There was no difference between the two treatment groups in overall mortality. In conclusion, intensive lipid-lowering therapy with 80 mg of atorvastatin per day in patients with stable CHD provides significant clinical benefit beyond that afforded by treatment with 10 mg of atorvastatin per day. This occurred with a greater incidence of elevated aminotransferase levels. The main message from this study in my opinion is that we should be striving for LDL cholesterol less than 2mmol/l in all diabetic pts with cardiovascular disease. I also, believe that this should be the case in diabetic pts without cardiovascular disease as recently suggested at DUK but this will meet much resistance in the community.
Mishra J, Dent C, Tarabishi R, Mitsnefes MM, Ma Q, Kelly C, Ruff SM, Zahedi K, Shao M, Bean J, Mori K, Barasch J, Devarajan P.Neutrophil gelatinase-associated lipocalin (NGAL) as a biomarker for acute renal injury after cardiac surgery. Lancet. 2005;365:1231-8.
With recent emphasis on estimating GFR using the MDRD equation (DUK and Renal NSF) I thought it was timely that this article was published in detecting acute renal failure early. The scarcity of early biomarkers for acute renal failure has hindered preventive and therapeutic measures for this disorder in a timely manner. Mishra et al tested the hypothesis that neutrophil gelatinase-associated lipocalin (NGAL) is an early biomarker for ischaemic renal injury after cardiopulmonary bypass. 71 children undergoing cardiopulmonary bypass were studied. Serial urine and blood samples were analysed by western blots and ELISA for NGAL expression. The primary outcome measure was acute renal injury, defined as a 50% increase in serum creatinine from baseline. 20 children (28%) developed acute renal injury, but diagnosis with serum creatinine was only possible 1-3 days after cardiopulmonary bypass. By contrast, urine concentrations of NGAL rose from a mean of 1.6 microg/L (SE 0.3) at baseline to 147 microg/L (23) 2 h after cardiopulmonary bypass, and the amount in serum increased from a mean of 3.2 microg/L (SE 0.5) at baseline to 61 microg/L (10) 2 h after the procedure. Univariate analysis showed a significant correlation between acute renal injury and the following: urine and serum concentrations of NGAL at 2 h, and cardiopulmonary bypass time. By multivariate analysis, the amount of NGAL in urine at 2 h after cardiopulmonary bypass was the most powerful independent predictor of acute renal injury. For concentration in urine of NGAL at 2 h, the area under the receiver-operating characteristic curve was 0.998, sensitivity was 1.00, and specificity was 0.98 for a cutoff value of 50 microg/L. In conclusion, concentrations in urine and serum of NGAL represent sensitive, specific, and highly predictive early biomarkers for acute renal injury after cardiac surgery. Watch this space!

NEXT NEWSLETTER Due out beginning of October 2005, so keep the gossip coming.

Endodiabology 2005; Issue 1 (February)

ENDODIABOLOGY

NORTHEAST NEWSLETTER
FOR SPRs AND BOSSES TRAPPED IN THE NORTHERN DEANERY

FEBRUARY 2005

Editors: Shahid Wahid and Petros Perros
Associate Editors: Peter Carey and Freda Razvi

SpR PLACEMENTS (NTN/VTN year of training from 1st October 2004)
RVI- Elin Lim(2), Simon Ashwell(4), Ibrahim M Ibrahim (4), Reena Thomas (3), Freda Razvi (3/4)
Freeman- David Woods(5), Arun(4), Arutchelvan Vijayaraman (3)
North Tyneside/Wansbeck- Vishmawitra Sharma/ Jaysri Ranjani
South Tyneside- Akheel Syed (3)
Gateshead- Olivia Pereira (1/2)
Sunderland- Asghar Madathil (1), Khaled Mansur-Dukhan (1)
North Tees/Hartlepool- Stella Kaddis(5) / Sukesh Chandran (1)
Middlesbrough- Kamal Abouglila(5), Peter Carey(3), Beas Bhatacharya (2)
Carlisle- Isabelle Howat (1)
Bishop Auckland / Durham- / Sony Anthony(3),
NGH/QEH- Subir Ray (1)
Research with numbers (supervisor)- Latika Sibal (Prof Home), Salman Razvi (Dr Weaver), B Ravikumar (Prof Taylor), Sath Nag (Dr Connolly), Mutu Jayapaul (Prof Walker), Ebaa El Ozairi (USA-Prof Home), Andrew Advani (Australia)

MEETINGS / LECTURES / ANNOUNCEMENTS
16th February 2005 Society for Endocrinology Clinical cases meeting, RCP London. Contact Society for Endocrinology
23rd February 2005 Northern Endocrine & Diabetes Winter CME, Freeman Hospital. Contact Simon Ashwell
1st March 2005 7th Clinicopathological Conference on Pituitary Disease, RCPL, London. Contact Cathy Stewart, Tel 01462 459 726.
12th March 2005 Association of Physicians Meeting, Queen Elizabeth Hospital. Contact Roy Taylor .
16th March 2005 Acute Medical Emergencies, RCPL, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
17th March 2005 1730-2000 28th Novo Nordisk Lecture, Lumley Castle, Durham. Contact Sally Marshall .
23rd March 2005 SpR GIM training ½ day-Freeman Hospital. Contact Contact Lorraine Waugh 0191 223 1247
4th-6th April 2005 British Endocrine Societies Conference 2005, Harrogate. Contact Society for Endocrinology
6th-7th April 2005 ABCD Spring Meeting, Harrogate. Contact P Winocour or ABCD website .
7th-8th April 2005 Insulin Pump Course, JCUH, Middlesbrough. Contact Helen Scales .
20th-22nd April 2005 DUK Annual Professional Conference, SECC, Glasgow. Contact Ben Holdstock or Diabetes UK website .
4th May 2005 (afternoon) NRDSAG and Diabetes Audit meeting. Contact Jola Weaver .
13-14th May 2005 European Diabetic Nephropathy Study Group, Arnhem, Netherlands. Contact Roby Trevisan .
18th May 2005 SpR GIM training ½ day-Sunderland Royal Hospital. Contact Contact Lorraine Waugh 0191 223 1247
26th May 2005 Northern Endocrine & Diabetes Summer CME, Freeman Hospital. Contact Simon Ashwell.
4th-7th June 2005 ENDO 2005, San Diego, USA. Contact ENDO email or ENDO website .
10th-14th June 2005 American Diabetes Association 65th Annual Scientific Sessions, San Diego, USA. Contact ADA email .
4th-8th July 2005 The Society For Endocrinology Summer School, Durham. Contact Simon Pearce or Ann Lloyd
6th July 2005 SpR GIM training ½ day-Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine Waugh

TRAINING ISSUES
Record of Internal Training Assessments The RITAs are planned for Thursday the 19th May 2005 and the morning of 20th May 2005. Shaz Wahid is co-ordinating them. If you have not had the information electronically or via the post please contact him. As well as completing the standard documentation Trainees will be asked to submit a structured CV and their agreed aims/objectives for the year with the latter documentation. Important dates to remember are:
Confirm availability for RITA before Monday 14th March 2005
Meet with Educational Supervisor before 22nd April 2005
Send all documentation to Shaz Wahid by 26th April 2005
These are essential dates to adhere to.
Joint Trainers/Trainees meeting the traditional annual get-together will be on Mon 20th June 2005 at the Education Centre, University Hospital of Hartlepool.
Change of circumstances It is essential that all trainees inform the STC via the programme director well in advance of any intentions such as resignation, maternity leave, undertake research, request for an interdeanery transfer, etc. Over the years the STC has been very understanding and bent over backwards to accommodate requests, however with the recent worrying trend that the STC is usually told last, the STC may have to adapt a hard nose approach and apply the 3 month rule or more if applicable.
Regional Endocrine Summer School The Society for Endocrinology Summer School will be hosted by us (Pearce, Ball and James) July 4th to 8th in Durham. There will be a clinical practice day, a molecular endocrinology workshop and the advanced endocrine course. It is a fantastic opportunity for all SpRs and consultants in the region to get local high-quality (cheap) CPD. Please adjust all clinics that week as there will be no SpRs or consultants to do them.
Training Committee Regional Speciality Advisor & Programme Director - Richard Quinton; Committee Chairman - Jola Weaver; Consultant member - Jean Macleod ; Consultant member (RITA Co-ordinator) - Shahid Wahid; Consultant member (Research Advisor) - Simon Pearce; SpR representatives - Simon Ashwell & Andrew Advani.
THE COMMITTEE WOULD LIKE TO ADD AN EXTRA CONSULTANT MEMBER Interested trainers please contact Richard Quinton.

NEW FACES ON THE SCENE
Welcome to Subir Roy, who joins us as a new SpR (with a training number) and is currently in the joint post between the QEH and Newcastle Diabetes Centre.
Welcome to Khaled Mansur-Dukhan, who joins us as a new SpR (with a training number) and is currently at Sunderland Royal.
OLD FACES ON THE GO
Andrew Advani is now in Australia undertaking a period of research. He is due to join the rotation again in October.
NEWS FROM THE NORTHEAST
Freda Razvi has returned from maternity leave.
Simon Pearce has joined the STC as a Consultant Member with the role as Research Advisor for any interested SpRs.
Congratulations to Mark Walker on his appointment to the Diabetes UK board of Trustees.
Congratulations to David Woods on the birth of his baby daughter (Eloise), promotion to Lieutenant Colonel, award of the Mitchiner Medal from the Army Medical Services, appointment as SpR representative on the Clinical Committee of the Society for Endocrinology and the award of his MD with a commendation.
Prof Taylor will be delivering the Arnold Bloom Lecture at this years DUK Annual Professional Conference.

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.

First Teaching EUGOGO course on Graves' orbitopathy-Petros Perros
The European Group On Graves’ Orbitopathy (EUGOGO) came to existence a few years ago aiming to enhance research and education relating to Graves’ eye disease. Newcastle was among the 9 founding centres for this organisation, which is hosting its first educational course due to take place in Thessaloniki, Greece on the 26th and 27th of May 2005. The course will include lectures, interactive sessions and “hands-on” practice in assessing patients. The course is suitable for Endocrinologists both at consultant and SpR level who may wish to enhance their knowledge and skills in managing this condition. The course has been allocated meeting has been awarded 9 European CME credits (ECMEC). Places for the course are restricted, so if you wish to register do so without delay by contacting Prof Krassas telephone: 00-30-2-310-479-633, fax: 00-30-2-310-282-476 & 0-30-23-10-479-633

Message From Bob Peaston-Screening for phaeochromocytoma is best undertaken by obtaining several timed overnight urine samples for catecholamine measurements. Furthermore, plasma metanephrines are a useful addition for the diagnosis of phaeochromocytoma. A proposed strategy for the detection of phaeochromocytoma (Figure)
For plasma metadrenalines send 2x5ml EDTA (FBC tube) samples to the Freeman Hospital FAO Bob Peaston, Clinical Biochemistry. For further information please contact Bob Peaston .

Radio Iodine Training-Shaz Wahid.
An ARSAC certificate can only be obtained by a Consultant Endocrinologist and then it is site specific, limited to treatment of thyrotoxicosis or non-toxic multinodular goitre and renewable after 5 years. For trainees wishing to apply for an ARSAC it is essential to build a portfolio of experience in nuclear endocrine medicine during a 5-year training programme. During each attachment it is essential to get know the medical physicist and ideally if you are in year 5 to arrange several seminars. Things to cover in your portfolio are:
1. Basic principles of radionuclide production, hazards and therapeutic use with emphasis on the management and protection of patients plus the medico-legal implications
2. Administration of Radio-Iodine-witnessing and confirming identification
3. Consenting patients for RAI and explaining therapy
4. Explaining contact restrictions following RAI
5. Follow-up and monitoring post RAI
6. The interpretation of endocrine nuclear imaging-Thyroid technetium scanning, parathyroid subtraction scans (Sestamibi), MIBG, pentetreotide imaging and selenor-cholesterol imaging
The inclusion of any audit/research projects related to nuclear medicine would be a plus point. On appointment to a Consultant post it is important to arrange some local seminars in Nuclear Physics with the Medical Physicist. An ARSAC application can be submitted 6-12 months in to the post. For more information see ARSAC website .

Book Review by Akheel Syed-Endotext.com
The Internet is a wonderful resource for information on anything and everything under the sun and endocrinology is no exception. However, it is not always easy to find trustworthy material without access controls such as paid subscriptions or intrusive advertising. Endotext.com is an online textbook of endocrinology that, try as you may, fails to disappoint. It is a completely free web-based resource sponsored by various pharmaceutical companies but refreshingly does not carry intrusive headline banners, pop-ups or advertising links. Pages are laid out in scrollable frames: the text in a large central frame, hyperlinks to other sections in a vertical frame on the left, and references in a horizontal frame at the bottom(Figure).
The textbook is organised into several sections covering the major endocrine organs edited by eminent endocrinologists in their fields. The chapters are well-written, well-organised, authoritative, adequately illustrated, provided with hyperlinks to relevant information in other sections in the textbook or reliable outside sources, and superbly referenced. However, the references frame does not provide hyperlinks to the source material – an enhancement that would serve the readers well. The book has a decent Search facility so one can easily home in on a topic of interest.
Verdict: Definitely one for the Favourites/Bookmarks list!!!

Childrens Camps-Stuart Bennett.
Diabetes UK needs individuals (doctors) to volunteer for their Children's Support Holidays and Family Support Weekends for 2005. Time to attend these events can be taken as approved study leave. I would recommend that all trainees in Diabetes & Endocrinology should attend one of these Care Support Events at least once during their specialist training. The relevant parts of the curriculapertaining to these requirements are included below. For further information on volunteering and an application form follow this link:Diabetes UK website
Competence based curricula (after Jan 2003)Section 6, Experience (Additional)17. Attend or speak at meetings of 'lay' patient support organisations.18. Attend a diabetic childrens' camp as a helper.
Curricula (before 1 Jan 2003)6. Management of children and adolescents with diabetes. The trainee must gain experience of management of children with diabetes. This will involve attendance at paediatric diabetic clinics and some exposure to in-patient management. The management of adolescents with diabetes is difficult and demanding. The trainee must acquire experience of this through regular involvement with the care of adolescents. These aspects of training will require close contact with and support from paediatricians. Valuable experience can be gained from involvement in diabetic children's camps and young persons' activity holidays.

RECENT PUBLICATIONS FROM THE NORTHEAST
Please send us your recent publication for inclusion in the next newsletter.

1. Boehm BO, Vaz JA, Brondsted L, Home PD. Long-term efficacy and safety of biphasic insulin aspart in patients with type 2 diabetes. Eur J Intern Med. 2004 Dec;15(8):496-502.
2. Consoli A, Gomis R, Halimi S, Home P, Mehnert H, Strojek K, Van Gaal L. Initiating oral glucose-lowering therapy with metformin in type 2 diabetic patients: an evidence-based strategy to reduce the burden of late-developing diabetes complications. Diabetes Metab. 2004 Dec;30(6):509-16.
3. Dickinson AJ, Vaidya B, Miller M, Coulthard A, Perros P, Baister E, Andrews CD, Hesse L, Heverhagen JT, Heufelder AE, Kendall-Taylor P. Double-blind, placebo-controlled trial of octreotide long-acting repeatable (LAR) in thyroid-associated ophthalmopathy. J Clin Endocrinol Metab. 2004 Dec;89(12):5910-5.
4. Home P, Mbanya JC, Horton E. Standardisation of glycated haemoglobin. BMJ. 2004 Nov 20;329(7476):1196-7.
5. James L, Onambele G, Woledge R, Skelton D, Woods D, Eleftheriou K, Hawe E, Humphries SE, Haddad F, Montgomery H.IL-6-174G/C genotype is associated with the bone mineral density response to oestrogen replacement therapy in post-menopausal women. Eur J Appl Physiol. 2004 92(1-2):227-30.
6. Marshall SM. Recent advances in diabetic nephropathy. Postgrad Med J. 2004 Nov;80(949):624-33.
7. McMillan CV, Bradley C, Woodcock A, Razvi S, Weaver JU. Design of new questionnaires to measure quality of life and treatment satisfaction in hypothyroidism. Thyroid. 2004 Nov;14(11):916-25.
8. Pearce SHS. Spontaneous reporting of adverse reaction to carbimazole and propylthiouracil in the United Kingdom. Clinical Endocrinology 2004: 61; 589-594.
9. Quinton R & Bouloux P-MG. 2004 The management of hypogonadism: a treatment update. Medicine Matters in Secondary Care. Nov 2004. Issue 89.
10. Ravikumar B, Carey PE, Snaar JE, Deelchand DK, Cook DB, Neely RD, English PT, Firbank MJ, Morris PG, Taylor R. Real time assessment of postprandial fat storage in liver and skeletal muscle in health and type 2 diabetes. Am J Physiol Endocrinol Metab. 2004 Nov 30; [Epub ahead of print].
11. Razvi S, Weaver JU. Subclinical hypothyroidism and cardiovascular risk. Thyroid. 2004 Oct;14(10):870; author reply 871-2.
12. Sibal L, Scoones DJ, Bilous R. Temporal arteritis in the absence of headache. Hosp Med. 2004 Nov;65(11):692-3.
13. Singhal P, Caumo A, Cobelli C, Taylor R. Effect of repaglinide and gliclazide on postprandial control of endogenous glucose production. Metabolism. 2005 Jan;54(1):79-84.
14. Smith BR, Bolton J, Young S, Collyer A, Weeden A, Bradbury J, Weightman D, Perros P, Sanders J, Furmaniak J. A new assay for thyrotropin receptor autoantibodies. Thyroid. 2004 Oct;14(10):830-5.
15. Syed AA, Redfern CP, Weaver JU. Aldosterone revisited. N Engl J Med. 2004 Nov 11;351(20):2131-3; author reply 2131-3.
16. Velaga MR, Wilson V, Jennings CE, Owen CJ, Herington S, Donaldson PT, Ball SG, James RA, Quinton R, Perros P, Pearce SHS. The codon 620 tryptophan allele of the lymphoid tyrosine phosphatase (LYP) gene is a major determinant of Graves’ Disease. J Clin Endocrinol Metab. 2004; 89: 5862-65.
17. Warren RE, Perros P, Nyirenda MJ, Frier BM. Serum thyrotropin is a better predictor of future thyroid dysfunction than thyroid autoantibody status in biochemically euthyroid patients with diabetes: implications for screening. Thyroid. 2004 Oct;14(10):853-7.
18. Weaver JU, Razvi S, Bartholomew P. The detrimental effect of anti-thyroid drugs on the outcome of radioiodine therapy is not directly due to decreased radioiodine uptake: Reply. Nucl Med Commun. 2005 Jan;26(1):70.

RECENT PUBLICATIONS IN DIABETES & ENDOCRINOLOGY THAT HIT THE NEWS OR THAT MAY HAVE A SIGNIFICANT IMPACT ON MANAGEMENT
Sjostrom L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C, Carlsson B, Dahlgren S, Larsson B, Narbro K, Sjostrom CD, Sullivan M, Wedel H; Swedish Obese Subjects Study Scientific Group. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2004;351:2683-93.
This prospective, controlled study involved obese subjects who underwent gastric surgery and matched with conventionally treated obese control subjects. The follow-up data for subjects (mean age, 48 years; mean body-mass index, 41) who had been enrolled for at least 2 years (4047 subjects) or 10 years (1703 subjects) before the analysis (January 1, 2004) were reported. The follow-up rate for laboratory examinations was 86.6% at 2 years and 74.5% at 10 years. After two years, the weight had increased by 0.1% in the control group and had decreased by 23.4% in the surgery group (P less than 0.001). After 10 years, the weight had increased by 1.6% and decreased by 16.1%, respectively (P less than 0.001). Energy intake was lower and the proportion of physically active subjects higher in the surgery group than in the control group throughout the observation period. Two- and 10-year rates of recovery from diabetes, hypertriglyceridaemia, low levels of high-density lipoprotein cholesterol, hypertension, and hyperuricaemia were more favourable in the surgery group than in the control group, whereas recovery from hypercholesterolaemia did not differ between the groups. The surgery group had lower 2- and 10-year incidence rates of diabetes, hypertriglyceridaemia, and hyperuricaemia than the control group; differences between the groups in the incidence of hypercholesterolaemia and hypertension were undetectable. This study has shown that compared with conventional therapy, bariatric surgery appears to be a viable option for the treatment of severe obesity, resulting in long-term weight loss, improved lifestyle, and, except for hypercholesterolaemia, amelioration in risk factors that were elevated at baseline. Although, not without its faults (non-randomised, non-blinded, the use of several types of surgery and lack of hard end-points) this study has demonstrated the long-term benefits of obesity surgery and now provides some ammunition for those involved in constructing business cases for an obesity service.
Ruggenenti P, Fassi A, Ilieva AP, Bruno S, Iliev IP, Brusegan V, Rubis N, Gherardi G, Arnoldi F, Ganeva M, Ene-Iordache B, Gaspari F, Perna A, Bossi A, Trevisan R, Dodesini AR, Remuzzi G; Bergamo Nephrologic Diabetes Complications Trial (BENEDICT) Investigators. Preventing microalbuminuria in type 2 diabetes. N Engl J Med. 2004;351:1941-51.
This multicenter double-blind, randomized study was designed to assess whether ACE inhibitors and non-dihydropyridine calcium-channel blockers, alone or in combination, prevent microalbuminuria in subjects with hypertension, type 2 diabetes mellitus, and normal urinary albumin excretion. 1204 subjects were randomly assigned to receive at least three years of treatment with trandolapril (at a dose of 2 mg per day) plus verapamil (sustained-release formulation, 180 mg per day), trandolapril alone (2 mg per day), verapamil alone (sustained release formulation, 240 mg per day), or placebo. The target blood pressure was 120/80 mm Hg. The primary end point was the development of persistent microalbuminuria (overnight albumin excretion, more than or =20 microg per minute at two consecutive visits). The primary outcome was reached in 5.7% of the subjects receiving trandolapril plus verapamil, 6.0% of the subjects receiving trandolapril, 11.9% of the subjects receiving verapamil, and 10.0% of control subjects receiving placebo. The estimated acceleration factor (which quantifies the effect of one treatment relative to another in accelerating or slowing disease progression) adjusted for predefined baseline characteristics was 0.39 for the comparison between verapamil plus trandolapril and placebo (P=0.01), 0.47 for the comparison between trandolapril and placebo (P=0.01), and 0.83 for the comparison between verapamil and placebo (P=0.54). Trandolapril plus verapamil and trandolapril alone delayed the onset of microalbuminuria by factors of 2.6 and 2.1, respectively. Serious adverse events were similar in all treatment groups. In subjects with type 2 diabetes and hypertension but with normoalbuminuria, the use of trandolapril plus verapamil and trandolapril alone decreased the incidence of microalbuminuria to a similar extent. The effect of verapamil alone was similar to that of placebo.
Barnett AH, Bain SC, Bouter P, Karlberg B, Madsbad S, Jervell J, Mustonen J; Diabetics Exposed to Telmisartan and Enalapril Study Group. Angiotensin-receptor blockade versus converting-enzyme inhibition in type 2 diabetes and nephropathy. N Engl J Med. 2004;351:1952-61
Tthis prospective, multicenter, double-blind, five-year study randomly assigned 250 subjects with type 2 diabetes and early nephropathy to receive either the angiotensin II-receptor blocker telmisartan (80 mg daily, in 120 subjects) or the ACE inhibitor enalapril (20 mg daily, in 130 subjects). The primary end point was the change in the glomerular filtration rate (determined by measuring the plasma clearance of iohexol) between the baseline value and the last available value during the five-year treatment period. Secondary end points included the annual changes in the glomerular filtration rate, serum creatinine level, urinary albumin excretion, and blood pressure; the rates of end-stage renal disease and cardiovascular events; and the rate of death from all causes. After five years, the change in the glomerular filtration rate was -17.9 ml per minute per 1.73 m2 of body-surface area, where the minus sign denotes a decrement, with telmisartan (in 103 subjects), as compared with -14.9 ml per minute per 1.73 m2 with enalapril (in 113 subjects), for a treatment difference of -3.0 ml per minute per 1.73 m2 (95 percent confidence interval, -7.6 to 1.6 ml per minute per 1.73 m2. The lower boundary of the confidence interval, in favour of enalapril, was greater than the predefined margin of -10.0 ml per minute per 1.73 m2, indicating that telmisartan was not inferior to enalapril. The effects of the two agents on the secondary end points were not significantly different after five years. Telmisartan is not inferior to enalapril in providing long-term renoprotection in persons with type 2 diabetes. These findings do not necessarily apply to persons with more advanced nephropathy, but they support the clinical equivalence of angiotensin II-receptor blockers and ACE inhibitors in persons with conditions that place them at high risk for cardiovascular events. The above 2 studies provide clear evidence that ACE inhibition is just as effective as Angiotensin receptor blockade in delaying the progression of renal dysfunction and microalbuminuria in diabetic nephropathy, although the “gold” standard would be comparative studies with hard end-point morbidity/mortality data. Furthermore, what is required are good quality study comparing dual blockade with single blockade in terms of renal function and protein excretion.

NEXT NEWSLETTER Due out beginning of June 2005, so keep the gossip coming.

Endodiabology 2004; Issue 3 (October)

ENDODIABOLOGY

NORTHEAST NEWSLETTER
FOR SPRs AND BOSSES TRAPPED IN THE NORTHERN DEANERY

OCTOBER 2004

Editors: Shahid Wahid and Petros Perros
Associate Editors: Peter Carey and Freda Razvi

SpR PLACEMENTS (NTN/VTN year of training from 1st October 2003)
RVI- E Lin Lim(2), Simon Ashwell(4), Ibrahim M Ibrahim (4), Reena Thomas (3), Feda Razvi (3/4)
Freeman- David Woods(5), Andrew Advani(3), Arun(4), Arutchelvan Vijayaraman (3)
North Tyneside/Wansbeck- Rafe Al-Mohammed / Jaysri Ranjani
South Tyneside- Akheel Syed (3)
Gateshead- Olivia Pereira (1/2)
Sunderland- Asghar Madathil
North Tees/Hartlepool- Stella Kaddis(5) / Sukesh Chandran (1)
Middlesbrough- Kamal Abouglila(5), Peter Carey(3), Dr Beas Bhatacharya (2)
Carlisle- Isabelle Howat (1)
Bishop Auckland/Durham- / Sony Anthony(3),
NGH/QEH-
Research with numbers (supervisor)- Latika Sibal (Prof Home), Salman Razvi (Dr Weaver), B Ravikumar (Prof Taylor), Sath Nag (Dr Connolly), Mutu Jayapaul (Prof Walker), Ebaa El Ozairi (USA-Prof Home)

MEETINGS / LECTURES / ANNOUNCEMENTS
13th October 2004 Northern Region Diabetes Service Advisory Group followed by Regional Audit meeting. Contact Shahid Wahid
27th October 2004 Northern Endocrine & Diabetes Autumn CME, James Cook University Hospital. Contact Simon Ashwell
1st-3rd November 2004 195th Meeting of the Society for Endocrinology, London RCPL, contact Society for Endocrinology
3rd November 2004 Updates in General Medicine, Freeman Hospital, Newcastle upon Tyne. Contact Lorraine Waugh 0191 223 1247
6th November 2004 Association of Physicians meeting, JCUH. Contact Roy Taylor
8-10th November 2004 Med Reg 2004, RCP London. Contact Mark Allen Group
10th November 2004 54th Meeting of British Thyroid Association, London. Contact Mark Vanderpump
10th November 2004 North East Obesity Forum, Medical School. Contact Nigel Unwin
11th and 12th November 2004 Autumn meeting of ABCD, London. Contact P Winocour or ABCD .
12th November 2004 Abstract deadline for BES 2005 conference in Harogate.
12th-13th November 2004 ABCD meeting for SpRs-Dillemas in Diabetes & Endocrinology, London. Contact Gusto Events and Gerry Rayman
15th November 2004 UK NETwork 3rd National Neuroendcrine Tumour Conference, London. Contact Maria Jones, Ipsen LTD, 190 Bath Road Slough, Berkshire, SL1 3XE.
18th November 2004 Regional Kidney/Pancreas symposium 1230-1730, Marrott Royal Hotel, Old Elvet, Durham. Contact Julie Wardle
19th November 2004 "BLOOD GLUCOSE MONITORING: WHO, WHAT AND WHEN?" Royal College of Physicians of Edinburgh 12-5pm. Contact RCPE
22nd November 2004 Emergency Medicine, contact RCP London via email or website
24th November 2004 Northern Endocrine audit and research group meeting, Lumley Castle, Durham, 3.30-6pm. Contact Bill Kelly
17th Januray 2005 SpR GIM training ½ day-Sunderland Royal Hospital. Contact Lorraine Waugh 0191 223 1247
16th February 2005 Society for Endocrinology Clinical cases meeting, RCP London. Contact Society for Endocrinology
23rd February 2005 Northern Endocrine & Diabetes Winter CME, Freeman Hospital. Contact Simon Ashwell
23rd March 2005 SpR GIM training ½ day-Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
4th-8th July 2005 The Society For Endocrinology Summer School, Durham. Contact Simon Pearce

TRAINING ISSUES
Study Leave No doubt the bombshell that the PIMD will no longer fund any study leave caused a major stir. The implications were far reaching. However, there was a U-turn by the PIMD in that they have agreed to fund essential study leave. What will entail essential study leave is left to the imagination, but the recently circulated list by the STC probably stands for now. It seems we are being pushed more and more upon relying on the pharmaceutical industry. There is also the thorny issue of how much study leave an SpR is allowed. The official word is 35 days per year and this includes any routinely scheduled half days in the working week for private study (Flexible trainees have the same amount as well). As example lets say the SpR at St. Elsewheres gets 1/2 day off each week. Assuming 6 weeks annual leave and thus a 46-week working year, this amounts to around 23 days. Moreover, there are 6 G(I)M CME 1/2 days, 3 Endo/DM CME days and the Lumley Castle Audit 1/2 day each year. Thus, the SpR at that site shouldn't expect to have any more than 6-7 days leave for conferences, writing up MD, etc.
The Next SpR Post It is that time of year when trainees will be moving to their new-post. You should already have made contact with your educational supervisor and talked about timetables, leave, etc. If you have not-there is no excuse. Planning your annual leave, study leave and specialist clinic experience whilst in your post for the next year is highly recommended. Furthermore have at least 1 project that gets you an abstract at a national meeting or a presentation at a regional meeting-it builds the CV. Furthermore, keep your CV up to date as you will expect to submit it along with other documentation before your RITAs.
Regional Endocrine Summer School The Society for Endocrinology Summer School will be hosted by us (Pearce, Ball and James) next July 4th to 8th in Durham. There will be a clinical practice day, a molecular endocrinology workshop and the advanced endocrine course. It is a fantastic opportunity for all SpRs and consultants in the region to get local high-quality (cheap) CPD. Please adjust all clinics that week as there will be no SpRs or consultants to do them.
Training Committee Training Committee Regional Speciality Advisor- Mark Walker; Committee Chairman- Petros Perros; Programme Director- Richard Quinton; Consultant member- Jola Weaver ; Consultant member- Jean Macleod ; SpR representatives- Simon Ashwell & Andrew Advani

NEW FACES ON THE SCENE
Welcome to Olivia Pereira who has started as SpR at QEH and Dr Chandran who has started at Hartlepool as SpR and recently was successful in obtaining an NTN in the region.
Welcome to Costas Oxynos (pal of Stella Kadis) as the 3rd Consultant at QEH. He trained in Manchester and did his research with Fred Wu and is a Testosterone expert. He is due to start in November.
Congratulations to Sukesh Chandran on obtaining his number and he will stay on at Hartlepool.
OLD FACES ON THE GO
Tom Barber has left us to undertake research at Oxford in that wonderful new Diabetes Centre-all the best.
Raz Nayar has moved on after transferring his NTN to London-all the best
NEWS FROM THE NORTHEAST
Congratulations to Andrew Advani on the award of the Samuel Leonard Simpson Fellowship in Endocrinology from the Royal College of Physicians, enabling him to undertake a period of research in Melbourne Australia from the New Year.
David woods will be supernumerary at Freeman Hospital for the next year so as to undertake some research.
Freda Razvi will be returning from maternity leave in February 2005.
Karen Adamson (who some of old fogies in the region-myself included will remember) was awarded her PhD in March. Well done Karen for out-living 3 different supervisors- not to mention a few mice.
Congratulations to Dr Ebaa Al-Ozairi on her William J Fulbright Visiting Scholar Grant by the US Department of State. She will begin her research placement at the Joslin Research Centre of Harvard University with Professor Ed Horton and supervision of her MD at a distance by Professor Home, this September and will return to the rotation on 1 October 2005.
Congratulations to Professor Roy Taylor on his Arnold Bloom Lectureship at the DUK APC in Glasgow 2005.
Congratulations to Liz McIntyre on obtaining a Consultant post in Scotland at Monklands.
Professor Sally Marshall will be the new Editor-in-Chief of Diabetic Medicine, with the Editorial office at Newcastle.
Professor Home is co-ordinating a global 'Levels of care' guideline on Type 2 diabetes for the IDF, and has raised Eur250000 for this.
The IDF congress in 2006 is in Cape Town - in December. A great month for weather in South Africa. Prof Alberti and Home are on the Executive Programme Committee - ideas are welcome.
Professor Jean-Claude Mbanya (Yaounde, Cameroon), who some of you old-hands would remember as spending some time in Newcastle in the 1980's as a trainee, was awarded the 2004 Harold Rifkin Medal for Distinguished International Service in the Cause of Diabetes by the American Diabetes Association (ADA).
The NICE Type 1 Diabetes Guidelines for children and adults were published in July. Vince Connelly was the link person between the adult and kids initiatives, and Prof Home the lead clinical advisor on the adult guideline.
Jim Shaw has been invited to speak on novel approaches to insulin replacement therapy at the annual IDF-Europe meeting this year in Slovenia.
Petros Perros has finished his tenure as Chairman of the STC-thanks for all his hard work.
Jola Weaver is now chair of the STC.
Shaz Wahid has joined the STC as a standing member-with the remit of aiding the Chair in organizing the RITAs.

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.

MEETING REPORT-Jean MacLeod
The SPARROWS Feedback meeting was held in Lumley Castle on Wednesday 28thJuly. All of the SPARROWS found the ADA Scientific Sessions interesting and useful. Not surprisingly they also enjoyed the social programme though American portion sizes did cause some astonishment. Prize money of £400 was donated by GSK for the meeting reports in addition to the travel funding. Joint first prize for the meeting reports was given to Drs David Woods and Ravikumar - £100 each. The three other presenters will receive £67 in prize money. Gerry Mackay was missed but a new baby seems a very good excuse for missing the feedback meeting. We are hopeful that funding will be given again for next year but are awaiting confirmation from GSK. Given the withdrawal of funding from PIMD such support is even more valuable and we are extremely grateful to GSK for their help in ensuring our trainees have exposure to international meetings.

THE FIRST YEAR-Shaz Wahid
Having been in post the first year, I thought I would share some generic survival tips for those of you about to make the leap. Believe me it is a leap and although the SpR rotation prepares you adequately for clinical practice only on the job training leads to honing ones management skills. The following areas are important to get right from the beginning:
1. OFFICE-consider this your castle. Sort the set up early with computer access (with printer and scanner) and net access. Make sure you can get lab and imaging results from your computer, and retinal imaging if applicable. Sort out refreshments-I would recommend a mini-cooler. Prepare a personalised filing system early for articles, memos, clinical guidelines, junior Dr issues etc.
2. SECRETARY-essential. Sort out filing system, in-tray, out-tray, who keeps diary, diary sharing, clinic admin, etc out early.
3. CLINIC ADMIN-Know your clinic codes and produce a personalised clinic appointment slip from the word go. Personalise your clinic templates early and things to ask are “do I see all new pts at the beginning or mix them with follow-ups”, “what time do I need for news and follow-ups”, “how many urgent slots”, etc. Every one has there own preferences. Prepare clinic boxes with things such as pt info sheets, BP cards, medication changes for GP notification, etc which can be stored in out-pts for your own use. Although, those of you lucky enough to have a Diabetes Centre will not need to do this for your diabetic clinics.
4. DICTATION-when one dictates clinic letters is personal preference, i.e. during clinic or when all results are available. It is important that you get into a routine, e.g. dictate Thursday clinic by end of Mon as an e.g. To prevent secretary overload I would recommend that you dictate miscellaneous letters in weekly blocks, e.g. responding to GP queries, and pass the tape for eg to your secretary every Friday so that its is typed by Tues. Dictation of in-pt discharge summaries is a thorny issue. My own controlling nature and the fact that Juniors are often snowed under and behind by 3-months mean that I dictate all of my own discharge summaries. The majority of you will be cringing when hearing this. The advantages of this are that it allows a quick check of any errors, gives thinking time, improves GP communication, allows you to explain your thinking to GPs and when you review the pt in clinic it can be quick. Again dictation of discharge summaries is something well worth sorting out early whether done by you or delegated.
5. LEAVE-plan annual and study leave early in 6-12 month blocks. You need to decide whether to cancel all clinics when you are away or leave them open for the SpR. My own advice is to cancel, simply because medical records are not infallible and situations can arise where the clinic has not been cancelled/reduced through no fault of your own. Make sure you get important generic courses under your belt early, e.g. recruitment course, educational supervision course, mentoring course, new consultants course, etc.
6. APPRAISAL-prepare for this early. Keep a diary for at least 2 months. Prepare achievable learning objectives for your first year, e.g. I will set up a diabetic foot clinic. Collect evidence of good practice, including audit figures.
7. Learn to say NO early in the first 6-months (no doubt John, Jean and Nick have fell off their chairs having read what I have just written!)
Getting to grips with the above early should smooth out the initial bumpy ride and by the time you get to 6-months in to the job you should realise that there is more to a Consultant post than running a service. You should then decide whether you would wish to branch out in to the 3 main areas of management/politics, research or education. It took me 9 months to realise it is education-hence the Undergraduate Tutor role. After the 1st year I can whole-heartedly say I have thoroughly enjoyed myself and I have managed to achieve a sustainable mix between GIM, Diabetes, Endocrinology and Education. Furthermore I am starting to develop the important skill of allowing things to drop off the end of my desk. Those with experience will understand what I mean by the latter. If you would like any other tips please contact me.


RECENT PUBLICATIONS FROM THE NORTHEAST
Please send us your recent publication for inclusion in the next newsletter.

1. Adamson KA, Pearce SH, Lamb JR, Seckl JR, Howie SE. A comparative study of mRNA and protein expression of the autoimmune regulator gene (Aire) in embryonic and adult murine tissues. J Pathol. 2004; 202:180-7.
2. Arun CS, Pandit R, Taylor R. Long-term progression of retinopathy after initiation of insulin therapy in Type 2 diabetes: an observational study. Diabetologia. 2004 Aug;47(8):1380-4. Epub 2004 Jul 28.
3. Houston FA, Wilson V, Jennings CE, Owen CJ, Donaldson P, Perros P, Pearce SHS. Role of the CD40 locus in Graves’ disease. Thyroid 2004; 14: 505- 509.
4. Marshall SM. Recent advances in diabetic nephropathy. Clin Med. 2004 May-Jun;4(3):277-82.
5. McDonald CG, Ryan EA, Paty BW, Senior PA, Marshall SM, Lakey JR, Shapiro AM. Cross-Sectional and Prospective Association Between Proinsulin Secretion and Graft Function After Clinical Islet Transplantation. Transplantation. 2004 Sep 27;78(6):934-937.
6. Mecci FN, Syed AA. How protective is the working time directive?: Two doctors mull over personal horror stories . BMJ 2004, 329(7465), 574.7. McIntyre EA, Halse R, Yeaman SJ, Walker M. Cultured muscle cells from insulin resistant type 2 diabetes patients have impaired insulin, but normal 5-amino-4 imidazolecarboxamide riboside-stimulated, glucose uptake. J Clin Endocrinol Metab. 2004 Jul;89(7):3440-8.
8. Mills GW, Avery PJ, McCarthy MI, Hattersley AT, Levy JC, Hitman GA, Sampson M, Walker M. Heritability estimates for beta cell function and features of the insulin resistance syndrome in UK families with an increased susceptibility to type 2 diabetes. Diabetologia. 2004 Apr;47(4):732-8.
9. Pearce SHS and Leech NJ. Towards precise forecasting of autoimmune endocrinopathy. J Clin Endocrinol Metab 2004; 89: 544-47.
10. Waller S, Kurzawinski T, Spitz L, Thakker R, Cranston T, Pearce S, Cheetham T, Van't Hoff WG. Neonatal severe hyperparathyroidism: genotype/phenotype correlation and the use of pamidronate as rescue therapy. Eur J Pediatr. 2004 Jul 6
11. Syed AA, Weaver JU. Hormone Resistance and Hypersensitivity States . CME Bulletin Endocrinology & Diabetes 2004, 5(1), 10.
12. Syed AA. Online visibility and availability of journals can attract authors and readers . Indian Journal of Medical Research 2004, 119(6), 289.
13. Syed AA. Should reviewers of papers have their names published?: Go one step further . BMJ 2004, 329(7457), 113.
14. White KE, Bilous RW. Estimation of podocyte number: a comparison of methods. Kidney Int. 2004 Aug;66(2):663-7.

RECENT PUBLICATIONS IN DIABETES & ENDOCRINOLOGY THAT HIT THE NEWS OR THAT MAY HAVE A SIGNIFICANT IMPACT ON MANAGEMENT REVIEWS
This is a new section and will comment on important review articles.

England JD, Asbury AK. Peripheral neuropathy. Lancet 2004; 363: 2151-2161.
This excellent article goes through this common condition systematically and provides an insight in to the differential diagnosis of neuropathy when seeing our diabetic patients.

Lew DP, Waldvogel FA. Osteomyelitis. Lancet 2004; 364: 369-379.
This is a stunning review that focuses on the pathophysiology and treatment of this common condition that I am sure you have battled over the years in the context of the diabetic foot. I would highly recommend it to trainees and trainers.

Alexander EK, Marqusee E, Lawrence J, Jarolim P, Fischer GA, Larsen PR.Timing and magnitude of increases in levothyroxine requirements during pregnancy in women with hypothyroidism. NEJM 2004; 351:241-249.
This prospective study attempted to identify precisely the timing and amount of thyroxine adjustment required during pregnancy. Women with hypothyroidism who were planning pregnancy were observed prospectively before and throughout their pregnancies. Thyroid function, humanHCG, and oestradiol were measured before conception, approximately every two weeks during the first trimester, and monthly thereafter. The dose of thyroxine was increased to maintain the TSH concentration at preconception values throughout pregnancy. 20 pregnancies occurred in 19 women and resulted in 17 full-term births. An increase in the thyroxine dose was necessary during 17 pregnancies. The mean thyroxine requirement increased 47% during the first half of pregnancy (median onset of increase, eight weeks of gestation) and plateaued by week 16. This increased dose was required until delivery. This study has shown that thyroxine requirements increase as early as the fifth week of gestation. This supports my own practice of asking women to increase their thyroxine dose by 25microg as soon as they know that they are pregnant. The study authors suggest a 25% increase.

Colhoun HM, Betteridge DJ, Durrington PN, Hitman GA, Neil HA, Livingstone SJ, Thomason MJ, Mackness MI, Charlton-Menys V, Fuller JH; CARDS investigators. Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo-controlled trial. Lancet 2004;364:685-696.
This study assessed the effectiveness of atorvastatin 10 mg daily for primary prevention of major cardiovascular events in patients with type 2 diabetes without high concentrations of LDL-cholesterol. 2838 patients aged 40-75 years were randomised to placebo (n=1410) or atorvastatin 10 mg daily (n=1428). Study entrants had no documented previous history of cardiovascular disease, an LDL-cholesterol concentration of 4.14 mmol/L or lower, a fasting triglyceride of 6.78 mmol/L or less, and at least one of the following: retinopathy, albuminuria, current smoking, or hypertension. The primary endpoint was time to first occurrence of the following: acute coronary heart disease events, coronary revascularisation, or stroke. Analysis was by intention to treat. The trial was terminated 2 years earlier than expected because the prespecified early stopping rule for efficacy had been met. Median duration of follow-up was 3.9 years (IQR 3.0-4.7). 127 patients allocated placebo and 83 allocated atorvastatin had at least one major cardiovascular event (rate reduction 37% [95% CI -52 to -17], p=0.001). Treatment would be expected to prevent at least 37 major vascular events per 1000 such people treated for 4 years. Assessed separately, acute coronary heart disease events were reduced by 36% (-55 to -9), coronary revascularisations by 31% (-59 to 16), and rate of stroke by 48% (-69 to -11). Atorvastatin reduced the death rate by 27% (-48 to 1, p=0.059). No excess of adverse events was noted in the atorvastatin group. This study has shown that Atorvastatin 10 mg daily is safe and efficacious in reducing the risk of first cardiovascular disease events, including stroke, in patients with type 2 diabetes without high LDL-cholesterol. This study has fuelled the debate that all diabetic patients should be on statin therapy regardless of their cholesterol and further supports the findings of the HPS. The accompanying editorial was not flattering at all about the study results. My own view is that when reviewing pts I look for reasons for why they should NOT be on statin therapy before discussing cardiovascular risk with the pt. Lipid treatment is becoming more and more complex, although it is reassuring to see that new therapies are on the horizon, e.g. the CETP inhibitor torcetrapib which raises HDL.

NEXT NEWSLETTER Due out beginning of February 2005, so keep the gossip coming.