Tuesday, May 22, 2007

Endodiabology 2007; Issue 2 (June)



JUNE 2007

Editors: Shaz Wahid and Petros Perros
Associate Editors: Freda Razvi, Akheel Syed, Arut Vijayaraman and Ebaa Al-Ozairi

SPR PLACEMENTS (NTN year of training from 1st October 2006)

RVI - Beas Bhatacharya (4), Ravikumar Balasubramanian (3), Sukesh Chandran(3), Subir Ray (3), Ebaa Al-Ozairi (5)
Freeman- Akheel Syed(4),
Muthu Jayapaul(4), Khaled Mansur-Dukhan (3)
North Tyneside/Wansbeck- LAS
/Preeti Rao
South Tyneside-
Salman Razvi (5)
Reena Thomas (5)
Peter Carey(5), Chris Rizzo
North Tees/Hartlepool- Ravi Erukalapati(2)/
Sony Anthony(5)
Middlesbrough- Jeevan Metafile (2), Shafer Kamarrudin (1), Srikanth Mada

Carlisle- Kerry Livingstone (1)
Bishop Auckland / Durham-
LAS/ Asgar Madathil (3)
Research with numbers (supervisor)-
Andrew Advani (4-Toronto), Chandima Idampitiya (2-Srilanka), Arutchelvan Vijayaraman (3-Prof Home), Eelin Lim(4-Prof Taylor)


2nd-5th June 2007 ENDO 2007, Toronto, Canada. Contact ENDO email or ENDO website
12th June 2007 Joint Trainers and Trainees meeting, Board room, 1730-1900, Medical School. Contact
Shaz Wahid
15th June 2007 Recent Advances in Medicine Symposium, North Tees. Contact Sue Dent, Postgrad Centre Manager, University Hospital of North Tees.

22nd-26th June 2007 American Diabetes Association 67th Annual Scientific Sessions, Chicago, USA. Contact ADA email
2nd July 2007 National Training Scheme for the use of thyroid ultrasound by Endocrinologists and other Specialists in Thyroid Disease, London. Contact
Joan Munt
Friday 6th July 2007 1430 Association of Physicians meeting, James Cook University Hospital. Contact Clive Kelly
9th July 2007 GIM training ½ day, Freeman Hospital. Contact
Lorraine Waugh 0191 223 1247
17th-21st September 2007 43rd EASD Annual meeting, Amsterdam. Contact EASD website
19th September 2007 GIM training ½ day, Freeman Hospital. Contact
Lorraine Waugh 0191 223 1247
8th October 2007 Northern Endocrine & Diabetes Autumn CME, James Cook University Hospital. Contacts Reena Thomas or Arut
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, ABCD website
5th-7th November 2007 Society for Endocrinology Clinical Update 2007, Manchester. Contact Society for Endocrinology website
21st November 2007 GIM training ½ day, Freeman Hospital. Contact
Lorraine Waugh 0191 223 1247
28th November 2007 Northern Endocrine Region Research and Audit Group annual meeting, Lumley Castle, Durham 2pm-8pm. Contact
Shaz Wahid
4th December 2007 RCP Update in Medicine, Freeman Hospital. Contact
Lorraine Waugh 0191 223 1247


Joint Trainers & Trainees meeting The annual T&T meeting will be held on Tuesday 12th June 2006 1715hrs Board Room Newcastle Medical School.

DIABETES & ENDOCRINOLOGY PIMD WEBSITE Our specialty website has been redesigned and is now available on PIMD website . 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 (even LATs) register with the PMETB through the newly created Joint Royal Colleges of Physicians Training Board (formally the JCHMT) on JRCPTB website although it is still possible to link with this site using the old JCHMT website 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 JRCPTB website. 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.

Mini-CEX documentation When undertaking a Mini-CEX retain 1 copy for yourself, give 1 copy to your Mini-CEX supervisor and have 1 copy available for the RITA panel. The Programme Director will retain this copy for the PIMD. Make sure that a Mini-CEX RITA summary is also completed for your RITA. MSF documentation It is essential that the SpR does not see any original MSF forms from individuals as it is an anonymous exercise. Make sure that the official MSF RITA summary form is completed and 1 copy made available for the RITA panel. This will be retained by the Programme Director.

Taught Programme Following guidance from PMETB having a taught specialty programme will be one of the quality indicators of any training programme. The STC plan the following:

-Formally recognise the annual NERRAG meeting and the bi-annual Diabetes Audit Group meetings as part of the taught programme in the region alongside the 3 annual days of the NED CME programme. This will require the STC to keep records of the programme and the register and allocate a mandatory 75% attendance record for the year for all SpRs at their RITAs. The Programme Director has agreement from the meeting organisers after talking to Narayanan and himself!

-After much debate the STC have agreed to introduce mandatory essay writing. The provisional plans are that every June, 4 compulsory and 1 optional essays based on the core Diabetes and Endocrine topics will be circulated amongst SpRs and made compulsory for all SpRs who have not had a PYA at the RITAs in May or are not in their final year. Essays 1 and 2 should be returned to the relevant markers by 1st December 2007 and Essays 3 and 4 to the relevant markers by 1st March 2008. Once marked the essays will be returned with either of the following Grades:

A - excellent. SpR demonstrates wider reading with an understanding and interpretation of the evidence base. There is also an understanding of the degree of variability when it comes to clinical practice due to individual pt variance. The theory is completely stated in the SpRs answers.

B - good. The theory is completely stated in the SpRs answers with some demonstration of wider reading, but not fully interpreted. Also, no real indication was given in the answers as to patient variability when it comes to management.

C - satisfactory. The key theory is completely stated in the SpRs answers in rather “text-bookish” style with very little evidence of wider reading and little attempt at interpretation of the evidence base.

D - needs attention. Key theory is missing from the SpRs answers with no demonstrable evidence of wider reading or interpretation of the evidence base.

E - FAIL. No attention has been given to key theory and the basics are dangerously incorrect. The latter could result in unsatisfactory clinical practice.

As well as the grade the marker will provide a short comment as to what improvements could be made. Any SpR scoring a C or D will have their answers reviewed by the TPD or STC chair or RSA, and a separate meeting organised with the TPD. Also, if they have not already done so they will be asked to submit the optional essay. The essays should be made available for the RITAs in May.

This process will provide a structured tool to aid SpR learning whilst at the same time allowing assessment and the use of targeted remedial supervision. It will also be less labour intensive for the already stretched fraternity of trainers. For the moment the plan is for the markers to be taken from the Consultants on the STC. More details will be presented at the joint T&T meeting on 12th June 2007.

Self-assessment is a powerful learning tool for individuals. The STC are developing a 50-question set of MCQs, based on a best of 3-answer, that will be circulated to trainees every October and the answers will be circulated every April for individuals to score themselves. They will also be posted on the specialty website. Consultants are welcome to participate! More details will be presented at the joint T&T meeting on 12th June 2007.

Consultant Member on STC A vacancy has arisen on the STC. We are looking for at least to fill this vacancy in the Consultant membership on the STC but would welcome expansion as well. Trainers who are interested please discuss with Shaz Wahid.

Laboratory Training Following the SpR feedback, the STC will be preparing guidance for training units and SpRs on the minimum training to be provided in relation to this important subject. More details will be presented at the joint T&T meeting on 12th June 2007.

Training Committee Chair – Jola Weaver; Regional Speciality Advisor – Richard Quinton; Programme Director – Shaz Wahid ; Consultant members – Jean Macleod, Simon Pearce (Research Advisor) & Simon Eaton; SpR representatives – Arutchelvam Vijayaraman & Andrew Advani

We were hoping to let you know of some new faces with NTNs, but MTAS has put paid to that!

Ibrahim is undertaking a period of acting-up followed by the locum post at University Hospital of North Durham.
Eric Sanders at Durham has retired.
Ronan Canavan has left to take up a new post at Dublin. He will be sore miss on the STC.
Costas Oxynos at QEH will be leaving soon to a new job in Cyprus.
Congratulations to Professor Home on being asked to be Chair of the Scientific Programme Committee of the IDF World Diabetes Congress, Montreal, 2009. He also recently met Bill Clinton and has the picture as a reminder! This was at the the Global Diabetes Leadership meeting in New York on 13 March 2007 following an invitation from the International Diabetes Federation. He also passes on the next 3 bits of news/gossip.
Robert Heine, research fellow in Newcastle in the early 1980's, is to be the next President of the EASD.
Jean Claude Mbanya, research fellow in Newcastle in the mid 1980's, is President elect of the IDF (President 2009-2012).
Massimo Massi-Benedetti, and Kaushik Ramaiya, research fellows here in the early and mid-1980's respectively were elected Vice-presidents of IDF at the Cape Town World Diabetes Congress.
Congratulations to Stuart Bennett and family on the birth of baby Rachel in February.
Professor Mark Walker has updated us on the Warren 2 initiative to identify novel type 2 diabetes genes with which Newcastle and the North East helped “this has come to fruitition as you'll see from the recent publications in Science cited below”. “You can see that this was very much a team effort-its very gratifying that we were involved and contributed to the success!”
Our grateful thanks to Professor Roy Taylor (and his PA Beverly Hailstone) for a job well done as secretary of the Association of Physicians for the past 14-years. Clive Kelly has taken his place.
Arut has joined the ENDODIABOLOGY editorial team and will work with Akheel as Web Editor in preparation
for Akheel’s departure in Feb 2008.
Well done to Salman, Jola and Simon Pearce on having an oral presentation at the Endocrine Society Conference in Toronto titled “Subclinical hypothyroidism is associated with increased cardiovascular risk- a meta-analysis”. Very prestigious, as it has been identified as being newsworthy and singled out for special media attention in the annual Research Summaries Book (RSB). The Society has also awarded a travel grant award towards the cost of attending the conference.

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.

MTAS-A Programme Director’s Perspective “Shaz Wahid”
For about 12-months I have been preparing for MTAS! With the on-going judicial review one wonders whether I should be writing this article or indeed whether I should get myself a good solicitor. I always envisaged there would be problems with this “centralised” recruitment & selection “machine” designed for the new ST3 posts and above. Computers! You hate them but you can not live without them. My concerns have been the loss of flexibility in “getting” the right job, the thought that we already had a well oiled machine in the PIMD (!), the impact of the new immigration regulations on international graduates and the need for another culture change on top of what was already happening in the NHS. Medicine has always been competitive, and often one treaded water in a post until you got the right job. Therefore, it is not surprising a large number of folk did not get short-listed for the post they wanted. Now we have the mad rush of getting people a “job” but not necessarily the “right job”. From a personal perspective I believe that short listing “worked” in our specialty because the candidates we had in the first interview were very strong and the second interviews arranged after National directives did not produce any change to the top 7 order ranking in the original list. 2 candidates made the appointable list as a N
TN one of whom narrowly missed out on short-listing originally because of lack of interview places and 1 candidate changed his preferences with the new “rules”. From the grapevine the same can be said of other specialties recruiting to ST3, but the issues in ST 1 and 2 remain. Of course it has not all been rosy. I have sent a list of improvements needed to the PIMD, e.g. more space on the MTAS scoring sheets so that 2 short listers did not have to spend another 40 hours between them short listing, more credit for academia on the application, more credit for “initiative skills” on the application, a clear indication of previous posts to name but a few. Oh and it would help if the applications were NEVER scrambled! I would not change anything about the interviews as our methods which we “piloted” in the first interviews clearly discriminated between candidates and also provide a paper trail for audit and the Lawyers! In fact we did not have a single tie place in any candidates. Throughout all the frustrations vented in thousands of e-mails and plenty of articles sent to the medical and non-medical press I resisted the urge of joining the Birmingham 6 by resigning from the whole process and thankfully so did the rest of the appointments panel to whom I am very grateful. Not because I was so embroiled in the process or that I had a contractual obligation, but because I believed in the principle of “first do no harm”. I am not paid by the PIMD, hence I could easily have walked away and as a result helped demonstrate the inadequacies of the process. But, I believed this would have been unfair on 2 main groups of trainees. Firstly those already short-listed and due to attend would have had a rough deal, and I feel vindicated having viewed their “qualities” at interview. Secondly, those trainees already on the rotation would not have had a RITA stalling their training progression. Having said this, recent revelations about personal details of applicants being open to general perusal including sexual orientation (which incidentally I can not see how this could inform the recruitment process) have seriously tested my patience. Updating this, the plug has been pulled on MTAS with a rather generic solution suggested. The one thing that has not changed is that there will still be a large number of folk not getting into ST3 and for our region I can not see a round 2 interview happening now other than recruiting LATs. Hopefully, REMEDY UKs actions will allow us to wrest some control from the DOH and “educationalists” allowing a proper design of R&S in relation to training.

Software review: Posteriza poster printing freeware – Akheel Syed
Printing full size quality posters for conferences and meetings has always been an expensive proposition, particularly within today’s constrained training budgets. It needn’t be so. Posteriza is a free poster printing program for creating poster or banner size prints from digital images. The program slices the images into multiple parts to fit into a number of regular size pages (A4, A3, letter, etc.), which can then be printed with an ordinary printer. The printed pages automatically include margins to overlap each other, enabling easy assembly into the full size poster by gluing the pages together. The program includes further refinements such as adding up to 4 lines of text, as well as inserting a frame to enhance the looks. It is easy to use, and you can create regular size posters, wall posters or anything in between that can be previewed before printing.
The program is free to use and available for download from Posteriza.com. It does not require installation. Simply save the file (700KB) on your hard drive and open to start the program. Posteriza requires digital image files for poster printing. Create your poster in PowerPoint or Presentation in the usual way (for tips and sample templates, see Newcastle University AV Services and save as image file: File → Save As → scroll down and select an image format such as JPEG, BMP, etc. – for Windows users I would recommend Enhanced Windows Metafile (*.emf). This image file can then be used in Posteriza for printing the full size poster.

Endodiabology on the web – Akheel Syed
Endodiabology has been live on the web since October 2005, with archive copies dating back to February 2004 (Endodiabology Archive), and I thought a few words of reflection were in order. The web editions were first set up with the express purpose of enabling the posting of the triennial newsletter, information of interest, sharing of ideas, and to serve as an informal portal of communication for trainees and trainers in Diabetes and Endocrinology in the North-East. Since May 2006, communications relating to training matters that needed to be advertised sooner than the next available scheduled issue of the flagship newsletter have been posted on Endodiabology Other Communications. The three linked blog sites have grown over the months – not just in content, but I hope in the quality of the user-experience as well.
Endodiabology hosts links to Endodiabology Other Communications and archived issues on Endodiabology Archive, Google Maps of hospitals on the rotation, and a variety of online resources including PubMed, Endotext.org, eGFR calculator, medical journals, learned societies, travel and conveniences, news channels and useful software. All content in Endodiabology Archive and Endodiabology Other Communications is permanently archived and fully searchable – the blog page has its own integrated search box on the top left-hand corner and a Google search box in the right-hand pane; you can also use blog search engines such as Google Blog Search. There is facility for setting up email alerts to new content on all three sites.

Who uses Endodiabology on the web? Many in the region apparently do, and for various reasons – reading the newsletter, looking up advertised educational programmes and for the links to web resources. Many from outside the region also do –testimony to the fact that this is perhaps the only online site that has a wealth of information on training matters in Diabetes and Endocrinology in the UK. Surprisingly, or perhaps not so surprisingly, the three sites also attract a considerable amount of worldwide traffic (Figure). The content is also mined by various search engines, patient and pressure groups, and online communities.

Figure 1: Endodiabology receives hits from all over the globe every day (Source: Google Analytics).

What is it like blogging for Endodiabology? For me personally it has been an enjoyable and rewarding experience. The popularity of the websites may be one measure of success; mention in the BMJ may be another. But it’s the feedback from you, our readers, that is most highly valued – your suggestions have continually helped shape the web editions. None of this would have been possible without the vision and enthusiasm of the senior editors – the web pages are but the pretty face of their behind-the-scenes hard work.

Have a good read!

Please send us your recent publication for inclusion in the next newsletter.

Khatami Z, Handley G, Narayanan K, Weaver JU. Applicability of estimated glomerular filtration rate in stratifying chronic kidney disease. Scand J Clin Lab Invest 2007;67(3):297-305.
Pitteloud N,
Quinton R, Pearce S, Raivio T, Acierno J, Dwyer A, Plummer L, Hughes V, Seminara S, Cheng YZ, Li WP, Maccoll G, Eliseenkova AV, Olsen SK, Ibrahimi OA, Hayes FJ, Boepple P, Hall JE, Bouloux P, Mohammadi M, Crowley W. Digenic mutations account for variable phenotypes in idiopathic hypogonadotropic hypogonadism. J Clin Invest. 2007 Feb;117(2):457-63.
Sanders J, Harris J, Cooper J, Gohlke P, Humphries SE, Montgomery H, Woods DR. Lack of change in serum angiotensin-converting enzyme activity during the menstrual cycle.J Renin Angiotensin Aldosterone Syst. 2006 Dec;7(4):231-5.
Dr Woods: The skeletal muscle RAS in health and disease “Frontiers in Research of the Renin-angiotensin System on Human Disease”.
In: Proteases in Biology and Disease Book Series, Volume 7, 2007, Springer, New York, United States of America.
McMillan C, Bradley C, Razvi S, Weaver J. Psychometric evaluation of a new questionnaire measuring treatment satisfaction in hypothyroidism: the ThyTSQ. Value Health 2006;9(2):132-9.
Razvi S, Ingoe L, Keeka G, Oates C, McMillan C, Weaver J. The beneficial effect of L-thyroxine on cardiovascular risk factors, endothelial function and quality of life in subclinical hypothyroidism: randomised, crossover trial. J Clin Endocrinol Metab 2007;ahead of print publication.
Frayling TM, Timpson NJ, Weedon MN, Zeggini E, Freathy RM, Lindgren CM, Perry JRB, Elliott KS, Lango H, Rayner NW, Shields B, Harries LW, Barrett JC, Ellard S, Groves CJ, Knight B, Patch AM, Ness AR, Ebrahim S, Lawlor DA, Ring SM, Ben-Shlomo Y, Jarvelin MR, Sovio U, Bennett AJ, Melzer D, Ferrucci L, Loos RJF, Barroso I, Wareham NJ, Karpe F, Owen KR, Cardon LR, Walker M, Hitman GA, Palmer CAN, Doney ASF, Morris AD, Davey-Smith G, The Wellcome Trust Case Control Consortium, Hattersley AT, McCarthy MI: A common variant in the FTO gene is associated with body mass index and predisposes to childhood and adult obesity [article online], 2007. Available from Sciencexpress, www.sciencexpress.org published 12 April.

Zeggini E, Weedon MN, Lindgren CM, Frayling TM, Elliott KS, Lango H, Timpson NJ, Perry JRB, Rayner NW, Freathy RM, Barrett JC, Shields B, Morris AP, Ellard S, Groves CJ, Harries LW, Marchini JL, Owen KR, Knight B, Cardon LR, Walker M, Hitman GA, Morris AD, Doney ASF, The Wellcome Trust Case Control Consortium, McCarthy MI, Hattersley AT: Replication of genome-wide association signals in UK samples reveals risk loci for type 2 diabetes. [article online], 2007. Available from Sciencexpres, www.sciencexpress.org published 26 April.

Syed AA. The endocrine system at a glance. Diabet Med. 2007;24:104 2.
Syed AA. Minerva. BMJ 2006; 333:1278.
Razvi S & Perros P. A 52-Year-Old Female with a Hoarse Voice and Tingling in the Hand. PLoS Med. 2007 Mar 6;4(3):e29


NALP1 in vitiligo-associated multiple autoimmune disease. Jin Y, Mailloux CM, Gowan K, Riccardi SL, LaBerge G, Bennett DC, Fain PR, Spritz RA. N Engl J Med. 2007 Mar 22;356(12):1216-25. The authors searched for a gene on chromosome 17p13 that contributes to a group of epidemiologically associated autoimmune and autoinflammatory diseases. The group includes various combinations of generalized vitiligo, autoimmune thyroid disease, latent autoimmune diabetes in adults, rheumatoid arthritis, psoriasis, pernicious anaemia, systemic lupus erythematosus, and Addison's disease. The investigators tested 177 single-nucleotide polymorphisms (SNPs) spanning the 17p13 linkage peak for association with disease and identified a strong candidate gene. The DNA in and around the gene was sequenced to identify additional SNPs. A second round of tests of association using some of these additional SNPs was conducted, thus elucidating the association with disease in the gene and its extended promoter region in fine detail. The association analyses results identified NALP1as a candidate gene, which encodes NACHT leucine-rich-repeat protein 1, a regulator of the innate immune system. Fine-scale association mapping with the use of DNA from affected families and additional SNPs in and around NALP1 showed an association of specific variants with vitiligo alone, with an extended autoimmune and autoinflammatory disease phenotype, or with both. Conditional logistic-regression analysis of NALP1 SNPs indicated that at least two variants contribute independently to the risk of disease. The authors concluded that DNA sequence variants in the NALP1 region are associated with the risk of several epidemiologically associated autoimmune and autoinflammatory diseases, implicating the innate immune system in the pathogenesis of these disorders. Read the accompanying editorial by Peter Gregersen (NEJM 2007;356:1263-1266) for an excellent insight into the subject of modern genetics and its link to the innate immune system.

Clomiphene, metformin, or both for infertility in the polycystic ovary syndrome. Legro RS, Barnhart HX, Schlaff WD, Carr BR, et al. N Engl J Med. 2007 Feb 8;356(6):551-66. The authors randomly assigned 626 infertile women with the polycystic ovary syndrome to receive clomiphene citrate plus placebo, extended-release metformin plus placebo, or a combination of metformin and clomiphene for up to 6 months. Medication was discontinued when pregnancy was confirmed, and subjects were followed until delivery. The live-birth rate was 22.5% (47 of 209 subjects) in the clomiphene group, 7.2% (15 of 208) in the metformin group, and 26.8% (56 of 209) in the combination-therapy group (P<0.001 p="0.31" p="0.002)">

Mortality and target haemoglobin concentrations in anaemic patients with chronic kidney disease treated with erythropoietin: a meta-analysis. Phrommintikul A, Haas SJ, Elsik M, Krum H. Lancet. 2007 Feb 3;369(9559):381-8. Renal anaemia is something that is often managed in my own renal diabetes clinic, hence this study is very timely and eye opening. The authors aimed to determine whether targeting different haemoglobin concentrations with erythropoietin treatment is associated with altered all-cause mortality and cardiovascular events in patients with anaemia caused by chronic kidney disease. The authors conducted a meta-analysis of randomised controlled clinical trials that were identified in medical databases and trial registration websites. Trials were eligible for inclusion if they assessed the effects of targeting different haemoglobin concentrations in patients with anaemia caused by chronic disease that were randomly assigned to treatment with recombinant human erythropoietin, recruited at least 100 patients, and had a minimum follow-up of 12 weeks. Nine randomised controlled trials that enrolled 5143 patients were analysed. There was a significantly higher risk of all-cause mortality (risk ratio 1.17, 95% CI 1.01-1.35; p=0.031) and arteriovenous access thrombosis (1.34, 1.16-1.54; p=0.0001) in the higher haemoglobin target group than in the lower haemoglobin target group in the fixed effects model without heterogeneity between studies. There was a significantly higher risk of poorly controlled blood pressure (1.27, 1.08-1.50; p=0.004) in the higher haemoglobin target group than in the lower target haemoglobin group with the fixed effects model; however, this was not significant in the random effects model (1.31, 0.97-1.78; p=0.075). The incidence of myocardial infarction was much the same in the two groups. These results were interpreted to show that targeting higher haemoglobin concentrations when treating patients with anaemia caused by chronic kidney disease with recombinant human erythropoietin puts such patients at increased risk of death. Current guidelines do not include an upper limit for the target haemoglobin concentration; such an upper limit should be considered in future recommendations. A level of 10.5-11.5 is being considered.

Effects of antithyroid drugs on radioiodine treatment: systematic review and meta-analysis of randomised controlled trials. Walter MA, Briel M, Christ-Crain M et al. BMJ. 2007 Mar 10;334(7592):514. Epub 2007 Feb 19. This metanalysis aim was to determine the effect of adjunctive antithyroid drugs on the risk of treatment failure, hypothyroidism, and adverse events after radioiodine treatment. Electronic databases (Cochrane central register of controlled trials, Medline, Embase) were searched to August 2006 and contact with experts was undertaken. Three reviewers independently assessed trial eligibility and quality. Pooled relative risks for treatment failure and hypothyroidism after radioiodine treatment with and without adjunctive antithyroid drugs were calculated with a random effects model. The authors identified 14 relevant randomised controlled trials with a total of 1306 participants. Adjunctive antithyroid medication was associated with an increased risk of treatment failure (relative risk 1.28, 95% confidence interval 1.07 to 1.52; P=0.006) and a reduced risk for hypothyroidism (0.68, 0.53 to 0.87; P=0.006) after radioiodine treatment. There was no difference in summary estimates for the different antithyroid drugs or for whether antithyroid drugs were given before or after radioiodine treatment. The authors conclude that antithyroid drugs potentially increase rates of failure and reduce rates of hypothyroidism if they are given in the week before or after radioiodine treatment, respectively. The accompanying editorial by Anthony Toft (BMJ 2007;334:483-484) is worth a read oh and ever is controversial!

Interleukin-1-receptor antagonist in type 2 diabetes mellitus. Larsen CM, Faulenbach M, Vaag A, et al. N Engl J Med. 2007 Apr 12;356(15):1517-26. The expression of interleukin-1-receptor antagonist is reduced in pancreatic islets of patients with type 2 diabetes mellitus, and high glucose concentrations induce the production of interleukin-1beta in human pancreatic beta cells, leading to impaired insulin secretion, decreased cell proliferation, and apoptosis. The latter is more commonly known as glucotoxicity and in clinical practice reducing hyperglycaemia temporarily with intravenous insulin allows the successful institution of oral hypoglycaemic agents in patients with type 2 diabetes. In this double-blind, parallel-group trial involving 70patients with type 2 diabetes, 34 patients received 100 mg of anakinra (a recombinant human interleukin-1-receptor antagonist) subcutaneously once daily for 13 weeks and 36 patients received placebo. At baseline and at 13 weeks, all patients underwent an oral glucose-tolerance test, followed by an intravenous bolus of 0.3 g of glucose per kilogram of body weight, 0.5 mg of glucagon, and 5 g of arginine. In addition, 35 patients underwent a hyperinsulinemic-euglycemic clamp study. The primary end point was a change in the level of HbA1c, and secondary end points were changes in beta-cell function, insulin sensitivity, and inflammatory markers. At 13 weeks, in the anakinra group, the HbA1c level was 0.46% point lower than in the placebo group (P=0.03); C-peptide secretion was enhanced (P=0.05), and there were reductions in the ratio of proinsulin to insulin (P=0.005) and in levels of interleukin-6 (P<0.001) p="0.002).">

Diabetic Gastroparesis. Michael Camilleri. NEJM 2007;356:820-829. This is an excellent review on this difficult to treat complication of diabetes. Wee worth a read for all grades.

Inhaled insulin for Diabetes Mellitus. Graham McMahon & Ronal Arky. NEJM 2007;356;497-502. Wee worth a read for an update on this new therapy in conjunction with the NICE guidelines. Personally I have not used it yet!

The incidentally discovered adrenal mass. William Young. NEJM 2007;356:601-610. Worth a read for an update, although be warned it is heavily North American biased. Personally I go for an MRI as we can get is quickly and the Radiologists prefer it for the fat content imaging better than Hounsfield units, they say!

Intermittent Claudication. Christopher White. NEJM 2007;356:1241-1250. An excellent read providing good practical advice with an evidence base.

Wilson’s disease. Aftab Ala et al. Lancet 2007;369:397-408. I still find this an intriguing condition and this is a good update.

Clinical Update: the low-glycaemic-index-diet. David Ludwig. Lancet 2007;369:890-892. A truly excellent update and mandatory reading for SpRs.

STOP PRESS Nissen SE, Wolski K. Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes. NEJM 2007;356;www.nejm.org. Utilising data from 42 studies the authors found an odds ratio of rosiglitazone compared to placebo for MI of 1.43 (95%CI1.03-1.98, p=0.03) and death from CVD 1.64 (95%CI0.98-2.74, p=0.06). Despite obvious limitations in the study design there is food for thought. Not a good time for glitazones. With the osteoporoses data being so strong at South Tyneside local guidance is being formulated however we still feel the jury is out in relation to this trial. It would be interesting to see what a GPwSI would make of this! Still a role for specialists despite central dictat.

NEXT NEWSLETTER Due out beginning of October 2007 so keep the gossip coming.


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