Endodiabology 2007; Issue 3 (October)
ENDODIABOLOGY
Endodiabology.blogspot.com
NORTHEAST
NEWSLETTER
FOR SPRs AND BOSSES TRAPPED
IN THE NORTHERN DEANERY
OCTOBER 2007
Editors : Shaz Wahid and Petros Perros
Associate Editors : Freda Razvi, Akheel Syed, Arutchelvam Vijayaraman
SpR PLACEMENTS (NTN year of training from 1st October 2007)
· RVI- Andrew Advani (5), Arutchelvan Vijayaraman (4), Jeevan Mettayil (3), Muthu Jayapaul(5), Khaled Mansur-Dukhan (4)
· Freeman- Chandima Idampitiya (3), Ravikumar Balasubramanian (5), Kerry Livingstone (2)
· North Tyneside/Wansbeck- Akheel Syed(5), Sukesh Chandran(4)
· South Tyneside- Kathryn Stewart (1)
· Gateshead- Asgar Madathil (4)
· Sunderland- Shafie Kamarrudin (2), LAT
· North Tees/Hartlepool- Beas Bhatacharya (4), Anjali Santhakumar (1)
· Middlesbrough- Srikanth Mada(1), Ravi Erukalapati(3), Preeti Rao
· Carlisle- Sudeep Manohar
· Bishop Auckland / Durham- Sony Anthony (5), Arif Ullah (1)
· NGH/QEH- Freda Razvi (3)
· Research with numbers (supervisor)- Eelin Lim(4-Prof Taylor)
MEETINGS / LECTURES / ANNOUNCEMENTS
· 8th October 2007 Northern Endocrine & Diabetes Autumn CME, James Cook University Hospital. Contact Arutchelvam Vijayaraman
· 16th October 2007 Regional Diabetes Audit Group meeting, preceded by NRDSAG. Contacts K Narayanan and Simon Eaton
· 19th October 2007 Deadline for submission of abstracts to DUK for APC in March 2008.
· 31st October 2007 National Training Scheme for the use of radioiodine in benign thyroid disease, Birmingham. Contact Helen Flood
· 1st November 2007 57th British Thyroid Association Annual meeting, London
· 1st-2nd November 2007 (3rd November is SpR meeting) ABCD Autumn Meeting, London, http://www.diabetologists.org.uk/
· 3rd November 2007 Association of Physicians meeting, Freeman Hospital. Contact clive Kelly at Queen Elizabeth hospital, Gateshead
· 5th-7th November 2007 Society for Endocrinology Clinical Update 2007, Manchester. Contact http://www.endocrinology.org/
· 15th November 2007 Deadline for submission of abstracts to Society for Endocrinology for BES conference in April 2008
· 21st November 2007 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine waugh
· 28th November 2007 Northern Endocrine Region Research and Audit Group annual meeting, Lumley Castle, Durham 2pm-8pm. Contact Shaz Wahid
· 3rd December 2007 UK Neuroendocrine Tumour Society Conference, London. Contact Rebecca Hannah uknets@banks-sadler.co.uk
· 4th December 2007 RCP Update in Medicine, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine waugh
· 14th January 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine waugh
· 29th January 2008 Northern Endocrine & Diabetes Winter CME, Freeman Hospital. Contact Arutchelvam Vijayaraman
· 26th February 2008 Clinical Cases Meeting, Society for Endocrinology, London. Contact http://www.endocrinology.org/
· 5th-7th March 2008 DUK Annual Professional Conference, Birmingham. Contact http://www.diabetes.org.uk/
· 17th March 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine waugh
· 7th-10th April 2008 BES 2008, Harrogate. Contact http://www.endocrinology.org/
· 10th-11th April 2008 ABCD Spring Meeting (follows straight after BES), Harrogate, http://www.diabetologists.org.uk/
· 16th April 2008 RCP Acute Medical Emergencies conference, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine waugh
· 6th May 2008 Northern Endocrine & Diabetes Summer CME, Freeman Hospital. Contact Arutchelvam Vijayaraman
· 8th October 2008 Northern Endocrine & Diabetes Autumn CME, James Cook University Hospital. Contact Arutchelvam Vijayaraman
· Endocrinology & Diabetes section of the RSM (www.rsm.ac.uk/endocrinology) offers the following meetings beginning at 9am: Thursday 1 Nov 07: Diabetes for Hospital Doctors. Wednesday 23 Jan 08: Adolescent Endocrinology (joint with Paed/Child Health) Wednesday 27 Feb 08: Diabetes in the Elderly (joint with ABCD) Wednesday 28 May 08: Evidence-based Endocrinology
TRAINING ISSUES
DIABETES & ENDOCRINOLOGY PIMD WEBSITE Our specialty website has been redesigned and is now available on http://mypimd.ncl.ac.uk/PIMDDev . Click onto the specialty training tab then follow to Diabetes & Endocrinology. This site is essential reading, especially for RITA preparation.
Registering with PMETB It is essential that all new SpRs/StRs (even LATs) register with the PMETB through the newly created Joint Royal Colleges of Physicians Training Board (formally the JCHMT) on http://www.jrcptb.org.uk/ although it is still possible to link with this site using the old http://www.jchmt.org.uk/ link. Not doing so means your training is not counted.
Log Book/Portfolio Documentation It is a trainee’s responsibility to make sure their portfolio/log book is prospectively completed and the necessary signatures obtained. Any experience that is not signed off by your educational supervisor at the time cannot be counted towards training.
Assessment tools Please see http://www.jrcptb.org.uk/, It is the trainee’s responsibility to give all the appropriate forms to their Educational or Clinical Supervisor. It is the trainee’s responsibility to make sure that the appropriate assessment summaries are available in their portfolio for RITA purposes, e.g. MSF Summary Form.
Laboratory Training Following SpR feedback, the STC has prepared a document providing guidance for training units and SpRs on the minimum training to be provided in relation to this important subject. It can be accessed on http://mypimd.ncl.ac.uk/PIMDDev .
ANOTHER CURRICULUM!!! Trainees who have been recently appointed now have a new curriculum for both the specialty, Acute Medicine to Level 2 and a generic curriculum. Essentially there is no difference other than the sections being reorganised into the subsections of OBJECTIVE/COMPETENCY, KNOWLEDGE, SKILLS, ATTITUDE. They are essential reading and can be accessed on http://www.jrcptb.org.uk/ .
The GOLD Guide This replaces the Orange guide, and is the definitive guide to all aspects of training in the UK. It can be accessed on http://www.jrcptb.org.uk/SiteCollectionDocuments/Gold%20Guide.pdf . A massive document that I delve into when the need arises, e.g. interdeanery transfers.
REPLACING RITA MMC/PMETB/JRCPTB has produced new guidance on assessing trainees’ progression. The RITA will be replaced with the Annual Review of Competence Progression. ARCP for short. Our region already fulfils the majority of the guidance as the RITAs were revamped 2-yrs ago. Further guidance will be issued in early 2008, once the TPD has been on the course!
ARCP (RITAs 2008) Next year they will be held on Weds 14th, Thursday 15th and Friday 16th May 2008. The PYAS are planned for Thursday am 15th May 2008. An early timetable has been circulated with initial guidance to trainees. Please reply to Shaz Wahid ASAP.
PERSONAL DEVELOPMENT PLANS One of the recommendations of the new Gold Guide is for each trainee to document a PDP at the beginning of each new post. This is something the STC will provide future guidance on, but it would do no harm for trainees to develop one at the start of their current training unit. A suggested template: What development needs have I? How will I address them? Date by which I plan to achieve development goal? Outcome? Completed? Another suggested template: What do I need to learn? How am I going to learn this? What resources do I need to achieve the learning? How will I measure when I have achieved this? How long will this take?
Training Committee Chair- Jola Weaver, Regional Speciality Advisor- Richard Quinton, Programme Director- Shaz Wahid,consultant member-Jean McLeod,consultant member (Research Advisor)-Simon Pearce, Consultant member-Simon Eaton, Consultant member-Nicky Leech SpR representative- Arutchelvan Vijayaraman SpR representative-Andrew Advani
NEW FACES ON THE SCENE
· Welcome to Kathryn Stewart, Anjali Santhakumar, Arif Ullah and Sudeep Manohar as new SpRs (now called StRs (Specialty Trainees) to the region.
· Welcome to Chris Strey as Consultant Endocrinologist at Wansbeck. Since graduation from medical school in Munich, Germany, Chris has been practicing medicine in England for eleven years; interrupted by a three year - PhD programme in New Zealand. He has been working in diabetes and endocrinology for the last eight years completing his specialty training at Addenbrooke’s Hospital, Cambridge University. His research interests focus on endothelial dysfunction in health and disease and endothelial hormones.
NEWS FROM THE NORTHEAST
· It may be a little early to officially announce, but unofficially then!, congratulations to Professor Simon Pearce on his Chair.
· Congratulations to Peter Carey on obtaining the Consultant post at Sunderland Royal. Also, our congratulations to Pete and family on the birth of his daughter Maebh which occurred just after the last newsletter was published.
· Congratulations to Salman Razvi on obtaining the Consultant post at Gateshead.
· Congratulations to Sony Anthony on obtaining the Consultant post at Hartlepool, he plans to act up before his CCT date.
· Reena Thomas will be undertaking a Locum Consultant post at Rochdale from October 2007.
· Congratulations to Srikanth Mada on obtaining his NTN at the recent interviews.
· Nicky Leech has joined the STC as a Consultant member.
· Our best wishes to Ebaa Al-Ozairi as she returns to Kuwait.
· Freda Razvi has returned from her period of career break in a part-time capacity.
· Richard Quinton has joined the Specialist Advisory Committee for Diabetes & Endocrinology, representing the Northern Deanery.
· Kerry Livingstone has joined the NED CME committee with Arut.
· Congratulations to Arut on his recent oral presentation at EASD titled “changes in plasma glucose following exercice:comparison of three basal insulins, V. Arutchelvam , T. Heise, S. Dellweg, B. Elbroend, I. Minns, P. D. Home”.
· Congratulations to Simon Eaton on being selected as Lead Clinician for Care Planning in Diabetes leading the national engagement and implementation of Care Planning with the National Diabetes Support Team and the Department of Health.
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.
Is Management for me?-Shaz Wahid
Having been a Consultant for 4-years I am now asked whether I would like to develop “formal” management skills by a number of individuals at the Trust and attend some regional/national events. Basically, it is a “code” for do you want to join “The Management”? There are 2 courses I could attend, the Kings Fund Development Programme for Diabetologists or the regional NHS course supported by the StHA and the PIMD (I was nominated by Nancy Redfern and my MD). Having looked at the course objectives both of them have a number of objectives which I have already obtained. This is backed up in my portfolio with reflection and via the BMJ Learning website with completed modules and practical examples from my working practice. My activities over the last 4-yrs in relation to Programme Director, Specialty service redesign and more recently Leading the clinical input into redesigning Acute Medicine at the Trust have required obvious managerial skills. If it had not been for this activity I certainly would have booked up on either of the latter courses for my own professional development. However, I personally at this point in time can not see myself wishing to reduce my clinical activities in the future to take on a formal management role. I still enjoy the “coal” face both when delivering a clinical service or an educational “service”. Joining “Management” at the moment is not right for me. My advice to those Consultants recently appointed is that trying to get onto a formal management course (the Kings Fund Course is probably the best one) would be worthwhile for professional development and is certainly a stepping stone to joining “The Management” in the future.
Laboratory Training-Shaz Wahid
As specialists we are frequently asked to comment on investigation that seems out of the “box”, e.g. funny TFTs. Having a working knowledge as to what the Labs do” is therefore essential and helps in test interpretation. It is part of being a specialist! Following SpR feedback the STC have produced the following guidance:
It is important to arrange exposure to laboratory medicine during each unit attachment backed up by background reading. It is important to cover the following topics:
n HbA1c assay measurement, cv, standardisation
n Glucose measurements in the lab and meters with causes of errors
n Hormone assay methods
n Immunometric; RIA, ELISA
n Chromatography
n Reasons for variability+errors, eg hook effect, protein binding
n Pitfalls in autoAb measuring, e.g. TBII, thyroid, adrenal
n Pitfalls in measuring or assessing the following hormones or endocrine axis
n TSH, fT4, fT4, thyroglobulin, total thyroid hormones
n Prolactin
n Cortisol, ACTH
n PTH, calcitonin, calcium, vitamin D
n Water & electrolyte handling; electrolytes, osmolality, ADH
n GH, IGF1
n LH, FSH, Testosterone, SHBG, E2
n Renin, aldosterone, PRA
n Catecholamines
The domains of a Consultant Diabetologist/Endocrinologist-Shaz Wahid
“A review of job satisfaction and current practice of consultant diabetologists in England-barriers and successes, MacLeod K, et al. Diabetic Medicine September 2007;24:946-954” is essential reading for ALL, including Endocrinologists! It is a wonderful collection of thoughts on what a Consultant in Diabetes&Endocrinology truly is in practice. There are 3 basic domains to being a specialist in our specialty:
Clinical Specialist Skills
Leadership Skills across boundaries
Clinical Educator
Each of the domains overlap and pertain to clinical activity, management activity, research activity, governance activity, etc. It is essential for trainees to develop these domains during their training. We far too often concentrate on the clinical skills development that is guided by the curriculum, but it is important to bear in mind that there is ample opportunity for the development of subspecialty skills (diabetic foot, transitional care, etc). It is important to develop leadership skills (eminently demonstrated by Simon Eaton in the letter below) and to undertake activity during training demonstrating these skills, e.g. rota leader, audit resulting in service change that is implemented by the trainee. It is important to demonstrate effective activity as a clinical educator of patients, students, junior Drs, allied health professionals, peers in the hospital and community. When undertaking PYAs one can get a sense of which domains have been developed by the trainee. I highly recommend reading this important piece of work.
The Diabetes Year of Care Pilot Project-Simon Eaton
Year of Care is about people with diabetes taking charge of their condition and working in partnership with healthcare professionals to plan their care. Year of Care describes all the planned care that a person with diabetes should expect to receive, usually over the course of a year. This includes support for self management in line with national standards and, where appropriate, planned specialist referrals.
This national pilot project, backed by Diabetes UK, the Department of Health and the National Diabetes Support Team, aims to find out how this will work in practice. The annual review appointment will become a care planning discussion where the person with diabetes is on equal footing with the healthcare professional. They will jointly decide on the right options for them. The plan they arrive at will form the basis of their individual Year of Care, which will have implications for commissioning. The pilot will test whether it is feasible for the system to work around individual needs in this way.
North Tyneside has been selected as a pilot site, along with Calderdale and Kirklees and Tower Hamlets. Please contact me if you would like any further information -Simon Eaton
RECENT PUBLICATIONS FROM THE NORTHEAST
Please send us your recent publication for inclusion in the next newsletter.
Dashora UK, Sibal L, Ashwell SG, Home PD. Insulin glargine in combination with nateglinide in people with Type 2 diabetes: a randomised placebo-controlled trial. Diabetic Medicine 2007; 24(4):344-9.
Al-Ozairi E, Sibal L, Home PD. Counterpoint: ADOPT; good for sulfonylureas? Diabetes Care 2007; Jun;30(6):1677-80.
Advani A, Kelly DJ, Advani SL, Cox AJ, Thai K, Zhang Y, White KE, Gow RM, Marshall SM, Steer BM, Marsden PA, Gilbert RE (2007) Role of VEGF in maintaining renal structure and function under normotensive and hypertensive conditions. Proc Natl Acad Sci USA 104, 14448-14453.
Raivio T, Falardeau J, Dwyer AA, Quinton R, Hayes FJ, Hughes VA, Cole LW, Pearce SHS, Lee H, Boepple P, Crowley WF, Jr, Pitteloud N. 2007 Reversal of congenital idiopathic hypogonadotropic hypogonadism. New England Journal of Medicine. 357: 863-873. 457-463. [with Editorial Comment: “Experiments of nature -a glimpse into the mysteries of the pubertal clock”, pp929-932].
Maggi M, Schulman C, Quinton R, Langham S, Uhl-Hochgräber K. 2007 The burden of testosterone deficiency in adult men: economic and quality-of-life impact. Journal of Sexual Medicine. 4: 1056-1069.
Rossor AM, Pearce SH, Adams PC. Left ventricular apical ballooning (takotsubo cardiomyopathy) in thyrotoxicosis. Thyroid. 2007; 17:181-2.
Fanciulli M, Norsworthy PJ, Petretto E, Dong R, Harper L, Kamesh L, Heward JM, Gough SC, Froguel P, Owen CJ, Pearce SHS, Teixeira L, Guillevin L, Cunningham Graham DS, Pusey CD, Cook HT, Vyse TJ, Aitman TJ. FCGR3B copy number variation is associated with susceptibility to systemic but not organ-specific autoimmunity. Nature Genetics. 2007; 39: 721-3.
Donaldson P, Veeramani S, Baragiotta A, Floreani A, Venturi C, Pearce S, Wilson V, Jones D, James O, Taylor J, Newton J, Bassendine M. Cytotoxic T-Lymphocyte-Associated Antigen-4 Single Nucleotide Polymorphisms and Haplotypes in Primary Biliary Cirrhosis. Clin Gastroenterol Hepatol. 2007; 5: 755-60.
Sutherland A, Davies J, Owen CJ, Vaikkakara S, Cheetham TD, James RA, Perros P, Cordell HJ, Donaldson PT, Quinton R, Pearce SHS. Genomic polymorphism at the interferon-induced helicase (IFIH1) locus is associated with Graves’ disease. J Clin Endocrinol Metab 2007: 92(8):3338-41.
Razvi S, Pearce SHS. Do antithyroid drugs influence outcome after radioiodine therapy for hyperthyroidism? Nat Clin Pract Endocrinol Metab 2007; 3: 628-9.
RECENT PUBLICATIONS IN DIABETES & ENDOCRINOLOGY THAT HIT THE NEWS OR THAT MAY HAVE A SIGNIFICANT IMPACT ON MANAGEMENT
Clinical update:adverse effects of antiretroviral therapy. Calmy A, et al. Lancet 2007;370:12-14. An excellent article summarising the metabolic problems associated with antiretroviral therapy. Essential reading for trainees.
Vitamin D Deficiency. Michael Holick. NEJM 2007;357:266-281. An excellent review and essential reading for trainees.
Clinical update: new treatments for hot flushes. Vered Stearns. Lancet 2007;369:2062-2064. A symptom we often come across as Endocrinologists which can be very difficult to treat. This update is well worth a read.
Polycystic Ovary Syndrome. Norman RJ, et al. Lancet 2007;370:685-697. An excellent review discussing pathophysiology, epidemiology, diagnosis and management. Well worth a read for an update.
Diagnosis and management of chronic fatigue syndrome or myalgic encephalomyelitis (or encephalopathy); Summary of NICE guidance. Baker R, Shaw EJ. BMJ 2007;335:446-448. Editorial White P, et al. BMJ 2007:411-412. Well worth a read for those of you have to deal with the common referral of “lethargy”.
Hypertriglyceridaemia. John Brunzell. NEJM 2007;357:1009-1017. An excellent practical review.
Gynecomastia. Glenn Braunstein. NEJM 2007;357:1229-1237. Mandatory reading for trainees. An excellent practical account. After reading it, I had a referral in clinic the next day. I had found this article useful.
Reversal of idiopathic hypogonadotropic hypogonadism. Raivio T, Falardeau J, Dwyer A, Quinton R, Hayes FJ, Hughes VA, Cole LW, Pearce SH, et al. N Engl J Med. 2007 Aug 30;357(9):863-73.
The authors describe 15 men in whom reversal of idiopathic hypogonadotropic hypogonadism was sustained after discontinuation of hormonal therapy. Sustained reversal of idiopathic hypogonadotropic hypogonadism was defined as the presence of normal adult testosterone levels after hormonal therapy was discontinued. Ten sustained reversals were identified retrospectively. Five sustained reversal were identified prospectively among 50 men with idiopathic hypogonadotropic hypogonadism after a mean (+/-SD) duration of treatment interruption of 6+/-3 weeks. Of the 15 men who had a sustained reversal, 4 had anosmia. At initial evaluation, 6 men had absent puberty, 9 had partial puberty, and all had abnormal secretion of GnRH-induced luteinising hormone. All 15 men had received previous hormonal therapy. Among those whose hypogonadism was reversed, the mean serum level of endogenous testosterone increased from 1.9+/-1.0 nmol/l to 13.4+/-3.2 nmol/l (P<0.001),> or =90 mm Hg) were randomly assigned to receive once-daily aliskiren 150 mg (n=437), valsartan 160 mg (455), a combination of aliskiren 150 mg and valsartan 160 mg (446), or placebo (459) for 4 weeks, followed by forced titration to double the dose to the maximum recommended dose for another 4 weeks. The primary endpoint was change in mean sitting diastolic blood pressure from baseline to week 8 endpoint. Analyses were done by intention to treat. 196 (11%) patients discontinued study treatment before the end of the trial (63 in the placebo group, 53 in the aliskiren group, 43 in the valsartan group, and 37 in the aliskiren/valsartan group), mainly due to lack of therapeutic effect. At week 8 endpoint, the combination of aliskiren 300 mg and valsartan 320 mg lowered mean sitting diastolic blood pressure from baseline by 12.2 mm Hg, significantly more than either monotherapy (aliskiren 300 mg 9.0 mm Hg decrease, p<0.0001; n="152);" n="150);" n="151)." p="0.12)." p="0.02" p="0.01)," p="0.001)." p="0.03)" p="0.004)" n="2196)" n="2189)," p="0.016)" n="815)" n="826)"> or =7 mmol/L) at baseline. Incidence of new-onset diabetes (new diabetes medication or fasting glucose > or =7 mmol/L) and impaired fasting glucose (fasting glucose > or =6.1 mmol/L and <7 mmol/L) were assessed at follow-up at 0.5, 1.0, 1.5, 2.5, and 3.5 years. Baseline data for body-mass index (BMI), other risk factors, dietary habits, and medications were updated during follow-up. A Mediterranean diet score was assigned according to consumption of cooked and raw vegetables, fruit, fish, and olive oil. Associations of demographic, clinical, and lifestyle risk-factors with incidence of diabetes and impaired fasting glucose were assessed with multivariable Cox proportional hazards. During 26 795 person-years (mean follow-up 3.2 years [SD 0.9]), 998 individuals (12%) developed new-onset diabetes. Of the 7533 without impaired fasting glucose at baseline, 2514 (33%) developed new-onset impaired fasting glucose or diabetes rising to 3859 (62%) of 6229 with the lower cut-off for impaired fasting glucose of 5.6 mmol/L. Independent risk factors for new-onset diabetes or impaired fasting glucose included older age, hypertension, use of beta-blockers, lipid-lowering medications (protective), and diuretic use. Independent lifestyle risk-factors included higher BMI, greater BMI gain during follow-up, current smoking, a lower Mediterranean dietary score, and wine consumption of more than 1 L/day. Data for physical activity were unavailable, but inability to perform exercise testing was associated with higher incidence of diabetes and impaired fasting glucose. In conclusion, this study has shown that compared with population-based cohorts, patients with a recent myocardial infarction had a higher annual incidence rate of impaired fasting glucose (1.8 vs 27.5%) and diabetes (0.8-1.6% compared with 3.7%). Thus, indicating that myocardial infarction could be a prediabetes risk equivalent. This makes the case for screening all patients who have had an MI for dysglycaemia. Each service should develop local protocols. The questions to answer are: fasting glucose vs OGTT and frequency of screening. As an example it would not be unreasonable to undertake an OGTT on all patients 6-weeks post MI initially followed by fasting blood glucose on annual basis via their GP. Any one disagree?
ROSIGLITAZONE Do not moan! As Rudy Bilous aptly stated in his excellent editorial in Diabetic Medicine on the issue of Rosiglitazone and MI risk “you must have been practicing Diabetes in Mars if have not heard about this”.
NEXT NEWSLETTER Due out beginning of February 2008 so keep the gossip coming.
Endodiabology.blogspot.com
NORTHEAST
NEWSLETTER
FOR SPRs AND BOSSES TRAPPED
IN THE NORTHERN DEANERY
OCTOBER 2007
Editors : Shaz Wahid and Petros Perros
Associate Editors : Freda Razvi, Akheel Syed, Arutchelvam Vijayaraman
SpR PLACEMENTS (NTN year of training from 1st October 2007)
· RVI- Andrew Advani (5), Arutchelvan Vijayaraman (4), Jeevan Mettayil (3), Muthu Jayapaul(5), Khaled Mansur-Dukhan (4)
· Freeman- Chandima Idampitiya (3), Ravikumar Balasubramanian (5), Kerry Livingstone (2)
· North Tyneside/Wansbeck- Akheel Syed(5), Sukesh Chandran(4)
· South Tyneside- Kathryn Stewart (1)
· Gateshead- Asgar Madathil (4)
· Sunderland- Shafie Kamarrudin (2), LAT
· North Tees/Hartlepool- Beas Bhatacharya (4), Anjali Santhakumar (1)
· Middlesbrough- Srikanth Mada(1), Ravi Erukalapati(3), Preeti Rao
· Carlisle- Sudeep Manohar
· Bishop Auckland / Durham- Sony Anthony (5), Arif Ullah (1)
· NGH/QEH- Freda Razvi (3)
· Research with numbers (supervisor)- Eelin Lim(4-Prof Taylor)
MEETINGS / LECTURES / ANNOUNCEMENTS
· 8th October 2007 Northern Endocrine & Diabetes Autumn CME, James Cook University Hospital. Contact Arutchelvam Vijayaraman
· 16th October 2007 Regional Diabetes Audit Group meeting, preceded by NRDSAG. Contacts K Narayanan and Simon Eaton
· 19th October 2007 Deadline for submission of abstracts to DUK for APC in March 2008.
· 31st October 2007 National Training Scheme for the use of radioiodine in benign thyroid disease, Birmingham. Contact Helen Flood
· 1st November 2007 57th British Thyroid Association Annual meeting, London
· 1st-2nd November 2007 (3rd November is SpR meeting) ABCD Autumn Meeting, London, http://www.diabetologists.org.uk/
· 3rd November 2007 Association of Physicians meeting, Freeman Hospital. Contact clive Kelly at Queen Elizabeth hospital, Gateshead
· 5th-7th November 2007 Society for Endocrinology Clinical Update 2007, Manchester. Contact http://www.endocrinology.org/
· 15th November 2007 Deadline for submission of abstracts to Society for Endocrinology for BES conference in April 2008
· 21st November 2007 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine waugh
· 28th November 2007 Northern Endocrine Region Research and Audit Group annual meeting, Lumley Castle, Durham 2pm-8pm. Contact Shaz Wahid
· 3rd December 2007 UK Neuroendocrine Tumour Society Conference, London. Contact Rebecca Hannah uknets@banks-sadler.co.uk
· 4th December 2007 RCP Update in Medicine, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine waugh
· 14th January 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine waugh
· 29th January 2008 Northern Endocrine & Diabetes Winter CME, Freeman Hospital. Contact Arutchelvam Vijayaraman
· 26th February 2008 Clinical Cases Meeting, Society for Endocrinology, London. Contact http://www.endocrinology.org/
· 5th-7th March 2008 DUK Annual Professional Conference, Birmingham. Contact http://www.diabetes.org.uk/
· 17th March 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine waugh
· 7th-10th April 2008 BES 2008, Harrogate. Contact http://www.endocrinology.org/
· 10th-11th April 2008 ABCD Spring Meeting (follows straight after BES), Harrogate, http://www.diabetologists.org.uk/
· 16th April 2008 RCP Acute Medical Emergencies conference, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine waugh
· 6th May 2008 Northern Endocrine & Diabetes Summer CME, Freeman Hospital. Contact Arutchelvam Vijayaraman
· 8th October 2008 Northern Endocrine & Diabetes Autumn CME, James Cook University Hospital. Contact Arutchelvam Vijayaraman
· Endocrinology & Diabetes section of the RSM (www.rsm.ac.uk/endocrinology) offers the following meetings beginning at 9am: Thursday 1 Nov 07: Diabetes for Hospital Doctors. Wednesday 23 Jan 08: Adolescent Endocrinology (joint with Paed/Child Health) Wednesday 27 Feb 08: Diabetes in the Elderly (joint with ABCD) Wednesday 28 May 08: Evidence-based Endocrinology
TRAINING ISSUES
DIABETES & ENDOCRINOLOGY PIMD WEBSITE Our specialty website has been redesigned and is now available on http://mypimd.ncl.ac.uk/PIMDDev . Click onto the specialty training tab then follow to Diabetes & Endocrinology. This site is essential reading, especially for RITA preparation.
Registering with PMETB It is essential that all new SpRs/StRs (even LATs) register with the PMETB through the newly created Joint Royal Colleges of Physicians Training Board (formally the JCHMT) on http://www.jrcptb.org.uk/ although it is still possible to link with this site using the old http://www.jchmt.org.uk/ link. Not doing so means your training is not counted.
Log Book/Portfolio Documentation It is a trainee’s responsibility to make sure their portfolio/log book is prospectively completed and the necessary signatures obtained. Any experience that is not signed off by your educational supervisor at the time cannot be counted towards training.
Assessment tools Please see http://www.jrcptb.org.uk/, It is the trainee’s responsibility to give all the appropriate forms to their Educational or Clinical Supervisor. It is the trainee’s responsibility to make sure that the appropriate assessment summaries are available in their portfolio for RITA purposes, e.g. MSF Summary Form.
Laboratory Training Following SpR feedback, the STC has prepared a document providing guidance for training units and SpRs on the minimum training to be provided in relation to this important subject. It can be accessed on http://mypimd.ncl.ac.uk/PIMDDev .
ANOTHER CURRICULUM!!! Trainees who have been recently appointed now have a new curriculum for both the specialty, Acute Medicine to Level 2 and a generic curriculum. Essentially there is no difference other than the sections being reorganised into the subsections of OBJECTIVE/COMPETENCY, KNOWLEDGE, SKILLS, ATTITUDE. They are essential reading and can be accessed on http://www.jrcptb.org.uk/ .
The GOLD Guide This replaces the Orange guide, and is the definitive guide to all aspects of training in the UK. It can be accessed on http://www.jrcptb.org.uk/SiteCollectionDocuments/Gold%20Guide.pdf . A massive document that I delve into when the need arises, e.g. interdeanery transfers.
REPLACING RITA MMC/PMETB/JRCPTB has produced new guidance on assessing trainees’ progression. The RITA will be replaced with the Annual Review of Competence Progression. ARCP for short. Our region already fulfils the majority of the guidance as the RITAs were revamped 2-yrs ago. Further guidance will be issued in early 2008, once the TPD has been on the course!
ARCP (RITAs 2008) Next year they will be held on Weds 14th, Thursday 15th and Friday 16th May 2008. The PYAS are planned for Thursday am 15th May 2008. An early timetable has been circulated with initial guidance to trainees. Please reply to Shaz Wahid ASAP.
PERSONAL DEVELOPMENT PLANS One of the recommendations of the new Gold Guide is for each trainee to document a PDP at the beginning of each new post. This is something the STC will provide future guidance on, but it would do no harm for trainees to develop one at the start of their current training unit. A suggested template: What development needs have I? How will I address them? Date by which I plan to achieve development goal? Outcome? Completed? Another suggested template: What do I need to learn? How am I going to learn this? What resources do I need to achieve the learning? How will I measure when I have achieved this? How long will this take?
Training Committee Chair- Jola Weaver, Regional Speciality Advisor- Richard Quinton, Programme Director- Shaz Wahid,consultant member-Jean McLeod,consultant member (Research Advisor)-Simon Pearce, Consultant member-Simon Eaton, Consultant member-Nicky Leech SpR representative- Arutchelvan Vijayaraman SpR representative-Andrew Advani
NEW FACES ON THE SCENE
· Welcome to Kathryn Stewart, Anjali Santhakumar, Arif Ullah and Sudeep Manohar as new SpRs (now called StRs (Specialty Trainees) to the region.
· Welcome to Chris Strey as Consultant Endocrinologist at Wansbeck. Since graduation from medical school in Munich, Germany, Chris has been practicing medicine in England for eleven years; interrupted by a three year - PhD programme in New Zealand. He has been working in diabetes and endocrinology for the last eight years completing his specialty training at Addenbrooke’s Hospital, Cambridge University. His research interests focus on endothelial dysfunction in health and disease and endothelial hormones.
NEWS FROM THE NORTHEAST
· It may be a little early to officially announce, but unofficially then!, congratulations to Professor Simon Pearce on his Chair.
· Congratulations to Peter Carey on obtaining the Consultant post at Sunderland Royal. Also, our congratulations to Pete and family on the birth of his daughter Maebh which occurred just after the last newsletter was published.
· Congratulations to Salman Razvi on obtaining the Consultant post at Gateshead.
· Congratulations to Sony Anthony on obtaining the Consultant post at Hartlepool, he plans to act up before his CCT date.
· Reena Thomas will be undertaking a Locum Consultant post at Rochdale from October 2007.
· Congratulations to Srikanth Mada on obtaining his NTN at the recent interviews.
· Nicky Leech has joined the STC as a Consultant member.
· Our best wishes to Ebaa Al-Ozairi as she returns to Kuwait.
· Freda Razvi has returned from her period of career break in a part-time capacity.
· Richard Quinton has joined the Specialist Advisory Committee for Diabetes & Endocrinology, representing the Northern Deanery.
· Kerry Livingstone has joined the NED CME committee with Arut.
· Congratulations to Arut on his recent oral presentation at EASD titled “changes in plasma glucose following exercice:comparison of three basal insulins, V. Arutchelvam , T. Heise, S. Dellweg, B. Elbroend, I. Minns, P. D. Home”.
· Congratulations to Simon Eaton on being selected as Lead Clinician for Care Planning in Diabetes leading the national engagement and implementation of Care Planning with the National Diabetes Support Team and the Department of Health.
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.
Is Management for me?-Shaz Wahid
Having been a Consultant for 4-years I am now asked whether I would like to develop “formal” management skills by a number of individuals at the Trust and attend some regional/national events. Basically, it is a “code” for do you want to join “The Management”? There are 2 courses I could attend, the Kings Fund Development Programme for Diabetologists or the regional NHS course supported by the StHA and the PIMD (I was nominated by Nancy Redfern and my MD). Having looked at the course objectives both of them have a number of objectives which I have already obtained. This is backed up in my portfolio with reflection and via the BMJ Learning website with completed modules and practical examples from my working practice. My activities over the last 4-yrs in relation to Programme Director, Specialty service redesign and more recently Leading the clinical input into redesigning Acute Medicine at the Trust have required obvious managerial skills. If it had not been for this activity I certainly would have booked up on either of the latter courses for my own professional development. However, I personally at this point in time can not see myself wishing to reduce my clinical activities in the future to take on a formal management role. I still enjoy the “coal” face both when delivering a clinical service or an educational “service”. Joining “Management” at the moment is not right for me. My advice to those Consultants recently appointed is that trying to get onto a formal management course (the Kings Fund Course is probably the best one) would be worthwhile for professional development and is certainly a stepping stone to joining “The Management” in the future.
Laboratory Training-Shaz Wahid
As specialists we are frequently asked to comment on investigation that seems out of the “box”, e.g. funny TFTs. Having a working knowledge as to what the Labs do” is therefore essential and helps in test interpretation. It is part of being a specialist! Following SpR feedback the STC have produced the following guidance:
It is important to arrange exposure to laboratory medicine during each unit attachment backed up by background reading. It is important to cover the following topics:
n HbA1c assay measurement, cv, standardisation
n Glucose measurements in the lab and meters with causes of errors
n Hormone assay methods
n Immunometric; RIA, ELISA
n Chromatography
n Reasons for variability+errors, eg hook effect, protein binding
n Pitfalls in autoAb measuring, e.g. TBII, thyroid, adrenal
n Pitfalls in measuring or assessing the following hormones or endocrine axis
n TSH, fT4, fT4, thyroglobulin, total thyroid hormones
n Prolactin
n Cortisol, ACTH
n PTH, calcitonin, calcium, vitamin D
n Water & electrolyte handling; electrolytes, osmolality, ADH
n GH, IGF1
n LH, FSH, Testosterone, SHBG, E2
n Renin, aldosterone, PRA
n Catecholamines
The domains of a Consultant Diabetologist/Endocrinologist-Shaz Wahid
“A review of job satisfaction and current practice of consultant diabetologists in England-barriers and successes, MacLeod K, et al. Diabetic Medicine September 2007;24:946-954” is essential reading for ALL, including Endocrinologists! It is a wonderful collection of thoughts on what a Consultant in Diabetes&Endocrinology truly is in practice. There are 3 basic domains to being a specialist in our specialty:
Clinical Specialist Skills
Leadership Skills across boundaries
Clinical Educator
Each of the domains overlap and pertain to clinical activity, management activity, research activity, governance activity, etc. It is essential for trainees to develop these domains during their training. We far too often concentrate on the clinical skills development that is guided by the curriculum, but it is important to bear in mind that there is ample opportunity for the development of subspecialty skills (diabetic foot, transitional care, etc). It is important to develop leadership skills (eminently demonstrated by Simon Eaton in the letter below) and to undertake activity during training demonstrating these skills, e.g. rota leader, audit resulting in service change that is implemented by the trainee. It is important to demonstrate effective activity as a clinical educator of patients, students, junior Drs, allied health professionals, peers in the hospital and community. When undertaking PYAs one can get a sense of which domains have been developed by the trainee. I highly recommend reading this important piece of work.
The Diabetes Year of Care Pilot Project-Simon Eaton
Year of Care is about people with diabetes taking charge of their condition and working in partnership with healthcare professionals to plan their care. Year of Care describes all the planned care that a person with diabetes should expect to receive, usually over the course of a year. This includes support for self management in line with national standards and, where appropriate, planned specialist referrals.
This national pilot project, backed by Diabetes UK, the Department of Health and the National Diabetes Support Team, aims to find out how this will work in practice. The annual review appointment will become a care planning discussion where the person with diabetes is on equal footing with the healthcare professional. They will jointly decide on the right options for them. The plan they arrive at will form the basis of their individual Year of Care, which will have implications for commissioning. The pilot will test whether it is feasible for the system to work around individual needs in this way.
North Tyneside has been selected as a pilot site, along with Calderdale and Kirklees and Tower Hamlets. Please contact me if you would like any further information -Simon Eaton
RECENT PUBLICATIONS FROM THE NORTHEAST
Please send us your recent publication for inclusion in the next newsletter.
Dashora UK, Sibal L, Ashwell SG, Home PD. Insulin glargine in combination with nateglinide in people with Type 2 diabetes: a randomised placebo-controlled trial. Diabetic Medicine 2007; 24(4):344-9.
Al-Ozairi E, Sibal L, Home PD. Counterpoint: ADOPT; good for sulfonylureas? Diabetes Care 2007; Jun;30(6):1677-80.
Advani A, Kelly DJ, Advani SL, Cox AJ, Thai K, Zhang Y, White KE, Gow RM, Marshall SM, Steer BM, Marsden PA, Gilbert RE (2007) Role of VEGF in maintaining renal structure and function under normotensive and hypertensive conditions. Proc Natl Acad Sci USA 104, 14448-14453.
Raivio T, Falardeau J, Dwyer AA, Quinton R, Hayes FJ, Hughes VA, Cole LW, Pearce SHS, Lee H, Boepple P, Crowley WF, Jr, Pitteloud N. 2007 Reversal of congenital idiopathic hypogonadotropic hypogonadism. New England Journal of Medicine. 357: 863-873. 457-463. [with Editorial Comment: “Experiments of nature -a glimpse into the mysteries of the pubertal clock”, pp929-932].
Maggi M, Schulman C, Quinton R, Langham S, Uhl-Hochgräber K. 2007 The burden of testosterone deficiency in adult men: economic and quality-of-life impact. Journal of Sexual Medicine. 4: 1056-1069.
Rossor AM, Pearce SH, Adams PC. Left ventricular apical ballooning (takotsubo cardiomyopathy) in thyrotoxicosis. Thyroid. 2007; 17:181-2.
Fanciulli M, Norsworthy PJ, Petretto E, Dong R, Harper L, Kamesh L, Heward JM, Gough SC, Froguel P, Owen CJ, Pearce SHS, Teixeira L, Guillevin L, Cunningham Graham DS, Pusey CD, Cook HT, Vyse TJ, Aitman TJ. FCGR3B copy number variation is associated with susceptibility to systemic but not organ-specific autoimmunity. Nature Genetics. 2007; 39: 721-3.
Donaldson P, Veeramani S, Baragiotta A, Floreani A, Venturi C, Pearce S, Wilson V, Jones D, James O, Taylor J, Newton J, Bassendine M. Cytotoxic T-Lymphocyte-Associated Antigen-4 Single Nucleotide Polymorphisms and Haplotypes in Primary Biliary Cirrhosis. Clin Gastroenterol Hepatol. 2007; 5: 755-60.
Sutherland A, Davies J, Owen CJ, Vaikkakara S, Cheetham TD, James RA, Perros P, Cordell HJ, Donaldson PT, Quinton R, Pearce SHS. Genomic polymorphism at the interferon-induced helicase (IFIH1) locus is associated with Graves’ disease. J Clin Endocrinol Metab 2007: 92(8):3338-41.
Razvi S, Pearce SHS. Do antithyroid drugs influence outcome after radioiodine therapy for hyperthyroidism? Nat Clin Pract Endocrinol Metab 2007; 3: 628-9.
RECENT PUBLICATIONS IN DIABETES & ENDOCRINOLOGY THAT HIT THE NEWS OR THAT MAY HAVE A SIGNIFICANT IMPACT ON MANAGEMENT
Clinical update:adverse effects of antiretroviral therapy. Calmy A, et al. Lancet 2007;370:12-14. An excellent article summarising the metabolic problems associated with antiretroviral therapy. Essential reading for trainees.
Vitamin D Deficiency. Michael Holick. NEJM 2007;357:266-281. An excellent review and essential reading for trainees.
Clinical update: new treatments for hot flushes. Vered Stearns. Lancet 2007;369:2062-2064. A symptom we often come across as Endocrinologists which can be very difficult to treat. This update is well worth a read.
Polycystic Ovary Syndrome. Norman RJ, et al. Lancet 2007;370:685-697. An excellent review discussing pathophysiology, epidemiology, diagnosis and management. Well worth a read for an update.
Diagnosis and management of chronic fatigue syndrome or myalgic encephalomyelitis (or encephalopathy); Summary of NICE guidance. Baker R, Shaw EJ. BMJ 2007;335:446-448. Editorial White P, et al. BMJ 2007:411-412. Well worth a read for those of you have to deal with the common referral of “lethargy”.
Hypertriglyceridaemia. John Brunzell. NEJM 2007;357:1009-1017. An excellent practical review.
Gynecomastia. Glenn Braunstein. NEJM 2007;357:1229-1237. Mandatory reading for trainees. An excellent practical account. After reading it, I had a referral in clinic the next day. I had found this article useful.
Reversal of idiopathic hypogonadotropic hypogonadism. Raivio T, Falardeau J, Dwyer A, Quinton R, Hayes FJ, Hughes VA, Cole LW, Pearce SH, et al. N Engl J Med. 2007 Aug 30;357(9):863-73.
The authors describe 15 men in whom reversal of idiopathic hypogonadotropic hypogonadism was sustained after discontinuation of hormonal therapy. Sustained reversal of idiopathic hypogonadotropic hypogonadism was defined as the presence of normal adult testosterone levels after hormonal therapy was discontinued. Ten sustained reversals were identified retrospectively. Five sustained reversal were identified prospectively among 50 men with idiopathic hypogonadotropic hypogonadism after a mean (+/-SD) duration of treatment interruption of 6+/-3 weeks. Of the 15 men who had a sustained reversal, 4 had anosmia. At initial evaluation, 6 men had absent puberty, 9 had partial puberty, and all had abnormal secretion of GnRH-induced luteinising hormone. All 15 men had received previous hormonal therapy. Among those whose hypogonadism was reversed, the mean serum level of endogenous testosterone increased from 1.9+/-1.0 nmol/l to 13.4+/-3.2 nmol/l (P<0.001),> or =90 mm Hg) were randomly assigned to receive once-daily aliskiren 150 mg (n=437), valsartan 160 mg (455), a combination of aliskiren 150 mg and valsartan 160 mg (446), or placebo (459) for 4 weeks, followed by forced titration to double the dose to the maximum recommended dose for another 4 weeks. The primary endpoint was change in mean sitting diastolic blood pressure from baseline to week 8 endpoint. Analyses were done by intention to treat. 196 (11%) patients discontinued study treatment before the end of the trial (63 in the placebo group, 53 in the aliskiren group, 43 in the valsartan group, and 37 in the aliskiren/valsartan group), mainly due to lack of therapeutic effect. At week 8 endpoint, the combination of aliskiren 300 mg and valsartan 320 mg lowered mean sitting diastolic blood pressure from baseline by 12.2 mm Hg, significantly more than either monotherapy (aliskiren 300 mg 9.0 mm Hg decrease, p<0.0001; n="152);" n="150);" n="151)." p="0.12)." p="0.02" p="0.01)," p="0.001)." p="0.03)" p="0.004)" n="2196)" n="2189)," p="0.016)" n="815)" n="826)"> or =7 mmol/L) at baseline. Incidence of new-onset diabetes (new diabetes medication or fasting glucose > or =7 mmol/L) and impaired fasting glucose (fasting glucose > or =6.1 mmol/L and <7 mmol/L) were assessed at follow-up at 0.5, 1.0, 1.5, 2.5, and 3.5 years. Baseline data for body-mass index (BMI), other risk factors, dietary habits, and medications were updated during follow-up. A Mediterranean diet score was assigned according to consumption of cooked and raw vegetables, fruit, fish, and olive oil. Associations of demographic, clinical, and lifestyle risk-factors with incidence of diabetes and impaired fasting glucose were assessed with multivariable Cox proportional hazards. During 26 795 person-years (mean follow-up 3.2 years [SD 0.9]), 998 individuals (12%) developed new-onset diabetes. Of the 7533 without impaired fasting glucose at baseline, 2514 (33%) developed new-onset impaired fasting glucose or diabetes rising to 3859 (62%) of 6229 with the lower cut-off for impaired fasting glucose of 5.6 mmol/L. Independent risk factors for new-onset diabetes or impaired fasting glucose included older age, hypertension, use of beta-blockers, lipid-lowering medications (protective), and diuretic use. Independent lifestyle risk-factors included higher BMI, greater BMI gain during follow-up, current smoking, a lower Mediterranean dietary score, and wine consumption of more than 1 L/day. Data for physical activity were unavailable, but inability to perform exercise testing was associated with higher incidence of diabetes and impaired fasting glucose. In conclusion, this study has shown that compared with population-based cohorts, patients with a recent myocardial infarction had a higher annual incidence rate of impaired fasting glucose (1.8 vs 27.5%) and diabetes (0.8-1.6% compared with 3.7%). Thus, indicating that myocardial infarction could be a prediabetes risk equivalent. This makes the case for screening all patients who have had an MI for dysglycaemia. Each service should develop local protocols. The questions to answer are: fasting glucose vs OGTT and frequency of screening. As an example it would not be unreasonable to undertake an OGTT on all patients 6-weeks post MI initially followed by fasting blood glucose on annual basis via their GP. Any one disagree?
ROSIGLITAZONE Do not moan! As Rudy Bilous aptly stated in his excellent editorial in Diabetic Medicine on the issue of Rosiglitazone and MI risk “you must have been practicing Diabetes in Mars if have not heard about this”.
NEXT NEWSLETTER Due out beginning of February 2008 so keep the gossip coming.
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