Endodiabology June 2008 Issue 2
Endodiabology June 2008
ENDODIABOLOGY
Endodiabology.blogspot.com
NORTHEAST NEWSLETTER
FOR SPRs AND BOSSES TRAPPED
IN THE NORTHERN DEANERY
JUNE 2008
Editors: Shaz Wahid and Petros Perros
Associate Editors: Arut Vijayaraman, Shafie Kamarrudin, Beas Bhattacharya, Ravi Erukulapati
SpR PLACEMENTS (NTN year of training from 1st October 2007)
· RVI- Arutchelvan Vijayaraman (4), Jeevan Mettayil (3), Khaled Mansur-Dukhan (4)
· Freeman- Chandima Idampitiya (3), Ravikumar Balasubramanian (5)
· North Tyneside/Wansbeck- Akheel Syed(5), Sukesh Chandran(4)
· South Tyneside- Kathryn Stewart (1)
· Gateshead- Asgar Madathil (4)
· Sunderland- Shafie Kamarrudin (2),
· North Tees/Hartlepool- Beas Bhatacharya (4), Anjali Santhakumar (1)
· Middlesbrough- Srikanth Mada(1), Ravi Erukalapati(3), Preeti Rao
· Carlisle- Sudeep Manohar
· Bishop Auckland / Durham- , Arif Ullah (1)
· NGH/QEH- Freda Razvi (3)
· Research with numbers (supervisor)- Eelin Lim(4-Prof Taylor)
MEETINGS / LECTURES / ANNOUNCEMENTS
· 6th-10th June 2008 American Diabetes Association 68th Annual Scientific Sessions, San Francisco, USA. Contact meetings@diabetes.org .
· 15th-18th June 2008 ENDO 2008, San Francisco. Contact endostaff@endo-societ.org or www.endo-society.org/scimeetings .
· 17th June 2008 Management of Type 2 Diabetes (NICE GUIDELINES), Royal College of Physicians London. See RCPL website.
· 24th June 2008 Joint Trainers & Trainees meeting from 1600, University Hospital North Tees. This follows the STC meeting and the SPARROWS feedback meeting will begin from 1730.
· 3rd July 2008 Association of Physicians meeting, Freeman Hospital from 6pm.
· 9th July 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 16th July 2008 Northern Endocrine & Diabetes Summer CME, Freeman Hospital. Contact
· 3rd September 2008 Advanced insulin pump day, James Cook University Hospital. Contact Apply on line at www.conferencessouthtees.co.uk
· 7th-11th September 2008 44th EASD Annual meeting, Rome, Italy. Contact www.easd.org
· 15th September 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 8th October 2008 Northern Endocrine & Diabetes Autumn CME, James Cook University Hospital. Contact
· 12th November 2008 North East Obesity Forum meeting. Obesogenic environment. Contact
· 12th November 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 26th November 2008 Northern Endocrine Regional Research and Audit Group (NERRAG) annual meeting, Lumley Castle, Durham. 27th November 2007 58th British Thyroid Association Annual meeting, London, www.british-thyroid-association.org .
· 27th and 28th November 2008 (29th November 2008 is SpR meeting) ABCD Autumn Meeting, London, www.diabetologists.org.uk
· 27th and 28th November 2008Insulin Pump Course, James Cook University Hospital. Apply on line at www.conferencessouthtees.co.uk
· 10th December 2008 RCP Updates in G(I)M, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
TRAINING ISSUES
IS THERE A CRISIS LOOMING Answers on a post card please. See the letter by Shaz Wahid in the letters section. The letter should stimulate discussion at the annual Trainers and Trainees meeting on the 24th June 2008.
QUALITY ASSURANCE Our specialty is undergoing a QA review by the PMETB. Richard Quinton is co-ordinating this and will be in touch with individual units shortly.
Information about the Pilot of Workplace-Based Assessments See the letters section.
Confusing paperwork The transitional period between SpR and StR training remains confusing and is especially hindered by the JRCPTBs poor communication and awful paperwork sent to the trainees. Despite the TPDs best attempts to try and reduce this confusion and introduce consistency it looks as though there will have to be separate instructions for the RITAs (old SpRs) and ARCPs (the new StR breed). As an example a new educational supervisor report was published by the JRCPTB the week before this years ARCPs/RITAs. The TPD now at least has some time to look at all the documents and ultimately produce separate instructions for regional use.
Acute Medicine Level 2 training for SpRs For next years ARCPs/RITAs any SpR who has not had their PYA will be expected to have 4 ACAT assessments and 4 Mini-CEXs specifically in relation to Acute Medicine in their portfolio for the panel to review.
Acute Medicine Level 2 training for StRs Any trainee appointed after August 2007 will be considered a StR and for their ARCP they will be expected to have 4 ACAT assessments, 4 Mini-CEXs specifically in relation to Acute Medicine, 4 CbDs in relation to Acute Medicine, a valid ALS qualification, evidence of achievement of all the procedures deemed necessary for Acute Medicine Level 2 training, Evidence of achievement of all emergency presentations to level 2, Evidence of achievement of 2/3rds top 20 presentations to level 2 and Evidence of ½ of other presentations to level 2. It is recommended to use the pages available from the Acute Medicine e-portfolio to collect the later evidence that CMT (ST1-ST2) trainees should already have. If you do not have access to this then contact your Post-Grad Education Centre Manager who should be able to get you access to the e-portfolio for CMTs.
DIABETES & ENDOCRINOLOGY PIMD WEBSITE Our specialty website is 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 ARCP 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 www.jrcptb.org.uk although it is still possible to link with this site using the old 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 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 ARCP purposes, e.g. MSF Summary Form.
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 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.
Acute Care Assessment Tool The ACAT is a tool that is commendable. It provides a method of assessing how Trainees managed their on-call period. It is recommended that at least one is available for ARCP purposes. It can be downloaded from the JRCPTB website.
Carbohydrate Counting Visit www.bdec-e-learning.com an essential resource that is free for now. Highly recommended for all caring for patients with Diabetes and something that could be considered mandatory for trainees.
Knowledge Based Assessments for Diabetes and Endocrinology will be rolled out by Spring 2009. The test will be compulsory for all SpRs who started on or after 1 August 2007. “Older” SpRs will also be encouraged to take it, but not compulsory for them. It will be administered by the RCP’s MRCP office and will look a lot like the written bits of MRCP parts 1 & 2. 2 sittings per year, starting in 2009. Cost £800. Not decided yet if this will be payable as a lump sum or in annual instalments added to the PMETB annual fee. Not decided yet if resits will mean paying the fee again. To be taken after SpR year 2 (=ST4) and passed before PYA Once passed, your MRCP UK will be amended to MRCP UK (Endocrinology & Diabetes).
Personal Development Plans (PDPs) Following the ARCPs all trainees will have their report. It is essential that this report is used to construct a PDP when starting your new post from 1st October. The format used should be standard template circulated by Shaz Wahid. This PDP should be completed by 26th November 2008 and a copy sent to Shaz Wahid for your training file. These PDPs are essential and compulsory from this year onwards.
Improving our links with Acute Medicine A number of Consultants in our specialty have a genuine interest in Acute Medicine (recently joined by Shaz Wahid). They do more than just the acute ward rounds, but are actively involved in designing the delivery of the emergency care of acute admissions. (a testament to the fact that Consultants in our specialty have a knack at service design across districts, regions and broad groups of health professionals). Several of the latter Consultants are closely involved with the training committees at the core and higher specialty level. Shaz Wahid is looking at improving the links with the latter STCs for the benefit of training in the specialty, recruitment to the specialty and careers counselling for the SpRs/StRs in preparation for a lukewarm Consultant job market.
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- Jeevan Mettayil
NEWS FROM THE NORTHEAST
· Congratulations to Preethi Rao and Sudeep Manohar on obtaining their NTNs following the recent gruelling National interviews and will join as StRs.
· Welcome to Cecil Thomas as the 3rd Consultant at South Tyneside. He trained on the Mersey rotation and has an interest in the diabetic foot and cardiovascular diabetes.
· Welcome to Sarah Steven and Stuart Little as new StR3s joining us from 6th August 2008 through the CMT programme.
· Congratulations to all of those of you that presented at the recent BES and DUK conferences. The region had a strong presence at both national events. Jeevan Mettayil did particularly well presenting at the Cushings in pregnancy meet the professor session at the BES.
· Congratulations to Salman Razvi on his election to the British Thyroid Association Executive Committee.
· Andrew Advani and Muthukamaran Jayapaul have both got their CCTs and have moved to pastures new, Toronto for Andrew and India for Muthu.
· Reena Thomas will be getting married soon and moving to the USA.
LETTERS
The future of training in the specialty-Shaz Wahid
In recent times there are 2 worrying trends for our specialty. One is the lack of Consultant posts and indeed no real scope of further Consultant expansion given the government agenda. Hence, we will rely on retirements for future Consultant posts for the SpR/StRs. Not an issue, unless you look around at the current crop of Consultants and notice that the majority are at the beginning or prime of their careers. The second trend is the lack of “new” blood entering the specialty at training level coupled with the perceived poor popularity of the specialty. Having been involved with the national interviews we had 185 applications. I would say barely 30 were of good quality. We ended up short listing 48 and 38 turned up for interview. Of the 38 only 17 made the grade to be appointable to a NTN. Of the 24 NTNs available nationally we filled 14! The top 2 ranked candidates (one of whom had the Northern Deanery as their 1st choice) declined the offer as they must have been successful at their preferred specialty interview. Having said this, the way Preethi and Sudeep interviewed did my kudos with my fellow TPDs a world of good and they were an excellent advert for the region. Those of us at the national interviews discussed these trends in some detail, thankfully over a nice meal in the evening. We were a mix of the young (myself, Rob Andrews, Philip Weston and Marie-France Kong) and the learned well travelled ones (Ian Scobie, Steven Olczak and Andrew Johnson (who at some point in their career had some experience of the Northern Deanery)). We are pushing our SAC to progress three main issues:
1. To make sure that every region has Diabetes & Endocrinology contributing to core medical training. To our surprise there were 2 regions where our specialty was taken out of the CMT programme as it was felt the specialty was best suited to GP training!!!!! A major surprise given that the average on-call take admits 10-25% of patients with a metabolic problem.
2. We need to seriously think about cutting our training posts locally and nationally so as to try and make sure that we have quality entering the specialty. What we do not want to become is a specialty that only produces cannon fodder for Acute Medicine alone. We should reclaim ourselves as an elite specialty.
3. We need to make strides in improving our popularity within the ranks of the “young”. This can only be done by getting the F2s and CMTs to clinic. Despite my misgivings about run-through training I think our region has benefited. This year we have attracted 2 from the CMT programme and I know of at least 3 ST1s showing a serious interest in our specialty and are making active improvements to their CVs to reflect this. I need all trainers to seriously look at the F2 and CMT trainees that rotate through their units and actively try to get them to clinics so as to attract them to the specialty. I suppose I could introduce a prize for the training unit that attracts the most CMTs into the specialty to be presented at the annual Trainers & Trainees meeting.
I look forward to discussing these issues with yourselves in the near future.
Pilot of Workplace-Based assessments-Richard Quinton & Shaz Wahid
The RCP are launching a study to look at the above. The STC are meeting to discuss a local Study Co-ordinator within their own ranks. Once appointed the LSC will ask for volunteers from the trainees. For now the general information is provided below.
Information about the Pilot of Workplace-Based Assessments
In recent years the Royal Colleges of Physicians have promoted the use of workplace-based assessments (DOPS, mini-CEX and multi-source feedback) for trainees, having researched and piloted these techniques. In 2007 all specialties of medicine were required by the Postgraduate Medical Education and Training Board (PMETB) to define assessment strategies to be followed by all trainees entering the new run-through training programmes. For each speciality we now have an integrated assessment system which identifies the appropriate methods to be used to assess curricula competencies. These include combinations of workplace-based assessments, including “new” methods in addition to those mentioned above. Before introducing these new methods the Colleges are piloting them to investigate their reliability (provides reproducible results), validity (measures what it is supposed to) and feasibility in busy working environments.
The Methods to be Piloted
All 29 specialties and sub-specialties of medicine are participating in the project. The following assessment methods will be piloted, though not all of them may be relevant to all specialties. We will try to establish common formats which are acceptable to all or most specialties.
Case Based Discussion
A CbD assesses the performance of a trainee in the assessment and management of a patient to provide an indication of competence in areas such as clinical reasoning, decision-making and application of medical knowledge in relation to patient care.
Acute Care Assessment Tool
The ACAT is designed to assess and facilitate feedback on a doctor’s performance during a period practising on the Acute Medical Take. It is intended to help trainees show they are competent in managing the Acute Medical Take by assessing performance in areas such as prioritisation, communication, teamwork, patient assessment and decision-making over the course of a take period.
Audit Assessment
The Audit Assessment is designed to assess a trainee’s ability to conduct an audit by reviewing, against agreed criteria, an audit which the trainee has carried out.
Patient Survey
The Patient Survey is a method of giving patients the opportunity to give feedback on the performance of a doctor following an out-patient consultation. A number of patients are invited to provide feedback to build up a picture of a doctor’s performance in areas such as communication and professionalism.
Teaching Observation
The Teaching Observation is designed to provide a framework for assessors to provide structured feedback to a trainee. It is a formative tool only and does not have a numerical rating scale.
Local study set up
We will try to include all medical specialties and all regions of the UK in the pilot. For each specialty and participating hospital/centre there will be a nominated consultant in charge who will be the Local Study Coordinator. The Local Study Coordinator will be responsible for recruiting trainees, informing potential assessors (e.g. consultants, associate specialists, senior trainees) and distributing initial paperwork. Educational Supervisors will be asked to participate in order to provide feedback to the trainee on the Patient Survey outcome. Clearly in small units the Local Study Coordinator, Educational Supervisor and Assessor may often be the same person.
The Local Study Coordinator will give participating trainees a code, so that they remain anonymous to the College. They will then distribute information and paperwork to the trainees – this will also be available to download from www.jrcptb.org.uk. All participants will receive a detailed study handbook.
The trainees will be responsible for initiating all assessments, ensuring all paperwork is completed and returned to the Local Study Coordinator. The Local Study Coordinator will return any completed paperwork to the College in self-addressed/stamped envelopes (SAEs). They will also be the point of contact for the College in the event of any problems, incomplete or unreturned documents. The process for managing the Patient Survey will be different but the details of this are still to be defined.
Timescale
We are aiming to start the pilot in April 2008 and to allow 6 months for the completion of the assessments. We will then report findings in winter 2008/9.
Contact
For more information or to take part in the pilot contact:
Joe Booth
Education Projects Manager
Education Department
Royal College of Physicians
London NW1 4LE
joe.booth@rcplondon.ac.uk
020 7935 1174 xtn 541
RECENT PUBLICATIONS FROM THE NORTHEAST
1. Komajda M, Curtis P, Hanefeld M, Beck-Nielsen H, Pocock SJ, Zambanini A, Jones NP, Gomis R, Home PD, for The RECORD Study Group. Effect of the addition of rosiglitazone to metformin or sulfonylureas versus metformin/sulfonylurea combination therapy on ambulatory blood pressure in people with type 2 diabetes: a randomized controlled trial (the RECORD study). Cardiovascular Diabetology 2008; 7:10. doi:10.1186/1475-2840-7-10
2. McMillan C, Bradley C, Razvi S, Weaver J. Evaluation of new measures of the impact of hypothyroidism on quality of life and symptoms: the ThyDQoL and ThySRQ. Value Health. 2008 Mar-Apr;11(2):285-94.
3. Leontiou CA, Gueorguiev M, van der Spuy J, Quinton R, Lolli F, Hassan S, Chahal HS, Igreja SC, Jordan S, Rowe J, Stolbrink M, Christian HC, Wray J, Bishop-Bailey D, Berney DM, Wass JA, Popovic V, Ribeiro-Oliveira A Jr, Gadelha MR, Monson JP, Akker SA, Davis JR, Clayton RN, Yoshimoto K, Iwata T, Matsuno A, Eguchi K, Musat M, Flanagan D, Peters G, Bolger GB, Chapple JP, Frohman LA, Grossman AB, Korbonits M. THE ROLE OF THE AIP GENE IN FAMILIAL AND SPORADIC PITUITARY ADENOMAS. J Clin Endocrinol Metab. 2008 Apr 17. [Epub ahead of print]
4. Al-Ozairi E, Quinton R, Advani A.Therapeutic response to metformin in an underweight patient with polycystic ovarian syndrome.Fertil Steril. 2008 Jan 25. [Epub ahead of print]PMID: 18222436 [PubMed - as supplied by publisher]
5. Vaikkakara S, Al-Ozairi E, Lim E, Advani A, Ball SG, James RA, Quinton R. The investigation and management of severe hyperandrogenism pre- and postmenopause: non-tumor disease is strongly associated with metabolic syndrome and typically responds to insulin-sensitization with metformin. Gynecol Endocrinol. 2008 Feb;24(2):87-92.
6. Syed AA, Quinton R. Congenital radioulnar synostosis, azoospermia, and pseudodicentric Y chromosome. Fertil Steril. 2008 Jan 2. [Epub ahead of print]
7. Al-Ozairi E, Michael E, Quinton R. Insulin resistance causing severe postmenopausal hyperandrogenism. Int J Gynaecol Obstet. 2008 Mar;100(3):280-1. Epub 2007 Nov 19. No abstract available.
8. Young JM, Strey CH, George PM, Florkowski CM, Sies CW, Frampton CM, Scott RS. Effect of atorvastatin on plasma levels of asymmetric dimethylarginine in patients with non-ischaemic heart failure. Eur J Heart Fail. 2008 May;10(5):463-6. Epub 2008 Apr 21.
RECENT PUBLICATIONS IN DIABETES & ENDOCRINOLOGY THAT HIT THE NEWS OR THAT MAY HAVE A SIGNIFICANT IMPACT ON MANAGEMENT
Diabetes in Pregnancy. Nice Clinical guideline 63. www.nice.org.uk. An essential read that brings together a number strands into succinct guidance that all services should use to review their practice. Of course there is controversy! Why go for 1 hour post-prandial monitoring and move away from the standard 2-hour post prandial monitoring? Why abandon the OGTT for post-natal screening? Read the following articles in the BMJ for an excellent overview on commentary on these guidelines: BMJ 2008;336:714-717 & BMJ 2008;336:717-718.
Careers in Diabetes and endocrinology. J Mettayil, R Quinton, S Wahid. BMJ Careers 1st March 2008, page 79. See BMJ vol 336 BMJ careers section. An interesting read and to be used as a recruitment tool.
Non-peptide arginine-vasopressin antagonists:the vaptans. Decauex G, et al. Lancet 2008;371:1624-1632. An excellent article summarising the basic science and trial evidence behind this new exciting class of drugs.
Osteoporosis in men. Peter Ebeling. NEJM 2008;358:1474-1482. An excellent clinical review well worth a read.
Non-surgical management of obesity in adults. Robert Eckel. NEJM 2008;358:1941-1950. An excellent practical review.
Assessment and management of medically unexplained symptoms. Hatcher S, Arroll B. BMJ 2008;336:1124-1128. A wonderful article that provides structure for managing this challenging group of patients.
Decision time for pancreatic islet-cell transplantation. Ruggenenti et al. The Lancet 2008;371:883-884. A thought provoking editorial well worth a read.
Should we dump the metabolic syndrome? Edwin Gale vs George Alberti and Paul Zimmet. BMJ 2008;336: 640-641. A wonderful debate, which still leaves me sceptical about the value of labelling some one as having the metabolic syndrome. But then others may well be on the other side.
Hyperthyroidism and pregnancy. Marx et al. BMJ 2008;336:663-666. An excellent clinical overview.
Lifelong learning at work. PW Teunissen and T Dornan. BMJ 2008;336:667-669. A wonderful read and an article I plan to hand out to all of the trainees I personally supervise.Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial. Davies MJ, et al. BMJ. 2008 Mar 1;336(7642):491-5. This Multicentre cluster randomized controlled trial in primary care (207 general practices in 13 primary care sites in the United Kingdom), randomized 824 adults (55% men, mean age 59.5 yrs) into either a structured group education programme for six hours delivered in the community by two trained healthcare professional educators or into usual care. After 12 months HbA1c levels had decreased by 1.49% in the intervention group compared with 1.21% in the control group. After adjusting for baseline and cluster, the difference was not significant: 0.05% (95% confidence interval -0.10% to 0.20%). The intervention group showed a greater weight loss: -2.98 kg (-3.54 to -2.41) compared with 1.86 kg (-2.44 to -1.28), P=0.027 at 12 months. The odds of not smoking were 3.56 (1.11 to 11.45), P=0.033 higher in the intervention group at 12 months. The intervention group showed significantly greater changes in illness belief scores (P=0.001); directions of change were positive indicating greater understanding of diabetes. The intervention group had a lower depression score at 12 months: mean difference was -0.50 (95% confidence interval -0.96 to -0.04); P=0.032. A positive association was found between change in perceived personal responsibility and weight loss at 12 months (P=0.008). The authors conclude that a structured group education programme for patients with newly diagnosed type 2 diabetes resulted in greater improvements in weight loss and smoking cessation and positive improvements in beliefs about illness but no difference in HbA1c levels up to 12 months after diagnosis. The accompanying editorial (BMJ 2008;336:459-460) is well worth a read.
Mutations in the iodotyrosine deiodinase gene and hypothyroidism. Moreno JC, et al. N Engl J Med. 2008 Apr 24;358(17):1811-8. DEHAL1 has been identified as the gene encoding iodotyrosine deiodinase in the thyroid, where it controls the reuse of iodide for thyroid hormone synthesis. The authors screened patients with hypothyroidism who had features suggestive of an iodotyrosine deiodinase defect for mutations in DEHAL1. Two missense mutations and a deletion of three base pairs were identified in four patients from three unrelated families; all the patients had a dramatic reduction of in vitro activity of iodotyrosine deiodinase. Patients had severe goitrous hypothyroidism, which was evident in infancy and childhood. Two patients had cognitive deficits due to late diagnosis and treatment. Thus, mutations in DEHAL1 led to a deficiency in iodotyrosine deiodinase in these patients. The significance of the study is that because infants with DEHAL1 defects may have normal thyroid function at birth, neonatal screening programs for congenital hypothyroidism might miss them. An excellent editorial by Peter Kopp (NEJM 2008;358:1856-1859) rounds off this article as a learning experience.Hyperglycemia and adverse pregnancy outcomes (HAPO). Metzger BE,et al. N Engl J Med. 2008 May 8;358(19):1991-2002. A total of 25,505 pregnant women at 15 centres in nine countries underwent 75-g oral glucose-tolerance testing at 24 to 32 weeks of gestation. Data remained blinded if the fasting plasma glucose level was 5.8 mmol/l or less and the 2-hour plasma glucose level was 11.1 mmol/l or less. For the 23,316 participants with blinded data, the adjusted odds ratios for adverse pregnancy outcomes associated with an increase in the fasting plasma glucose level of 1 SD (0.4 mmol/l), an increase in the 1-hour plasma glucose level of 1 SD (1.7 mmol/l), and an increase in the 2-hour plasma glucose level of 1 SD (1.3 mmol/l) were calculated. For birth weight above the 90th percentile, the odds ratios were 1.38 (95% confidence interval [CI], 1.32 to 1.44), 1.46 (1.39 to 1.53), and 1.38 (1.32 to 1.44), respectively; for cord-blood serum C-peptide level above the 90th percentile, 1.55 (95% CI, 1.47 to 1.64), 1.46 (1.38 to 1.54), and 1.37 (1.30 to 1.44); for primary caesarean delivery, 1.11 (95% CI, 1.06 to 1.15), 1.10 (1.06 to 1.15), and 1.08 (1.03 to 1.12); and for neonatal hypoglycaemia, 1.08 (95% CI, 0.98 to 1.19), 1.13 (1.03 to 1.26), and 1.10 (1.00 to 1.12). There were no obvious thresholds at which risks increased. These results indicate a strong, continuous association of maternal glucose levels below those diagnostic of diabetes with increased birth weight and increased cord-blood serum C-peptide levels (a proxy marker of foetal insulin resistance, with a higher level suggesting high foetal insulin levels). At South Tyneside we treat any 2 hour blood glucose post OGTT of 7.8-11.o mmol/l as GDM. Does HAPO change that. NO! It adds strength to it as a value and shifting the value lower than this is really not cost effective as argued by Jeffrey Ecker and Michael Greene in the accompanying editorial (NEJM 2008;358:2061-2063). However, does HAPO mean that we should screen all women for GDM instead of selective screening as most units do and recommended by NICE? Given that there is a continuum of risk with glucose it is attractive to suggest blanket screening, however again the cost-effectiveness of such an approach would nee careful examination.Metformin versus insulin for the treatment of gestational diabetes. Rowan JA,et al. N Engl J Med. 2008 May 8;358(19):2003-15. Metformin has been recommended by NICE as option to treat hyperglycaemia in GDM along with glibenclamide or insulin, hence this trial is timely. 751 women with gestational diabetes mellitus at 20 to 33 weeks of gestation were randomly assigned to open treatment with metformin (with supplemental insulin if required) or insulin. The primary outcome was a composite of neonatal hypoglycaemia, respiratory distress, need for phototherapy, birth trauma, 5-minute Apgar score less than 7, or prematurity. Secondary outcomes included neonatal anthropometric measurements, maternal glycaemic control, maternal hypertensive complications, postpartumglucose tolerance, and acceptability of treatment. Of the 363 women assigned to metformin, 92.6% continued to receive metformin until delivery and 46.3% received supplemental insulin. The rate of the primary composite outcome was 32.0% in the group assigned to metformin and 32.2% in the insulin group(relative risk, 1.00; 95% confidence interval, 0.90 to 1.10). More women in the metformin group than in the insulin group stated that they would choose to receive their assigned treatment again (76.6% vs. 27.2%, P<0.001). The rates of other secondary outcomes did not differ significantly between the groups. There were no serious adverse events associated with the use of metformin. This trial has shown that in women with gestational diabetes mellitus, metformin (alone or with supplemental insulin) is not associated with increased perinatal complications as compared with insulin and that not surprisingly metformin was preferred to insulin. Once-daily basal insulin glargine versus thrice-daily prandial insulin lispro in people with type 2 diabetes on oral hypoglycaemic agents(APOLLO): an open randomised controlled trial. Bretzel RG,et al. Lancet. 2008 Mar 29;371(9618):1073-84.In this 44-week, parallel, open study 418 patients with type 2 diabetes mellitus inadequately controlled by oral hypoglycaemic agents were randomly assigned to either once-daily insulin glargine taken at the same time every day or to insulin lispro administered three times per day with meals. 205 patients were randomly assigned to insulin glargine and 210 to insulin lispro. Mean HbA1c decrease in the insulin glargine group was -1.7% (from 8.7% [SD 1.0] to 7.0% [0.7]) and -1.9% in the insulin lispro group (from 8.7% [1.0] to 6.8% [0.9], a mean difference of 0.157 (95% CI -0.008 to 0.322). 57% patients reached HbA1c of 7% or less in the glargine group and 69% in the lispro group. In the glargine group, the fall in mean fasting blood glucose (-4.3 [SD 2.3] mmol/L vs -1.8 [2.3] mmol/L; p<0.0001) and nocturnal blood glucose (-3.3[2.8] mmol/L vs -2.6 [2.9] mmol/L; p=0.0041) was better than it was in the insulin lispro group, whereas insulin lispro better controlled postprandial blood glucose throughout the day (p<0.0001). The incidence of hypoglycaemic events was less with insulin glargine than with lispro (5.2 [95% CI 1.9-8.9] vs 24.0 [21-28] events per patient per year; p<0.0001). Respective mean weight gains were 3.01 (SD 4.33) kg and 3.54 (4.48) kg. The improvement of treatment satisfaction was greater for insulin glargine than for insulin lispro (mean difference 3.13; 95% CI 2.04-4.22). The authors conclude that insulin glargine provides a simple and effective option that is more satisfactory to patients than is lispro for early initiation of insulin therapy, since it was associated with a lower risk of hypoglycaemia, fewer injections, less blood glucose self monitoring, and greater patient satisfaction than was insulin lispro. Does this trial change my approach. No! I (Shaz) still individualise therapy. Once daily insulin may be better for certain patients, but in my experience the majority end up on more doses. Given the resource implications in my local district I prefer the once-two-three mixed insulin approach with metformin if tolerated. I try to emphasize approaches to reduce weight gain as well. Furthermore, the availability of exenatide adds more to the armourmentarium. The current therapies available for type 2 diabetes remind me a lot of the promulgumation of therapies available for chronic heart failure overnight, resulting in “heart failure nurses”. The difference in diabetes is that not one glove fits all and it is not all about titrating up the dose or adding more therapies. We have a major psychological barrier to mange in terms of weight and physical activity. Simvastatin with or without ezetimibe in familial hypercholesterolemia. Kastelein JJ,et al. N Engl J Med. 2008 Apr 3;358(14):1431-43. This double-blind, randomised, 24-month trial compared the effects of daily therapy with 80 mg of simvastatin either with placebo or with 10 mg of ezetimibe in 720 patients with familial hypercholesterolaemia. Patients underwent B mode ultrasonography to assess the intima-media thickness of the walls of the carotid and femoral arteries. The primary outcome measure was the change in the mean carotid-artery intima-media thickness. The primary outcome, the mean (SE) change in the carotid-artery intima-media thickness, was 0.0058(0.0037)mm in the simvastatin-only group and 0.0111(0.0038)mm in the combined-therapy group (P=0.29). At the end of the study, the mean (+/-SD) LDL cholesterol level was 4.98(1.56)mmol/l in the simvastatin group and 3.65(1.36)mmol/l in the combined-therapy group (a between-group difference of 16.5%, P<0.01). The differences between the two groups in reductions in levels of triglycerides and C-reactive protein were 6.6% and 25.7%, respectively, with greater reductions in the combined-therapy group (P<0.01 for both comparisons). Side-effect and safety profiles were similar in the two groups. In conclusion, in patients with familial hypercholesterolaemia, combined therapy with ezetimibe and simvastatin did not result in a significant difference in changes in intima-media thickness, as compared with simvastatin alone, despite decreases in levels of LDL cholesterol and C-reactive protein. A very interesting study with a surprising result. The accompanying editorials (Brown GB, Taylor AJ NEJM 2008;358:1504-1507 & Drazen JM et al NEJM 2008;358:1507-1508) are well worth a read as they try to pick through possible reasons for this surprising result.
NEXT NEWSLETTER Due out beginning of October 2008 so keep the gossip coming.
POSTED BY ARUTCHELVAM AT 10:51 PM
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NORTHEAST NEWSLETTER
FOR SPRs AND BOSSES TRAPPED
IN THE NORTHERN DEANERY
JUNE 2008
Editors: Shaz Wahid and Petros Perros
Associate Editors: Arut Vijayaraman, Shafie Kamarrudin, Beas Bhattacharya, Ravi Erukulapati
SpR PLACEMENTS (NTN year of training from 1st October 2007)
· RVI- Arutchelvan Vijayaraman (4), Jeevan Mettayil (3), Khaled Mansur-Dukhan (4)
· Freeman- Chandima Idampitiya (3), Ravikumar Balasubramanian (5)
· North Tyneside/Wansbeck- Akheel Syed(5), Sukesh Chandran(4)
· South Tyneside- Kathryn Stewart (1)
· Gateshead- Asgar Madathil (4)
· Sunderland- Shafie Kamarrudin (2),
· North Tees/Hartlepool- Beas Bhatacharya (4), Anjali Santhakumar (1)
· Middlesbrough- Srikanth Mada(1), Ravi Erukalapati(3), Preeti Rao
· Carlisle- Sudeep Manohar
· Bishop Auckland / Durham- , Arif Ullah (1)
· NGH/QEH- Freda Razvi (3)
· Research with numbers (supervisor)- Eelin Lim(4-Prof Taylor)
MEETINGS / LECTURES / ANNOUNCEMENTS
· 6th-10th June 2008 American Diabetes Association 68th Annual Scientific Sessions, San Francisco, USA. Contact meetings@diabetes.org .
· 15th-18th June 2008 ENDO 2008, San Francisco. Contact endostaff@endo-societ.org or www.endo-society.org/scimeetings .
· 17th June 2008 Management of Type 2 Diabetes (NICE GUIDELINES), Royal College of Physicians London. See RCPL website.
· 24th June 2008 Joint Trainers & Trainees meeting from 1600, University Hospital North Tees. This follows the STC meeting and the SPARROWS feedback meeting will begin from 1730.
· 3rd July 2008 Association of Physicians meeting, Freeman Hospital from 6pm.
· 9th July 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 16th July 2008 Northern Endocrine & Diabetes Summer CME, Freeman Hospital. Contact
· 3rd September 2008 Advanced insulin pump day, James Cook University Hospital. Contact Apply on line at www.conferencessouthtees.co.uk
· 7th-11th September 2008 44th EASD Annual meeting, Rome, Italy. Contact www.easd.org
· 15th September 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 8th October 2008 Northern Endocrine & Diabetes Autumn CME, James Cook University Hospital. Contact
· 12th November 2008 North East Obesity Forum meeting. Obesogenic environment. Contact
· 12th November 2008 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 26th November 2008 Northern Endocrine Regional Research and Audit Group (NERRAG) annual meeting, Lumley Castle, Durham. 27th November 2007 58th British Thyroid Association Annual meeting, London, www.british-thyroid-association.org .
· 27th and 28th November 2008 (29th November 2008 is SpR meeting) ABCD Autumn Meeting, London, www.diabetologists.org.uk
· 27th and 28th November 2008Insulin Pump Course, James Cook University Hospital. Apply on line at www.conferencessouthtees.co.uk
· 10th December 2008 RCP Updates in G(I)M, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
TRAINING ISSUES
IS THERE A CRISIS LOOMING Answers on a post card please. See the letter by Shaz Wahid in the letters section. The letter should stimulate discussion at the annual Trainers and Trainees meeting on the 24th June 2008.
QUALITY ASSURANCE Our specialty is undergoing a QA review by the PMETB. Richard Quinton is co-ordinating this and will be in touch with individual units shortly.
Information about the Pilot of Workplace-Based Assessments See the letters section.
Confusing paperwork The transitional period between SpR and StR training remains confusing and is especially hindered by the JRCPTBs poor communication and awful paperwork sent to the trainees. Despite the TPDs best attempts to try and reduce this confusion and introduce consistency it looks as though there will have to be separate instructions for the RITAs (old SpRs) and ARCPs (the new StR breed). As an example a new educational supervisor report was published by the JRCPTB the week before this years ARCPs/RITAs. The TPD now at least has some time to look at all the documents and ultimately produce separate instructions for regional use.
Acute Medicine Level 2 training for SpRs For next years ARCPs/RITAs any SpR who has not had their PYA will be expected to have 4 ACAT assessments and 4 Mini-CEXs specifically in relation to Acute Medicine in their portfolio for the panel to review.
Acute Medicine Level 2 training for StRs Any trainee appointed after August 2007 will be considered a StR and for their ARCP they will be expected to have 4 ACAT assessments, 4 Mini-CEXs specifically in relation to Acute Medicine, 4 CbDs in relation to Acute Medicine, a valid ALS qualification, evidence of achievement of all the procedures deemed necessary for Acute Medicine Level 2 training, Evidence of achievement of all emergency presentations to level 2, Evidence of achievement of 2/3rds top 20 presentations to level 2 and Evidence of ½ of other presentations to level 2. It is recommended to use the pages available from the Acute Medicine e-portfolio to collect the later evidence that CMT (ST1-ST2) trainees should already have. If you do not have access to this then contact your Post-Grad Education Centre Manager who should be able to get you access to the e-portfolio for CMTs.
DIABETES & ENDOCRINOLOGY PIMD WEBSITE Our specialty website is 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 ARCP 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 www.jrcptb.org.uk although it is still possible to link with this site using the old 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 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 ARCP purposes, e.g. MSF Summary Form.
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 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.
Acute Care Assessment Tool The ACAT is a tool that is commendable. It provides a method of assessing how Trainees managed their on-call period. It is recommended that at least one is available for ARCP purposes. It can be downloaded from the JRCPTB website.
Carbohydrate Counting Visit www.bdec-e-learning.com an essential resource that is free for now. Highly recommended for all caring for patients with Diabetes and something that could be considered mandatory for trainees.
Knowledge Based Assessments for Diabetes and Endocrinology will be rolled out by Spring 2009. The test will be compulsory for all SpRs who started on or after 1 August 2007. “Older” SpRs will also be encouraged to take it, but not compulsory for them. It will be administered by the RCP’s MRCP office and will look a lot like the written bits of MRCP parts 1 & 2. 2 sittings per year, starting in 2009. Cost £800. Not decided yet if this will be payable as a lump sum or in annual instalments added to the PMETB annual fee. Not decided yet if resits will mean paying the fee again. To be taken after SpR year 2 (=ST4) and passed before PYA Once passed, your MRCP UK will be amended to MRCP UK (Endocrinology & Diabetes).
Personal Development Plans (PDPs) Following the ARCPs all trainees will have their report. It is essential that this report is used to construct a PDP when starting your new post from 1st October. The format used should be standard template circulated by Shaz Wahid. This PDP should be completed by 26th November 2008 and a copy sent to Shaz Wahid for your training file. These PDPs are essential and compulsory from this year onwards.
Improving our links with Acute Medicine A number of Consultants in our specialty have a genuine interest in Acute Medicine (recently joined by Shaz Wahid). They do more than just the acute ward rounds, but are actively involved in designing the delivery of the emergency care of acute admissions. (a testament to the fact that Consultants in our specialty have a knack at service design across districts, regions and broad groups of health professionals). Several of the latter Consultants are closely involved with the training committees at the core and higher specialty level. Shaz Wahid is looking at improving the links with the latter STCs for the benefit of training in the specialty, recruitment to the specialty and careers counselling for the SpRs/StRs in preparation for a lukewarm Consultant job market.
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- Jeevan Mettayil
NEWS FROM THE NORTHEAST
· Congratulations to Preethi Rao and Sudeep Manohar on obtaining their NTNs following the recent gruelling National interviews and will join as StRs.
· Welcome to Cecil Thomas as the 3rd Consultant at South Tyneside. He trained on the Mersey rotation and has an interest in the diabetic foot and cardiovascular diabetes.
· Welcome to Sarah Steven and Stuart Little as new StR3s joining us from 6th August 2008 through the CMT programme.
· Congratulations to all of those of you that presented at the recent BES and DUK conferences. The region had a strong presence at both national events. Jeevan Mettayil did particularly well presenting at the Cushings in pregnancy meet the professor session at the BES.
· Congratulations to Salman Razvi on his election to the British Thyroid Association Executive Committee.
· Andrew Advani and Muthukamaran Jayapaul have both got their CCTs and have moved to pastures new, Toronto for Andrew and India for Muthu.
· Reena Thomas will be getting married soon and moving to the USA.
LETTERS
The future of training in the specialty-Shaz Wahid
In recent times there are 2 worrying trends for our specialty. One is the lack of Consultant posts and indeed no real scope of further Consultant expansion given the government agenda. Hence, we will rely on retirements for future Consultant posts for the SpR/StRs. Not an issue, unless you look around at the current crop of Consultants and notice that the majority are at the beginning or prime of their careers. The second trend is the lack of “new” blood entering the specialty at training level coupled with the perceived poor popularity of the specialty. Having been involved with the national interviews we had 185 applications. I would say barely 30 were of good quality. We ended up short listing 48 and 38 turned up for interview. Of the 38 only 17 made the grade to be appointable to a NTN. Of the 24 NTNs available nationally we filled 14! The top 2 ranked candidates (one of whom had the Northern Deanery as their 1st choice) declined the offer as they must have been successful at their preferred specialty interview. Having said this, the way Preethi and Sudeep interviewed did my kudos with my fellow TPDs a world of good and they were an excellent advert for the region. Those of us at the national interviews discussed these trends in some detail, thankfully over a nice meal in the evening. We were a mix of the young (myself, Rob Andrews, Philip Weston and Marie-France Kong) and the learned well travelled ones (Ian Scobie, Steven Olczak and Andrew Johnson (who at some point in their career had some experience of the Northern Deanery)). We are pushing our SAC to progress three main issues:
1. To make sure that every region has Diabetes & Endocrinology contributing to core medical training. To our surprise there were 2 regions where our specialty was taken out of the CMT programme as it was felt the specialty was best suited to GP training!!!!! A major surprise given that the average on-call take admits 10-25% of patients with a metabolic problem.
2. We need to seriously think about cutting our training posts locally and nationally so as to try and make sure that we have quality entering the specialty. What we do not want to become is a specialty that only produces cannon fodder for Acute Medicine alone. We should reclaim ourselves as an elite specialty.
3. We need to make strides in improving our popularity within the ranks of the “young”. This can only be done by getting the F2s and CMTs to clinic. Despite my misgivings about run-through training I think our region has benefited. This year we have attracted 2 from the CMT programme and I know of at least 3 ST1s showing a serious interest in our specialty and are making active improvements to their CVs to reflect this. I need all trainers to seriously look at the F2 and CMT trainees that rotate through their units and actively try to get them to clinics so as to attract them to the specialty. I suppose I could introduce a prize for the training unit that attracts the most CMTs into the specialty to be presented at the annual Trainers & Trainees meeting.
I look forward to discussing these issues with yourselves in the near future.
Pilot of Workplace-Based assessments-Richard Quinton & Shaz Wahid
The RCP are launching a study to look at the above. The STC are meeting to discuss a local Study Co-ordinator within their own ranks. Once appointed the LSC will ask for volunteers from the trainees. For now the general information is provided below.
Information about the Pilot of Workplace-Based Assessments
In recent years the Royal Colleges of Physicians have promoted the use of workplace-based assessments (DOPS, mini-CEX and multi-source feedback) for trainees, having researched and piloted these techniques. In 2007 all specialties of medicine were required by the Postgraduate Medical Education and Training Board (PMETB) to define assessment strategies to be followed by all trainees entering the new run-through training programmes. For each speciality we now have an integrated assessment system which identifies the appropriate methods to be used to assess curricula competencies. These include combinations of workplace-based assessments, including “new” methods in addition to those mentioned above. Before introducing these new methods the Colleges are piloting them to investigate their reliability (provides reproducible results), validity (measures what it is supposed to) and feasibility in busy working environments.
The Methods to be Piloted
All 29 specialties and sub-specialties of medicine are participating in the project. The following assessment methods will be piloted, though not all of them may be relevant to all specialties. We will try to establish common formats which are acceptable to all or most specialties.
Case Based Discussion
A CbD assesses the performance of a trainee in the assessment and management of a patient to provide an indication of competence in areas such as clinical reasoning, decision-making and application of medical knowledge in relation to patient care.
Acute Care Assessment Tool
The ACAT is designed to assess and facilitate feedback on a doctor’s performance during a period practising on the Acute Medical Take. It is intended to help trainees show they are competent in managing the Acute Medical Take by assessing performance in areas such as prioritisation, communication, teamwork, patient assessment and decision-making over the course of a take period.
Audit Assessment
The Audit Assessment is designed to assess a trainee’s ability to conduct an audit by reviewing, against agreed criteria, an audit which the trainee has carried out.
Patient Survey
The Patient Survey is a method of giving patients the opportunity to give feedback on the performance of a doctor following an out-patient consultation. A number of patients are invited to provide feedback to build up a picture of a doctor’s performance in areas such as communication and professionalism.
Teaching Observation
The Teaching Observation is designed to provide a framework for assessors to provide structured feedback to a trainee. It is a formative tool only and does not have a numerical rating scale.
Local study set up
We will try to include all medical specialties and all regions of the UK in the pilot. For each specialty and participating hospital/centre there will be a nominated consultant in charge who will be the Local Study Coordinator. The Local Study Coordinator will be responsible for recruiting trainees, informing potential assessors (e.g. consultants, associate specialists, senior trainees) and distributing initial paperwork. Educational Supervisors will be asked to participate in order to provide feedback to the trainee on the Patient Survey outcome. Clearly in small units the Local Study Coordinator, Educational Supervisor and Assessor may often be the same person.
The Local Study Coordinator will give participating trainees a code, so that they remain anonymous to the College. They will then distribute information and paperwork to the trainees – this will also be available to download from www.jrcptb.org.uk. All participants will receive a detailed study handbook.
The trainees will be responsible for initiating all assessments, ensuring all paperwork is completed and returned to the Local Study Coordinator. The Local Study Coordinator will return any completed paperwork to the College in self-addressed/stamped envelopes (SAEs). They will also be the point of contact for the College in the event of any problems, incomplete or unreturned documents. The process for managing the Patient Survey will be different but the details of this are still to be defined.
Timescale
We are aiming to start the pilot in April 2008 and to allow 6 months for the completion of the assessments. We will then report findings in winter 2008/9.
Contact
For more information or to take part in the pilot contact:
Joe Booth
Education Projects Manager
Education Department
Royal College of Physicians
London NW1 4LE
joe.booth@rcplondon.ac.uk
020 7935 1174 xtn 541
RECENT PUBLICATIONS FROM THE NORTHEAST
1. Komajda M, Curtis P, Hanefeld M, Beck-Nielsen H, Pocock SJ, Zambanini A, Jones NP, Gomis R, Home PD, for The RECORD Study Group. Effect of the addition of rosiglitazone to metformin or sulfonylureas versus metformin/sulfonylurea combination therapy on ambulatory blood pressure in people with type 2 diabetes: a randomized controlled trial (the RECORD study). Cardiovascular Diabetology 2008; 7:10. doi:10.1186/1475-2840-7-10
2. McMillan C, Bradley C, Razvi S, Weaver J. Evaluation of new measures of the impact of hypothyroidism on quality of life and symptoms: the ThyDQoL and ThySRQ. Value Health. 2008 Mar-Apr;11(2):285-94.
3. Leontiou CA, Gueorguiev M, van der Spuy J, Quinton R, Lolli F, Hassan S, Chahal HS, Igreja SC, Jordan S, Rowe J, Stolbrink M, Christian HC, Wray J, Bishop-Bailey D, Berney DM, Wass JA, Popovic V, Ribeiro-Oliveira A Jr, Gadelha MR, Monson JP, Akker SA, Davis JR, Clayton RN, Yoshimoto K, Iwata T, Matsuno A, Eguchi K, Musat M, Flanagan D, Peters G, Bolger GB, Chapple JP, Frohman LA, Grossman AB, Korbonits M. THE ROLE OF THE AIP GENE IN FAMILIAL AND SPORADIC PITUITARY ADENOMAS. J Clin Endocrinol Metab. 2008 Apr 17. [Epub ahead of print]
4. Al-Ozairi E, Quinton R, Advani A.Therapeutic response to metformin in an underweight patient with polycystic ovarian syndrome.Fertil Steril. 2008 Jan 25. [Epub ahead of print]PMID: 18222436 [PubMed - as supplied by publisher]
5. Vaikkakara S, Al-Ozairi E, Lim E, Advani A, Ball SG, James RA, Quinton R. The investigation and management of severe hyperandrogenism pre- and postmenopause: non-tumor disease is strongly associated with metabolic syndrome and typically responds to insulin-sensitization with metformin. Gynecol Endocrinol. 2008 Feb;24(2):87-92.
6. Syed AA, Quinton R. Congenital radioulnar synostosis, azoospermia, and pseudodicentric Y chromosome. Fertil Steril. 2008 Jan 2. [Epub ahead of print]
7. Al-Ozairi E, Michael E, Quinton R. Insulin resistance causing severe postmenopausal hyperandrogenism. Int J Gynaecol Obstet. 2008 Mar;100(3):280-1. Epub 2007 Nov 19. No abstract available.
8. Young JM, Strey CH, George PM, Florkowski CM, Sies CW, Frampton CM, Scott RS. Effect of atorvastatin on plasma levels of asymmetric dimethylarginine in patients with non-ischaemic heart failure. Eur J Heart Fail. 2008 May;10(5):463-6. Epub 2008 Apr 21.
RECENT PUBLICATIONS IN DIABETES & ENDOCRINOLOGY THAT HIT THE NEWS OR THAT MAY HAVE A SIGNIFICANT IMPACT ON MANAGEMENT
Diabetes in Pregnancy. Nice Clinical guideline 63. www.nice.org.uk. An essential read that brings together a number strands into succinct guidance that all services should use to review their practice. Of course there is controversy! Why go for 1 hour post-prandial monitoring and move away from the standard 2-hour post prandial monitoring? Why abandon the OGTT for post-natal screening? Read the following articles in the BMJ for an excellent overview on commentary on these guidelines: BMJ 2008;336:714-717 & BMJ 2008;336:717-718.
Careers in Diabetes and endocrinology. J Mettayil, R Quinton, S Wahid. BMJ Careers 1st March 2008, page 79. See BMJ vol 336 BMJ careers section. An interesting read and to be used as a recruitment tool.
Non-peptide arginine-vasopressin antagonists:the vaptans. Decauex G, et al. Lancet 2008;371:1624-1632. An excellent article summarising the basic science and trial evidence behind this new exciting class of drugs.
Osteoporosis in men. Peter Ebeling. NEJM 2008;358:1474-1482. An excellent clinical review well worth a read.
Non-surgical management of obesity in adults. Robert Eckel. NEJM 2008;358:1941-1950. An excellent practical review.
Assessment and management of medically unexplained symptoms. Hatcher S, Arroll B. BMJ 2008;336:1124-1128. A wonderful article that provides structure for managing this challenging group of patients.
Decision time for pancreatic islet-cell transplantation. Ruggenenti et al. The Lancet 2008;371:883-884. A thought provoking editorial well worth a read.
Should we dump the metabolic syndrome? Edwin Gale vs George Alberti and Paul Zimmet. BMJ 2008;336: 640-641. A wonderful debate, which still leaves me sceptical about the value of labelling some one as having the metabolic syndrome. But then others may well be on the other side.
Hyperthyroidism and pregnancy. Marx et al. BMJ 2008;336:663-666. An excellent clinical overview.
Lifelong learning at work. PW Teunissen and T Dornan. BMJ 2008;336:667-669. A wonderful read and an article I plan to hand out to all of the trainees I personally supervise.Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial. Davies MJ, et al. BMJ. 2008 Mar 1;336(7642):491-5. This Multicentre cluster randomized controlled trial in primary care (207 general practices in 13 primary care sites in the United Kingdom), randomized 824 adults (55% men, mean age 59.5 yrs) into either a structured group education programme for six hours delivered in the community by two trained healthcare professional educators or into usual care. After 12 months HbA1c levels had decreased by 1.49% in the intervention group compared with 1.21% in the control group. After adjusting for baseline and cluster, the difference was not significant: 0.05% (95% confidence interval -0.10% to 0.20%). The intervention group showed a greater weight loss: -2.98 kg (-3.54 to -2.41) compared with 1.86 kg (-2.44 to -1.28), P=0.027 at 12 months. The odds of not smoking were 3.56 (1.11 to 11.45), P=0.033 higher in the intervention group at 12 months. The intervention group showed significantly greater changes in illness belief scores (P=0.001); directions of change were positive indicating greater understanding of diabetes. The intervention group had a lower depression score at 12 months: mean difference was -0.50 (95% confidence interval -0.96 to -0.04); P=0.032. A positive association was found between change in perceived personal responsibility and weight loss at 12 months (P=0.008). The authors conclude that a structured group education programme for patients with newly diagnosed type 2 diabetes resulted in greater improvements in weight loss and smoking cessation and positive improvements in beliefs about illness but no difference in HbA1c levels up to 12 months after diagnosis. The accompanying editorial (BMJ 2008;336:459-460) is well worth a read.
Mutations in the iodotyrosine deiodinase gene and hypothyroidism. Moreno JC, et al. N Engl J Med. 2008 Apr 24;358(17):1811-8. DEHAL1 has been identified as the gene encoding iodotyrosine deiodinase in the thyroid, where it controls the reuse of iodide for thyroid hormone synthesis. The authors screened patients with hypothyroidism who had features suggestive of an iodotyrosine deiodinase defect for mutations in DEHAL1. Two missense mutations and a deletion of three base pairs were identified in four patients from three unrelated families; all the patients had a dramatic reduction of in vitro activity of iodotyrosine deiodinase. Patients had severe goitrous hypothyroidism, which was evident in infancy and childhood. Two patients had cognitive deficits due to late diagnosis and treatment. Thus, mutations in DEHAL1 led to a deficiency in iodotyrosine deiodinase in these patients. The significance of the study is that because infants with DEHAL1 defects may have normal thyroid function at birth, neonatal screening programs for congenital hypothyroidism might miss them. An excellent editorial by Peter Kopp (NEJM 2008;358:1856-1859) rounds off this article as a learning experience.Hyperglycemia and adverse pregnancy outcomes (HAPO). Metzger BE,et al. N Engl J Med. 2008 May 8;358(19):1991-2002. A total of 25,505 pregnant women at 15 centres in nine countries underwent 75-g oral glucose-tolerance testing at 24 to 32 weeks of gestation. Data remained blinded if the fasting plasma glucose level was 5.8 mmol/l or less and the 2-hour plasma glucose level was 11.1 mmol/l or less. For the 23,316 participants with blinded data, the adjusted odds ratios for adverse pregnancy outcomes associated with an increase in the fasting plasma glucose level of 1 SD (0.4 mmol/l), an increase in the 1-hour plasma glucose level of 1 SD (1.7 mmol/l), and an increase in the 2-hour plasma glucose level of 1 SD (1.3 mmol/l) were calculated. For birth weight above the 90th percentile, the odds ratios were 1.38 (95% confidence interval [CI], 1.32 to 1.44), 1.46 (1.39 to 1.53), and 1.38 (1.32 to 1.44), respectively; for cord-blood serum C-peptide level above the 90th percentile, 1.55 (95% CI, 1.47 to 1.64), 1.46 (1.38 to 1.54), and 1.37 (1.30 to 1.44); for primary caesarean delivery, 1.11 (95% CI, 1.06 to 1.15), 1.10 (1.06 to 1.15), and 1.08 (1.03 to 1.12); and for neonatal hypoglycaemia, 1.08 (95% CI, 0.98 to 1.19), 1.13 (1.03 to 1.26), and 1.10 (1.00 to 1.12). There were no obvious thresholds at which risks increased. These results indicate a strong, continuous association of maternal glucose levels below those diagnostic of diabetes with increased birth weight and increased cord-blood serum C-peptide levels (a proxy marker of foetal insulin resistance, with a higher level suggesting high foetal insulin levels). At South Tyneside we treat any 2 hour blood glucose post OGTT of 7.8-11.o mmol/l as GDM. Does HAPO change that. NO! It adds strength to it as a value and shifting the value lower than this is really not cost effective as argued by Jeffrey Ecker and Michael Greene in the accompanying editorial (NEJM 2008;358:2061-2063). However, does HAPO mean that we should screen all women for GDM instead of selective screening as most units do and recommended by NICE? Given that there is a continuum of risk with glucose it is attractive to suggest blanket screening, however again the cost-effectiveness of such an approach would nee careful examination.Metformin versus insulin for the treatment of gestational diabetes. Rowan JA,et al. N Engl J Med. 2008 May 8;358(19):2003-15. Metformin has been recommended by NICE as option to treat hyperglycaemia in GDM along with glibenclamide or insulin, hence this trial is timely. 751 women with gestational diabetes mellitus at 20 to 33 weeks of gestation were randomly assigned to open treatment with metformin (with supplemental insulin if required) or insulin. The primary outcome was a composite of neonatal hypoglycaemia, respiratory distress, need for phototherapy, birth trauma, 5-minute Apgar score less than 7, or prematurity. Secondary outcomes included neonatal anthropometric measurements, maternal glycaemic control, maternal hypertensive complications, postpartumglucose tolerance, and acceptability of treatment. Of the 363 women assigned to metformin, 92.6% continued to receive metformin until delivery and 46.3% received supplemental insulin. The rate of the primary composite outcome was 32.0% in the group assigned to metformin and 32.2% in the insulin group(relative risk, 1.00; 95% confidence interval, 0.90 to 1.10). More women in the metformin group than in the insulin group stated that they would choose to receive their assigned treatment again (76.6% vs. 27.2%, P<0.001). The rates of other secondary outcomes did not differ significantly between the groups. There were no serious adverse events associated with the use of metformin. This trial has shown that in women with gestational diabetes mellitus, metformin (alone or with supplemental insulin) is not associated with increased perinatal complications as compared with insulin and that not surprisingly metformin was preferred to insulin. Once-daily basal insulin glargine versus thrice-daily prandial insulin lispro in people with type 2 diabetes on oral hypoglycaemic agents(APOLLO): an open randomised controlled trial. Bretzel RG,et al. Lancet. 2008 Mar 29;371(9618):1073-84.In this 44-week, parallel, open study 418 patients with type 2 diabetes mellitus inadequately controlled by oral hypoglycaemic agents were randomly assigned to either once-daily insulin glargine taken at the same time every day or to insulin lispro administered three times per day with meals. 205 patients were randomly assigned to insulin glargine and 210 to insulin lispro. Mean HbA1c decrease in the insulin glargine group was -1.7% (from 8.7% [SD 1.0] to 7.0% [0.7]) and -1.9% in the insulin lispro group (from 8.7% [1.0] to 6.8% [0.9], a mean difference of 0.157 (95% CI -0.008 to 0.322). 57% patients reached HbA1c of 7% or less in the glargine group and 69% in the lispro group. In the glargine group, the fall in mean fasting blood glucose (-4.3 [SD 2.3] mmol/L vs -1.8 [2.3] mmol/L; p<0.0001) and nocturnal blood glucose (-3.3[2.8] mmol/L vs -2.6 [2.9] mmol/L; p=0.0041) was better than it was in the insulin lispro group, whereas insulin lispro better controlled postprandial blood glucose throughout the day (p<0.0001). The incidence of hypoglycaemic events was less with insulin glargine than with lispro (5.2 [95% CI 1.9-8.9] vs 24.0 [21-28] events per patient per year; p<0.0001). Respective mean weight gains were 3.01 (SD 4.33) kg and 3.54 (4.48) kg. The improvement of treatment satisfaction was greater for insulin glargine than for insulin lispro (mean difference 3.13; 95% CI 2.04-4.22). The authors conclude that insulin glargine provides a simple and effective option that is more satisfactory to patients than is lispro for early initiation of insulin therapy, since it was associated with a lower risk of hypoglycaemia, fewer injections, less blood glucose self monitoring, and greater patient satisfaction than was insulin lispro. Does this trial change my approach. No! I (Shaz) still individualise therapy. Once daily insulin may be better for certain patients, but in my experience the majority end up on more doses. Given the resource implications in my local district I prefer the once-two-three mixed insulin approach with metformin if tolerated. I try to emphasize approaches to reduce weight gain as well. Furthermore, the availability of exenatide adds more to the armourmentarium. The current therapies available for type 2 diabetes remind me a lot of the promulgumation of therapies available for chronic heart failure overnight, resulting in “heart failure nurses”. The difference in diabetes is that not one glove fits all and it is not all about titrating up the dose or adding more therapies. We have a major psychological barrier to mange in terms of weight and physical activity. Simvastatin with or without ezetimibe in familial hypercholesterolemia. Kastelein JJ,et al. N Engl J Med. 2008 Apr 3;358(14):1431-43. This double-blind, randomised, 24-month trial compared the effects of daily therapy with 80 mg of simvastatin either with placebo or with 10 mg of ezetimibe in 720 patients with familial hypercholesterolaemia. Patients underwent B mode ultrasonography to assess the intima-media thickness of the walls of the carotid and femoral arteries. The primary outcome measure was the change in the mean carotid-artery intima-media thickness. The primary outcome, the mean (SE) change in the carotid-artery intima-media thickness, was 0.0058(0.0037)mm in the simvastatin-only group and 0.0111(0.0038)mm in the combined-therapy group (P=0.29). At the end of the study, the mean (+/-SD) LDL cholesterol level was 4.98(1.56)mmol/l in the simvastatin group and 3.65(1.36)mmol/l in the combined-therapy group (a between-group difference of 16.5%, P<0.01). The differences between the two groups in reductions in levels of triglycerides and C-reactive protein were 6.6% and 25.7%, respectively, with greater reductions in the combined-therapy group (P<0.01 for both comparisons). Side-effect and safety profiles were similar in the two groups. In conclusion, in patients with familial hypercholesterolaemia, combined therapy with ezetimibe and simvastatin did not result in a significant difference in changes in intima-media thickness, as compared with simvastatin alone, despite decreases in levels of LDL cholesterol and C-reactive protein. A very interesting study with a surprising result. The accompanying editorials (Brown GB, Taylor AJ NEJM 2008;358:1504-1507 & Drazen JM et al NEJM 2008;358:1507-1508) are well worth a read as they try to pick through possible reasons for this surprising result.
NEXT NEWSLETTER Due out beginning of October 2008 so keep the gossip coming.
POSTED BY ARUTCHELVAM AT 10:51 PM
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