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.