Endodiabology 2004; Issue 2 (June)
ENDODIABOLOGY
NORTHEAST NEWSLETTER
FOR SPRs AND BOSSES TRAPPED IN THE NORTHERN DEANERY
JUNE 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- David Woods(4), Rahul Nayar(3), Peter Carey(2), Sony Anthony(2),
Freeman- Kamal Abouglila(4), Simon Ashwell(3), Stella Kaddis(3/4)
North Tyneside/Wansbeck- Arun(4)/
South Tyneside- Andrew Advani(2)
Gateshead- Dr Bhatacharya
Sunderland- Tom Barber(2)
North Tees/Hartlepool- E Lin Lim(1)/
Middlesbrough- McIntyre(5), Arutchelvan Vijayaraman (2)
Carlisle- Isabelle Howat (1)
Bishop Auckland- Rafe Al-Mohammed
NGH-E Al-Ozairi
Research with numbers (supervisor)- Latika Sibal (Prof Home), Salman Razvi (Dr Weaver), B Ravikumar (Prof Taylor), Ibrahim M Ibrahim (Prof Walker), Akheel Syed (Dr Weaver), Sath Nag (Dr Connolly), Reena Thomas (Dr Shaw), Mutu Jayapaul (Prof Walker)
MEETINGS / LECTURES / ANNOUNCEMENTS
4-8th June 2004 American Diabetes Association Conference, Orlando, Florida, USA. Contact ADA
16-19th June 2004 ENDO 2004, New Orleans, USA. Contact Beverly Glover
23rd June 2004 North East Obesity Forum, Small Lecture Theatre, Centuria Building, University of Teesside. Contact Jackie Downie 01642 384124 or
1st-2nd July 2004 MILAN Thyroid Cancer Conference, Milan, Italy. Contact esoncology.org
5th July 2004 GIM SpR training ½ day, Sunderland Royal. Contact Lorraine Waugh 0191 223 1247
7th-9th July 2004 UK Advanced Diabetes Course, Exeter, UK. Contact Rosemary Snowden
13th July 2004 Society for Endocrinology Molecular endocrinology workshop, Oxford, UK. Contact Ann Lloyd Society for Endocrinology
14th-15th July 2004 Society for Endocrinology Advanced endocrine course, Oxford, UK. Contact Ann Lloyd Society for Endocrinology
16th July 2004 Society for Endocrinology Clinical Practice day, Oxford, UK. Contact Ann Lloyd Society for Endocrinology
28th July 2004 ADA SPARROWS FOLLOW-UP MEETING, Lumley Castle, Durham. Contact Jean MacLeod Jean Macleod
31st August- 4th September 2004 12th International Congress of Endocrinology, Lisbon, Portugal. Contact ICE
5th-9th September 2004 40th EASD, Munich, Germany. Contact EASD
29th September 2004 GIM SpR training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
30th September 2004 Abstract deadline date for Northern Endocrine audit and research group. Contact Andy James or Shahid Wahid or Bill Kelly
13th October 2004 Northern Region Diabetes Service Advisory Group followed by Regional Audit meeting. Contact Shahid Wahid
27th October 2004 Northern Endocrine & Diabetes Summer CME, James Cook University Hospital. Contact Simon Ashwell
3rd November 2004 Updates in General Medicine, Freeman Hospital, Newcastle upon Tyne. Contact Lorraine Waugh 0191 223 1247
10th November 2004 54th Meeting of British Thyroid Association, London. Contact Mark Vanderpump
11th and 12th November 2004 Autumn meeting of ABCD, London. Contact P Winocour or ABCD .
24th November 2004 Northern Endocrine audit and research group meeting, Lumley Castle, Durham, 3.30-6pm. Contact Bill Kelly
TRAINING ISSUES
Joint Trainees+Trainers meeting This important annual meeting is to be held at the Medical School, William Leech Building, Room L4.3 on Monday 21st June 2004 from 1815 hrs onwards, following the STC meeting.
Study Leave Simon Ashwell (with input from Shaz Wahid and Stuart Bennett) has produced an excellent list of conferences/meetings that trainees can use to plan their study leave. This document along with an updated version of the generic document dealing with specialist clinics will be circulated sometime in September.
New Curriculum Those of you using the new curriculum would do well to read an article by Bill Burr in the CME edition of Diabetic Medicine in May 2004. It gives insight in to what the new competency based curriculum is about. My own advice for trainees is to collect EVIDENCE, EVIDENCE, EVIDENCE. As an example, lets say you worked up a pt with polyuria who turned out to have cranial DI. Write a detailed case history and stress your own role. Have this case history signed off by your educational supervisor during that posting. Also, when being observed in clinic or on a ward-round make sure that a joint clinic letter or ward-round report from your observer is included in your record. Reflecting on each clinic at its finish and identifying learning incidents is an ideal way to collect evidence of competency. Perhaps we as a region should look at how to promote reflection skills in our trainees, but until then I would recommend that trainees read up a review from MEDLINE to do with reflection.
The Next SpR Post It is that time of year when trainees will be post-RITA and thinking carefully about where they have requested to rotate to next. If you had no idea of where you would have liked to have gone, then in future ask yourself the following 4 questions before the RITA: What have I done in the last 6-months? What does it mean? Have I changed? What could I have done differently? Answering these questions will give you an idea of your objectives for your next posting. Which ever post you go to when leaving there are 3 essential things to have gained: a brace of specialist clinics experience, a poster or regional meeting presentation and a balance between diabetes and endocrinology. All posts can provide these essentials with the content being individualised.
Research It is important that data collection, analysis and interpretation skills along with writing and critiquing papers are developed by all trainees during their 5-6 year programme. The ideal way to achieve this is by undertaking a formal period of research. BMJ careers 15th May 2004 had 2 excellent articles discussing ways of planning projects and how to go about finding the right research project. In the region it is important to discuss research with your educational supervisor who should point you in the right direction. Jola Weaver is the person on the training committee to discuss research with and off course keep you eyes peeled for adverts in BMJ Careers and for announcements in ENDODIABOLOGY (see the letters section below in this edition).
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 Nick Quinn as the second Consultant at Friarage Hospital with Roger Fisken. He will also have some sessions at James Cook University Hospital in Middlesbrough.
Welcome to Isabel Howat who has started as SpR at Carlisle and recently was successful in obtaining an NTN in the region.
Congratulations to Olivia Pereira in obtaining a NTN in the region. She will be joining in August and will start at Middlesbrough.
OLD FACES ON THE GO
Alison Gallagher is busy writing up her MD whilst Locuming as a Consultant at Freeman on an ad-hoc basis.
Liz McIntyre is planning to look for a job in bonny Scotland once she has finished acting up at Wansbeck.
NEWS FROM THE NORTHEAST
Congratulations to Freda Razvi on the birth of her baby daughter (slightly late-sorry!).
Shaz Wahid has joined Bill Kelly and Andy James on the organising committee of the Northern Endocrine Audit and Research Group, which meets annually in November.
Congratulations to Beas Bhatacharya, Arutchelvan Vijayaraman and E Al-Ozairi on recently obtaining an NTN in the region.
Congratulations to Ibrahim Ibrahim, Muthu Jayapaul, Arun, David Woods and Gerry McKay on being selected to attend the ADA in June 2004 through the SPARROWS programme.
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.
BOOK REVIEW-Shaz Wahid
A Practical Manual of Diabetic Foot care. Eds. Michael Edmonds, Alethea Foster and Lee Sanders. 2004 Blackwell Publishing Ltd, Oxford. ISBN 1-4051-0751-4. This excellent book is well illustrated with colour photographs. It is based on a simple classification system of the diabetic foot and provides wonderful practical advice for the whole multidisciplinary diabetic foot team. I have found it immensely helpful whilst restructuring the foot service in my locality. I would strongly recommend it as compulsory reading for trainees. My only gripe is that some of the information is fragmented, so that when one wants a simple answer to a question several sections might have to be read to get an overview. This is exemplified by the charcot foot. Whilst preparing local guidelines I have had to read 5 different sections to get a feel for the management of the charcot foot, although the lack of evidence based info on the use of bisphosphonate therapy in acute charcot feet is disappointing. Despite these gripes, I believe this book true justice to the multidisciplinary approach that is essential in good diabetic foot care.
BOOK REVIEW-Shaz Wahid
Educational Research: contemporary issues and practical approaches. Jerry Wellington 2003, Continuum, London. ISBN 0-8264-4971-9.
Undertaking my Research Methods Module for the Diploma in Clinical Education has opened a whole new “theatre” of research-QUALITATIVE RESEARCH. Often regarded as the poor relation of true scientific research, I believe the field of qualitative research has a lot to offer research in to patients perceptions in diabetes care. Diabetes is all about changing behaviour and the only way to do so is to get a clear understanding of patient perceptions. Furthermore, in the field of health care delivery it can be truly difficult designing a scientific study which accounts for all influencing factors therefore methodologies such as nominal group techniques and focus groups have a lot to offer in evaluating health care delivery. Jerry Wellington’s book provides an excellent introduction in to educational research and the different methods available in the field of qualitative research. I would highly recommend this book to those of you interested in expanding your understanding of research, especially those of you with an interest in delivering education.
CALL FOR RESEARCH APPLICANTS- Professor Roy Taylor
I shall be advertising for a clinical research fellow in the next few weeks. The work concerns postprandial interaction between lipid and glucose metabolism using in vivo MR spectroscopy. It is funded as past of my Wellcome Trust Programme Grant which is about to start. The position would be for two years in the first instance and would be suitable for MD degree work. The training offered would be particularly suitable for a person intending a career in academic medicine, although this is not a pre-condition. Informal enquiries to Roy Taylor
CALL FOR RESEARCH APPLICANTS- Dr Jola Weaver
Dear Shaz,
I would be very grateful if you could include an internal advert for research opportunities available from October 2004 in the field of glucocorticoid regulation, endothelial function and thyroid disease at Medical School and Queen Elizabeth Hospital. For further details please contact Jola Weaver (Uni) or Jola Weaver (QEH)
MEETING REPORT-Shaz Wahid
I attended my first Association of British Clinical Diabetologists (ABCD) meeting at Manchester on the 21st May 2004. I thoroughly enjoyed it. The presentations dealt with practical issues and allowed hob-nobbing with colleagues. Fred Wu provided a good overview of male hypogonadism. Solomon Tesfaye’s interactive presentation dealing with difficult diabetic neuropathy was the highlight of the meeting. Felix Burden and James Walker conducted a lively debate on whether comprehensive measurement of microalbuminuria in routine Type 2 Diabetes Care is useful-the winner was James with the ayes. Shirine Boardman and Jonathan Roland presented interesting data on sibutramine and PCOS and the diabetes healthcare technician, respectively. Clive Weston (a Cardiologist) provided an excellent overview on current and future management of diabetic heart disease-besides his slides were hilarious. The meeting finished with Peter Betts from Southampton providing a superb blue print for the care of Young People with diabetes and I and others were both impressed and full of envy. This meeting is ideal for the “jobbing” Diabetologist and endocrinologist. Would I attend again. Yes resoundingly, but will probably try to attend the meal the evening before in future. The meeting is open for senior SpRs with the next planned meeting on the 11th/12th November 2004 in London. Future SpR training days and back to back meetings with the BES are planned. For further info check out the ABCD website.
RECENT PUBLICATIONS FROM THE NORTHEAST
Please send us your recent publication for inclusion in the next newsletter.
1. Advani A, Marshall SM, Thomas TH. Impaired neutrophil store-mediated calcium entry in Type 2 diabetes. Eur J Clin Invest. 2004;34:43-9.
2. Ashwell SG, Bevan JS, Edwards OM, Harris MM, Holmes C, Middleton MA, James RA. The efficacy and safety of lanreotide autogel in patients with acromegaly previously treated with octreotide LAR. European Journal of Endocrinology 2004;150:473-480.
3. Bennett SM, Agrawal A, Elasha H, Heise M, Jones NP, Walker M, Wilding JP. Rosiglitazone improves insulin sensitivity, glucose tolerance and ambulatory blood pressure in subjects with impaired glucose tolerance. Diabet Med. 2004;21:415-22.
4. Bilous RW. End-stage renal failure and management of diabetes. Diabet Med. 2004;21 Suppl 1:12-4.
5. Home P, Bartley P, Russell-Jones D, Hanaire-Broutin H, et al. Insulin Detemir offers improved glycaemic control compared with NPH insulin in people with type 1 diabetes: a randomised controlled trial. Diabetes Care 2004;27:1081-1087.
6. McFarland R, Schaefer AM, Gardner JL, Lynn S, Hayes CM, Barron MJ, Walker M, Chinnery PF, Taylor RW, Turnbull DM. Familial myopathy: new insights into the T14709C mitochondrial tRNA mutation. Ann Neurol. 2004 55:478-84.
7. Narendran P, Elsegood K, Leech NJ, Macindoe WM, Boons GJ, Dayan M. Dendritic cell-based assays, but not mannosylation of antigen, improves detection of T- cell responses to proinsulin in type 1 diabetes. Immunology. 2004 ;111:422-9.
8. Palmer AJ, Annemans L, Roze S, Lamotte M, Rodby RA, Bilous RW. An economic evaluation of the Irbesartan in Diabetic Nephropathy Trial (IDNT) i n a UK setting. Hum Hypertens. 2004 Apr 29.
9. Piper K, Brickwood S, Turnpenny LW, Cameron IT, Ball SG, Wilson DI, Hanley NA. Beta cell differentiation during early human pancreas development. J Endocrinol. 2004;181:11-23.
10. Pollock RD, Unwin NC, Connolly V. Knowledge and practice of foot care in people with diabetes. Diabetes Res Clin Pract. 2004;64:117-22.
11. Saeed BO, Nixon SJ, White AJ, Summerfield GP, Skillen AW, Weaver JU. Fasting homocysteine levels in adults with type 1 diabetes and retinopathy. Clin Chim Acta. 2004;341:27-32.
12. Syed AA, Wheatley HA, Badminton MN, McDowell IFW. Urinary catecholamines and metabolites in the immediate postoperative period following major surgery. J Clin Pathol 2004;57:548-550.
13. Vaidya B, Pearce S. The emerging role of the CTLA-4 gene in autoimmune endocrinopathies. Eur J Endocrinol. 2004;150:619-26.
14. Weaver JU, Robertson D, Atkin SJ. Nateglinide alone or with metformin safely improves glycaemia to target in patients up to an age of 84. Diabetes, Obesity and Metabolism 2004;6:00-00.
RECENT PUBLICATIONS IN DIABETES & ENDOCRINOLOGY THAT HIT THE NEWS OR THAT MAY HAVE A SIGNIFICANT IMPACT ON MANAGEMENT
Hamrahian AH, Oseni TS, Arafah BM. Measurements of serum free cortisol in critically ill patients. N Engl J Med. 2004;350:1601-2.
This excellent article explores a common situation that we have all faced when rang from ITU. More than 90 percent of circulating cortisol in human serum is protein-bound, therefore changes in the binding proteins can alter measured serum total cortisol concentrations without influencing free concentrations of this hormone. Hamrahian et al investigated the effect of decreased amounts of cortisol-binding proteins on serum total and free cortisol concentrations during critical illness, when glucocorticoid secretion is maximally stimulated. Base-line total cortisol, synacthen-stimulated total cortisol, aldosterone, and free cortisol concentrations were measured in 66 critically ill patients and 33 healthy volunteers in groups equally matched for sex and age. Of the 66 patients, 36 had low albumin levels and 30 had near-normal albumin concentrations. Base-line and synacthen-stimulated total cortisol concentrations were lower in the patients with hypoalbuminaemia than in those with near-normal serum albumin concentrations (pless than 0.001). However, the mean (+/-SD) base-line free cortisol concentrations were similar in the two groups of patients (140.7+/-113.1and 143.5+/-96.6 nmol/l) and were several times higher than the values in controls (16.6+/-8.3 nmol/l, pless than 0.001 for both comparisons). Synacthen-stimulated total cortisol concentrations were subnormal (510.4 nmol/l or less) in 14 of the patients, all of whom had hypoalbuminaemia. In all 66 patients, including these 14 who had hypoalbuminaemia, the base-line and synacthen-stimulated free cortisol concentrations were high-normal or elevated. Hamrahian et al have shown that during critical illness, glucocorticoid secretion markedly increases, but the increase is not discernible when only the serum total cortisol concentration is measured. In this study, nearly 40 percent of critically ill patients with hypoalbuminaemia had subnormal total cortisol concentrations, even though their adrenal function was normal. Measuring free cortisol concentrations in critically ill patients with hypoalbuminaemia may help prevent the unnecessary use of glucocorticoid therapy. This trial provides a practical lesson and should lead to discussions about measuring free cortisol and selected patients.
Scofield RH. Autoantibodies as predictors of disease. Lancet 2004 May ;363:1544-6.
This brilliant review focuses on a question that I have had to ask myself when confronted by both endocrine and general medical patients with positive autoantibodies but no symptoms or signs of disease. Many human diseases are the result of autoimmune attack, presumably related to a loss of tolerance to self. Autoimmune disease can be divided into either organ-specific illnesses, such as thyroid disease, type 1 diabetes, and mysasthenia gravis, or systemic illnesses, such as rheumatoid arthritis and systemic lupus erythematosus. The pathogenesis of autoimmune damage also segregates autoimmune disease in that some diseases or manifestations are mainly induced by autoantibodies. Pathogenesis may be mainly mediated by autoimmune T lymphocytes. Notwithstanding the underlying mechanism of disease, virtually all autoimmune diseases are associated with circulating autoantibodies, which bind self-protein. Furthermore, for many diseases these autoantibodies are found in serum samples many years before disease onset. In the past several years a new autoantibody specificity has been identified in the sera of patients with rheumatoid arthritis. These autoantibodies bind citrulline, a post-translational modification of arginine. Markus Nielen and colleagues recently studied the presence of these autoantibodies and rheumatoid factor in blood donors who later developed rheumatoid arthritis (Arthritis Rheum 2004; 50: 380-86). About half the patients were positive for at least autoantibody at a median of 4.5 years before the onset of disease. The negative predictive value of these tests was high, while the positive predictive value was very high. However, Autoantibodies might not be directly responsible for many of the manifestations of autoimmune disease, but they are markers of future disease in presently healthy individuals. Long-term large studies of outcome are needed to assess the use of assaying autoantibodies for prediction of disease. Such data could lead to intervention trials to prevent autoimmune disease, as are already underway and some have recently reported in type 1 diabetes.
Pemberton’s Sign.
For those of you have never seen Pemberton’s sign checkout Basaria S, Salvatori R. Peberton’s sign. New Engl J Med 2004;350: 1338.
Wilson SR, Vakili BA, Sherman W, Sanborn TA, Brown DL. Effect of diabetes on long-term mortality following contemporary percutaneous coronary intervention: analysis of 4,284 cases. Diabetes Care. 2004;27:1137-42.
Diabetic patients are known to have reduced long-term survival following percutaneous transluminal coronary angioplasty compared with nondiabetic patients. However, it is unknown whether this survival disadvantage has persisted in the era of contemporary percutaneous coronary intervention (PCI) techniques, which include the widespread use of stents and the availability of platelet glycoprotein (GP) IIb/IIIa inhibitors. The authors in this study collected data on 4,284 patients undergoing PCI. The primary end point was all-cause mortality following hospital discharge for PCI. Hypertension, renal impairment, and dialysis were all more common in diabetic patients, whereas active smoking was less frequent. Congestive heart failure on admission was more common in diabetic than nondiabetic patients (7.7 vs. 4.0%, p less than 0.001). Stents were placed in 78% of nondiabetic patients and 75% of diabetic patients (p = 0.045). Platelet GP IIb/IIIa antagonists were administered to 23% of nondiabetic and 24% of diabetic patients (p= NS). At a mean follow-up of 3 years, mortality was 8% among nondiabetic patients and 13% for diabetic patients (p less than 0.001). After adjustment for differences in baseline characteristics between nondiabetic and diabetic patients, diabetes remained a significant independent hazard for late mortality (hazard ratio 1.462, 95% CI 1.169-1.828; p = 0.001). This study suggests that following contemporary PCI, diabetic patients continue to have worse survival than nondiabetic patients. However the retrospective design of the study may not have identified confounders, the authors only looked at mortality and the study preceded the availability of drug eluting stents.
Hovind P, Tarnow L, Rossing P, Jensen BR, Graae M, Torp I, Binder C, Parving HH.Predictors for the development of microalbuminuria and macroalbuminuria in patients with type 1 diabetes: inception cohort study. BMJ. 2004;328:1105.
This retrospective observational study of an inception cohort evaluated baseline predictors for the development of persistent microalbuminuria and macroalbuminuria prospectively in patients with type 1 diabetes. 286 patients (216 adults) newly diagnosed with type 1 diabetes consecutively admitted to the clinic between 1 September 1979 and 31 August 1984 were studied. The main outcome measures were persistent microalbuminuria and persistent macroalbuminuria. During a median follow up of 18.0 years (range 1.0-21.5 years), 79 of 277 (29%) patients developed persistent microalbuminuria. 27 of 79 progressed further to persistent macroalbuminuria. The cumulative incidence of persistent microalbuminuria and persistent macroalbuminuria was 33.6% (95%CI: 27.2% to 40.0%) and 14.6% (8.9% to 20.3%), respectively. Significant predictors for the development of persistent microalbuminuria were a 10-fold increase in urinary albumin excretion rate (relative risk 3.78, 1.57 to 9.13), being male (2.41, 1.43 to 4.06), a 10 mm Hg increase in mean arterial blood pressure (1.38, 1.20 to 1.57), a 1% increase in haemoglobin A1c (1.18, 1.04 to 1.32), and a 1 cm increase in height (0.96, 0.95 to 0.98). 28 patients with microalbuminuria (35%) regressed to normoalbuminuria either transiently (n = 15) or permanently (n = 13). This study has shown that approximately one third of newly diagnosed with type 1 diabetic patients develop persistent microalbuminuria within the first 20 years of diabetes. Several potentially modifiable risk factors predict the development of persistent microalbuminuria and persistent macroalbuminuria.
NEXT NEWSLETTER Due out beginning of October 2004, so keep the gossip coming.
NORTHEAST NEWSLETTER
FOR SPRs AND BOSSES TRAPPED IN THE NORTHERN DEANERY
JUNE 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- David Woods(4), Rahul Nayar(3), Peter Carey(2), Sony Anthony(2),
Freeman- Kamal Abouglila(4), Simon Ashwell(3), Stella Kaddis(3/4)
North Tyneside/Wansbeck- Arun(4)/
South Tyneside- Andrew Advani(2)
Gateshead- Dr Bhatacharya
Sunderland- Tom Barber(2)
North Tees/Hartlepool- E Lin Lim(1)/
Middlesbrough- McIntyre(5), Arutchelvan Vijayaraman (2)
Carlisle- Isabelle Howat (1)
Bishop Auckland- Rafe Al-Mohammed
NGH-E Al-Ozairi
Research with numbers (supervisor)- Latika Sibal (Prof Home), Salman Razvi (Dr Weaver), B Ravikumar (Prof Taylor), Ibrahim M Ibrahim (Prof Walker), Akheel Syed (Dr Weaver), Sath Nag (Dr Connolly), Reena Thomas (Dr Shaw), Mutu Jayapaul (Prof Walker)
MEETINGS / LECTURES / ANNOUNCEMENTS
4-8th June 2004 American Diabetes Association Conference, Orlando, Florida, USA. Contact ADA
16-19th June 2004 ENDO 2004, New Orleans, USA. Contact Beverly Glover
23rd June 2004 North East Obesity Forum, Small Lecture Theatre, Centuria Building, University of Teesside. Contact Jackie Downie 01642 384124 or
1st-2nd July 2004 MILAN Thyroid Cancer Conference, Milan, Italy. Contact esoncology.org
5th July 2004 GIM SpR training ½ day, Sunderland Royal. Contact Lorraine Waugh 0191 223 1247
7th-9th July 2004 UK Advanced Diabetes Course, Exeter, UK. Contact Rosemary Snowden
13th July 2004 Society for Endocrinology Molecular endocrinology workshop, Oxford, UK. Contact Ann Lloyd Society for Endocrinology
14th-15th July 2004 Society for Endocrinology Advanced endocrine course, Oxford, UK. Contact Ann Lloyd Society for Endocrinology
16th July 2004 Society for Endocrinology Clinical Practice day, Oxford, UK. Contact Ann Lloyd Society for Endocrinology
28th July 2004 ADA SPARROWS FOLLOW-UP MEETING, Lumley Castle, Durham. Contact Jean MacLeod Jean Macleod
31st August- 4th September 2004 12th International Congress of Endocrinology, Lisbon, Portugal. Contact ICE
5th-9th September 2004 40th EASD, Munich, Germany. Contact EASD
29th September 2004 GIM SpR training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
30th September 2004 Abstract deadline date for Northern Endocrine audit and research group. Contact Andy James or Shahid Wahid or Bill Kelly
13th October 2004 Northern Region Diabetes Service Advisory Group followed by Regional Audit meeting. Contact Shahid Wahid
27th October 2004 Northern Endocrine & Diabetes Summer CME, James Cook University Hospital. Contact Simon Ashwell
3rd November 2004 Updates in General Medicine, Freeman Hospital, Newcastle upon Tyne. Contact Lorraine Waugh 0191 223 1247
10th November 2004 54th Meeting of British Thyroid Association, London. Contact Mark Vanderpump
11th and 12th November 2004 Autumn meeting of ABCD, London. Contact P Winocour or ABCD .
24th November 2004 Northern Endocrine audit and research group meeting, Lumley Castle, Durham, 3.30-6pm. Contact Bill Kelly
TRAINING ISSUES
Joint Trainees+Trainers meeting This important annual meeting is to be held at the Medical School, William Leech Building, Room L4.3 on Monday 21st June 2004 from 1815 hrs onwards, following the STC meeting.
Study Leave Simon Ashwell (with input from Shaz Wahid and Stuart Bennett) has produced an excellent list of conferences/meetings that trainees can use to plan their study leave. This document along with an updated version of the generic document dealing with specialist clinics will be circulated sometime in September.
New Curriculum Those of you using the new curriculum would do well to read an article by Bill Burr in the CME edition of Diabetic Medicine in May 2004. It gives insight in to what the new competency based curriculum is about. My own advice for trainees is to collect EVIDENCE, EVIDENCE, EVIDENCE. As an example, lets say you worked up a pt with polyuria who turned out to have cranial DI. Write a detailed case history and stress your own role. Have this case history signed off by your educational supervisor during that posting. Also, when being observed in clinic or on a ward-round make sure that a joint clinic letter or ward-round report from your observer is included in your record. Reflecting on each clinic at its finish and identifying learning incidents is an ideal way to collect evidence of competency. Perhaps we as a region should look at how to promote reflection skills in our trainees, but until then I would recommend that trainees read up a review from MEDLINE to do with reflection.
The Next SpR Post It is that time of year when trainees will be post-RITA and thinking carefully about where they have requested to rotate to next. If you had no idea of where you would have liked to have gone, then in future ask yourself the following 4 questions before the RITA: What have I done in the last 6-months? What does it mean? Have I changed? What could I have done differently? Answering these questions will give you an idea of your objectives for your next posting. Which ever post you go to when leaving there are 3 essential things to have gained: a brace of specialist clinics experience, a poster or regional meeting presentation and a balance between diabetes and endocrinology. All posts can provide these essentials with the content being individualised.
Research It is important that data collection, analysis and interpretation skills along with writing and critiquing papers are developed by all trainees during their 5-6 year programme. The ideal way to achieve this is by undertaking a formal period of research. BMJ careers 15th May 2004 had 2 excellent articles discussing ways of planning projects and how to go about finding the right research project. In the region it is important to discuss research with your educational supervisor who should point you in the right direction. Jola Weaver is the person on the training committee to discuss research with and off course keep you eyes peeled for adverts in BMJ Careers and for announcements in ENDODIABOLOGY (see the letters section below in this edition).
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 Nick Quinn as the second Consultant at Friarage Hospital with Roger Fisken. He will also have some sessions at James Cook University Hospital in Middlesbrough.
Welcome to Isabel Howat who has started as SpR at Carlisle and recently was successful in obtaining an NTN in the region.
Congratulations to Olivia Pereira in obtaining a NTN in the region. She will be joining in August and will start at Middlesbrough.
OLD FACES ON THE GO
Alison Gallagher is busy writing up her MD whilst Locuming as a Consultant at Freeman on an ad-hoc basis.
Liz McIntyre is planning to look for a job in bonny Scotland once she has finished acting up at Wansbeck.
NEWS FROM THE NORTHEAST
Congratulations to Freda Razvi on the birth of her baby daughter (slightly late-sorry!).
Shaz Wahid has joined Bill Kelly and Andy James on the organising committee of the Northern Endocrine Audit and Research Group, which meets annually in November.
Congratulations to Beas Bhatacharya, Arutchelvan Vijayaraman and E Al-Ozairi on recently obtaining an NTN in the region.
Congratulations to Ibrahim Ibrahim, Muthu Jayapaul, Arun, David Woods and Gerry McKay on being selected to attend the ADA in June 2004 through the SPARROWS programme.
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.
BOOK REVIEW-Shaz Wahid
A Practical Manual of Diabetic Foot care. Eds. Michael Edmonds, Alethea Foster and Lee Sanders. 2004 Blackwell Publishing Ltd, Oxford. ISBN 1-4051-0751-4. This excellent book is well illustrated with colour photographs. It is based on a simple classification system of the diabetic foot and provides wonderful practical advice for the whole multidisciplinary diabetic foot team. I have found it immensely helpful whilst restructuring the foot service in my locality. I would strongly recommend it as compulsory reading for trainees. My only gripe is that some of the information is fragmented, so that when one wants a simple answer to a question several sections might have to be read to get an overview. This is exemplified by the charcot foot. Whilst preparing local guidelines I have had to read 5 different sections to get a feel for the management of the charcot foot, although the lack of evidence based info on the use of bisphosphonate therapy in acute charcot feet is disappointing. Despite these gripes, I believe this book true justice to the multidisciplinary approach that is essential in good diabetic foot care.
BOOK REVIEW-Shaz Wahid
Educational Research: contemporary issues and practical approaches. Jerry Wellington 2003, Continuum, London. ISBN 0-8264-4971-9.
Undertaking my Research Methods Module for the Diploma in Clinical Education has opened a whole new “theatre” of research-QUALITATIVE RESEARCH. Often regarded as the poor relation of true scientific research, I believe the field of qualitative research has a lot to offer research in to patients perceptions in diabetes care. Diabetes is all about changing behaviour and the only way to do so is to get a clear understanding of patient perceptions. Furthermore, in the field of health care delivery it can be truly difficult designing a scientific study which accounts for all influencing factors therefore methodologies such as nominal group techniques and focus groups have a lot to offer in evaluating health care delivery. Jerry Wellington’s book provides an excellent introduction in to educational research and the different methods available in the field of qualitative research. I would highly recommend this book to those of you interested in expanding your understanding of research, especially those of you with an interest in delivering education.
CALL FOR RESEARCH APPLICANTS- Professor Roy Taylor
I shall be advertising for a clinical research fellow in the next few weeks. The work concerns postprandial interaction between lipid and glucose metabolism using in vivo MR spectroscopy. It is funded as past of my Wellcome Trust Programme Grant which is about to start. The position would be for two years in the first instance and would be suitable for MD degree work. The training offered would be particularly suitable for a person intending a career in academic medicine, although this is not a pre-condition. Informal enquiries to Roy Taylor
CALL FOR RESEARCH APPLICANTS- Dr Jola Weaver
Dear Shaz,
I would be very grateful if you could include an internal advert for research opportunities available from October 2004 in the field of glucocorticoid regulation, endothelial function and thyroid disease at Medical School and Queen Elizabeth Hospital. For further details please contact Jola Weaver (Uni) or Jola Weaver (QEH)
MEETING REPORT-Shaz Wahid
I attended my first Association of British Clinical Diabetologists (ABCD) meeting at Manchester on the 21st May 2004. I thoroughly enjoyed it. The presentations dealt with practical issues and allowed hob-nobbing with colleagues. Fred Wu provided a good overview of male hypogonadism. Solomon Tesfaye’s interactive presentation dealing with difficult diabetic neuropathy was the highlight of the meeting. Felix Burden and James Walker conducted a lively debate on whether comprehensive measurement of microalbuminuria in routine Type 2 Diabetes Care is useful-the winner was James with the ayes. Shirine Boardman and Jonathan Roland presented interesting data on sibutramine and PCOS and the diabetes healthcare technician, respectively. Clive Weston (a Cardiologist) provided an excellent overview on current and future management of diabetic heart disease-besides his slides were hilarious. The meeting finished with Peter Betts from Southampton providing a superb blue print for the care of Young People with diabetes and I and others were both impressed and full of envy. This meeting is ideal for the “jobbing” Diabetologist and endocrinologist. Would I attend again. Yes resoundingly, but will probably try to attend the meal the evening before in future. The meeting is open for senior SpRs with the next planned meeting on the 11th/12th November 2004 in London. Future SpR training days and back to back meetings with the BES are planned. For further info check out the ABCD website.
RECENT PUBLICATIONS FROM THE NORTHEAST
Please send us your recent publication for inclusion in the next newsletter.
1. Advani A, Marshall SM, Thomas TH. Impaired neutrophil store-mediated calcium entry in Type 2 diabetes. Eur J Clin Invest. 2004;34:43-9.
2. Ashwell SG, Bevan JS, Edwards OM, Harris MM, Holmes C, Middleton MA, James RA. The efficacy and safety of lanreotide autogel in patients with acromegaly previously treated with octreotide LAR. European Journal of Endocrinology 2004;150:473-480.
3. Bennett SM, Agrawal A, Elasha H, Heise M, Jones NP, Walker M, Wilding JP. Rosiglitazone improves insulin sensitivity, glucose tolerance and ambulatory blood pressure in subjects with impaired glucose tolerance. Diabet Med. 2004;21:415-22.
4. Bilous RW. End-stage renal failure and management of diabetes. Diabet Med. 2004;21 Suppl 1:12-4.
5. Home P, Bartley P, Russell-Jones D, Hanaire-Broutin H, et al. Insulin Detemir offers improved glycaemic control compared with NPH insulin in people with type 1 diabetes: a randomised controlled trial. Diabetes Care 2004;27:1081-1087.
6. McFarland R, Schaefer AM, Gardner JL, Lynn S, Hayes CM, Barron MJ, Walker M, Chinnery PF, Taylor RW, Turnbull DM. Familial myopathy: new insights into the T14709C mitochondrial tRNA mutation. Ann Neurol. 2004 55:478-84.
7. Narendran P, Elsegood K, Leech NJ, Macindoe WM, Boons GJ, Dayan M. Dendritic cell-based assays, but not mannosylation of antigen, improves detection of T- cell responses to proinsulin in type 1 diabetes. Immunology. 2004 ;111:422-9.
8. Palmer AJ, Annemans L, Roze S, Lamotte M, Rodby RA, Bilous RW. An economic evaluation of the Irbesartan in Diabetic Nephropathy Trial (IDNT) i n a UK setting. Hum Hypertens. 2004 Apr 29.
9. Piper K, Brickwood S, Turnpenny LW, Cameron IT, Ball SG, Wilson DI, Hanley NA. Beta cell differentiation during early human pancreas development. J Endocrinol. 2004;181:11-23.
10. Pollock RD, Unwin NC, Connolly V. Knowledge and practice of foot care in people with diabetes. Diabetes Res Clin Pract. 2004;64:117-22.
11. Saeed BO, Nixon SJ, White AJ, Summerfield GP, Skillen AW, Weaver JU. Fasting homocysteine levels in adults with type 1 diabetes and retinopathy. Clin Chim Acta. 2004;341:27-32.
12. Syed AA, Wheatley HA, Badminton MN, McDowell IFW. Urinary catecholamines and metabolites in the immediate postoperative period following major surgery. J Clin Pathol 2004;57:548-550.
13. Vaidya B, Pearce S. The emerging role of the CTLA-4 gene in autoimmune endocrinopathies. Eur J Endocrinol. 2004;150:619-26.
14. Weaver JU, Robertson D, Atkin SJ. Nateglinide alone or with metformin safely improves glycaemia to target in patients up to an age of 84. Diabetes, Obesity and Metabolism 2004;6:00-00.
RECENT PUBLICATIONS IN DIABETES & ENDOCRINOLOGY THAT HIT THE NEWS OR THAT MAY HAVE A SIGNIFICANT IMPACT ON MANAGEMENT
Hamrahian AH, Oseni TS, Arafah BM. Measurements of serum free cortisol in critically ill patients. N Engl J Med. 2004;350:1601-2.
This excellent article explores a common situation that we have all faced when rang from ITU. More than 90 percent of circulating cortisol in human serum is protein-bound, therefore changes in the binding proteins can alter measured serum total cortisol concentrations without influencing free concentrations of this hormone. Hamrahian et al investigated the effect of decreased amounts of cortisol-binding proteins on serum total and free cortisol concentrations during critical illness, when glucocorticoid secretion is maximally stimulated. Base-line total cortisol, synacthen-stimulated total cortisol, aldosterone, and free cortisol concentrations were measured in 66 critically ill patients and 33 healthy volunteers in groups equally matched for sex and age. Of the 66 patients, 36 had low albumin levels and 30 had near-normal albumin concentrations. Base-line and synacthen-stimulated total cortisol concentrations were lower in the patients with hypoalbuminaemia than in those with near-normal serum albumin concentrations (pless than 0.001). However, the mean (+/-SD) base-line free cortisol concentrations were similar in the two groups of patients (140.7+/-113.1and 143.5+/-96.6 nmol/l) and were several times higher than the values in controls (16.6+/-8.3 nmol/l, pless than 0.001 for both comparisons). Synacthen-stimulated total cortisol concentrations were subnormal (510.4 nmol/l or less) in 14 of the patients, all of whom had hypoalbuminaemia. In all 66 patients, including these 14 who had hypoalbuminaemia, the base-line and synacthen-stimulated free cortisol concentrations were high-normal or elevated. Hamrahian et al have shown that during critical illness, glucocorticoid secretion markedly increases, but the increase is not discernible when only the serum total cortisol concentration is measured. In this study, nearly 40 percent of critically ill patients with hypoalbuminaemia had subnormal total cortisol concentrations, even though their adrenal function was normal. Measuring free cortisol concentrations in critically ill patients with hypoalbuminaemia may help prevent the unnecessary use of glucocorticoid therapy. This trial provides a practical lesson and should lead to discussions about measuring free cortisol and selected patients.
Scofield RH. Autoantibodies as predictors of disease. Lancet 2004 May ;363:1544-6.
This brilliant review focuses on a question that I have had to ask myself when confronted by both endocrine and general medical patients with positive autoantibodies but no symptoms or signs of disease. Many human diseases are the result of autoimmune attack, presumably related to a loss of tolerance to self. Autoimmune disease can be divided into either organ-specific illnesses, such as thyroid disease, type 1 diabetes, and mysasthenia gravis, or systemic illnesses, such as rheumatoid arthritis and systemic lupus erythematosus. The pathogenesis of autoimmune damage also segregates autoimmune disease in that some diseases or manifestations are mainly induced by autoantibodies. Pathogenesis may be mainly mediated by autoimmune T lymphocytes. Notwithstanding the underlying mechanism of disease, virtually all autoimmune diseases are associated with circulating autoantibodies, which bind self-protein. Furthermore, for many diseases these autoantibodies are found in serum samples many years before disease onset. In the past several years a new autoantibody specificity has been identified in the sera of patients with rheumatoid arthritis. These autoantibodies bind citrulline, a post-translational modification of arginine. Markus Nielen and colleagues recently studied the presence of these autoantibodies and rheumatoid factor in blood donors who later developed rheumatoid arthritis (Arthritis Rheum 2004; 50: 380-86). About half the patients were positive for at least autoantibody at a median of 4.5 years before the onset of disease. The negative predictive value of these tests was high, while the positive predictive value was very high. However, Autoantibodies might not be directly responsible for many of the manifestations of autoimmune disease, but they are markers of future disease in presently healthy individuals. Long-term large studies of outcome are needed to assess the use of assaying autoantibodies for prediction of disease. Such data could lead to intervention trials to prevent autoimmune disease, as are already underway and some have recently reported in type 1 diabetes.
Pemberton’s Sign.
For those of you have never seen Pemberton’s sign checkout Basaria S, Salvatori R. Peberton’s sign. New Engl J Med 2004;350: 1338.
Wilson SR, Vakili BA, Sherman W, Sanborn TA, Brown DL. Effect of diabetes on long-term mortality following contemporary percutaneous coronary intervention: analysis of 4,284 cases. Diabetes Care. 2004;27:1137-42.
Diabetic patients are known to have reduced long-term survival following percutaneous transluminal coronary angioplasty compared with nondiabetic patients. However, it is unknown whether this survival disadvantage has persisted in the era of contemporary percutaneous coronary intervention (PCI) techniques, which include the widespread use of stents and the availability of platelet glycoprotein (GP) IIb/IIIa inhibitors. The authors in this study collected data on 4,284 patients undergoing PCI. The primary end point was all-cause mortality following hospital discharge for PCI. Hypertension, renal impairment, and dialysis were all more common in diabetic patients, whereas active smoking was less frequent. Congestive heart failure on admission was more common in diabetic than nondiabetic patients (7.7 vs. 4.0%, p less than 0.001). Stents were placed in 78% of nondiabetic patients and 75% of diabetic patients (p = 0.045). Platelet GP IIb/IIIa antagonists were administered to 23% of nondiabetic and 24% of diabetic patients (p= NS). At a mean follow-up of 3 years, mortality was 8% among nondiabetic patients and 13% for diabetic patients (p less than 0.001). After adjustment for differences in baseline characteristics between nondiabetic and diabetic patients, diabetes remained a significant independent hazard for late mortality (hazard ratio 1.462, 95% CI 1.169-1.828; p = 0.001). This study suggests that following contemporary PCI, diabetic patients continue to have worse survival than nondiabetic patients. However the retrospective design of the study may not have identified confounders, the authors only looked at mortality and the study preceded the availability of drug eluting stents.
Hovind P, Tarnow L, Rossing P, Jensen BR, Graae M, Torp I, Binder C, Parving HH.Predictors for the development of microalbuminuria and macroalbuminuria in patients with type 1 diabetes: inception cohort study. BMJ. 2004;328:1105.
This retrospective observational study of an inception cohort evaluated baseline predictors for the development of persistent microalbuminuria and macroalbuminuria prospectively in patients with type 1 diabetes. 286 patients (216 adults) newly diagnosed with type 1 diabetes consecutively admitted to the clinic between 1 September 1979 and 31 August 1984 were studied. The main outcome measures were persistent microalbuminuria and persistent macroalbuminuria. During a median follow up of 18.0 years (range 1.0-21.5 years), 79 of 277 (29%) patients developed persistent microalbuminuria. 27 of 79 progressed further to persistent macroalbuminuria. The cumulative incidence of persistent microalbuminuria and persistent macroalbuminuria was 33.6% (95%CI: 27.2% to 40.0%) and 14.6% (8.9% to 20.3%), respectively. Significant predictors for the development of persistent microalbuminuria were a 10-fold increase in urinary albumin excretion rate (relative risk 3.78, 1.57 to 9.13), being male (2.41, 1.43 to 4.06), a 10 mm Hg increase in mean arterial blood pressure (1.38, 1.20 to 1.57), a 1% increase in haemoglobin A1c (1.18, 1.04 to 1.32), and a 1 cm increase in height (0.96, 0.95 to 0.98). 28 patients with microalbuminuria (35%) regressed to normoalbuminuria either transiently (n = 15) or permanently (n = 13). This study has shown that approximately one third of newly diagnosed with type 1 diabetic patients develop persistent microalbuminuria within the first 20 years of diabetes. Several potentially modifiable risk factors predict the development of persistent microalbuminuria and persistent macroalbuminuria.
NEXT NEWSLETTER Due out beginning of October 2004, so keep the gossip coming.
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