Tuesday, November 08, 2005

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.

1 Comments:

Blogger Kent MSK Clinic said...

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Regards,
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