Endodiabology October 2009
ENDODIABOLOGY
Endodiabology.blogspot.com
NORTHEAST
NEWSLETTER
FOR SPRs AND BOSSES TRAPPED
IN THE NORTHERN DEANERY
OCTOBER 2009
Editors: Shaz Wahid and
Petros Perros and Arut Vijayaraman
Associate Editors: Shafie Kamarrudin, Ravi Erukulapati
SpR PLACEMENTS (NTN year of training from 1st October 2008)
· Newcastle- Ravi Erukalapati(5), Sudeep Manohar (3), Nimanth De Alwis (1), Arif Ullah (3), Srikanth Mada(3) Naveen Siddaramaiha (2), Sarah Steven (2)
· North Tyneside/Wansbeck- Anjali Santhakumar (3), Kathryn Stewart (3)
· South Tyneside- Rohanna Wright (2),
· Gateshead- Preeti Rao (3)
· Sunderland- Beas Bhattacharya (5) then Naveen Aggarwal (1), Chandima Idampitiya (5)
· North Tees/Hartlepool- Shafie Kamarrudin (4), Hamza Ali Khan (1)
· Middlesbrough- Freda Razvi (5), Dr Munir (1), Sajid Ethol Kalathil (1), Catherine Napier (1)
· Carlisle-
· Bishop Auckland Khaled Mansur-Dukhan (5)
· Durham- Jeevan Mettayil (4)
· NGH/QEH- Vacant
· Research with numbers (supervisor)- Eelin Lim(5-Prof Taylor); Stuart Little (2-Dr Shaw) & Asgar Madathil (4-Dr Weaver)
MEETINGS / LECTURES / ANNOUNCEMENTS
· 12th October 2009 Northern Endocrine & Diabetes Autumn CME, JCUH, Middlesbrough
· 23rd October 2009 Diabetic Foot Teaching day-for medical and surgical trainees. Freeman Hospital
· 31st October 2009 Association of Physicians, Darlington Memorial Hospital.
· 2nd-4th November 2009 Society for Endocrinology Clinical Update 2009, Manchester. Contact www.endocrinology.org
· 2nd November 2009 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 3rd November 2009 RCPL Medicine Update, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 11th November 2009 North East Obesity Forum, 1600-1830, Newcastle University. Contact
· 19th November 2009 1st Joint Meeting of The British Thyroid Association and British Association Of Endocrine and Thyroid Surgeons, St Thomas Hospital. Contact www.british-thyroid-association.org
· 19th-20th November 2009 ABCD autumn meeting, London. Contact www.diabetologists.org.uk followed by SpRs meeting 21-22nd November 2009.
· 25th November 2009 Northern Endocrine Region Research and Audit Group annual meeting, Lumley Castle, Durham 2pm-8pm. Contact
· 26th & 27th November 2009 Middlesbrough insulin pump course. Contact
· 4th December 2009 Society for Endocrinology regional cases meeting, Edinburgh. Contact www.endocrinology.org
· 26th January 2010 Northern Endocrine & Diabetes Winter CME, Freeman Hospital. Contact
· 26th January 2010 Diabetes-A Hospital Perspective, RCPL. Contact conferences@rcp.ac.uk
· 23rd February 2010 SfE National Clinical Cases meeting, venue TBC. Contact www.endocrinology.org
· 3rd- 5th March 2010 DUK Annual Professional Conference, Liverpool. Contact www.diabetes.org.uk
· 15th – 18th March 2010 BES 2010, Manchester. Contact www.endocrinology.org.
· 28th April 2010 RCP Acute Medicine symposium, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
· 6th-7th May 2010 ABCD Spring Meeting, The Hilton, GATESHEAD. Contact www.diabetologists.org.uk
· 8th June 2010 Northern Endocrine & Diabetes Spring CME, Freeman Hospital. Contact mshafie_kamaruddin@yahoo.co.uk
· 19th – 22nd June 2010 ENDO 2010, San Diego, USA. Contact endostaff@endo-societ.org or www.endo-society.org/scimeetings .
· 25th – 29th June 2010 American Diabetes Association 70th Annual Scientific Sessions, Orlando, Florida, USA. Contact meetings@diabetes.org .
TRAINING ISSUES
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.
A new Trainee Rep With Arut now having his CCT AND Consultant post an opportunity for a new trainee rep has arisen on the STC. SEE OUR TPDs REGULAR LETTER BELOW.
A novel training opportunity Any one interested in working towards a diploma or MSc in Public Health? If yes, SEE OUR TPDs REGULAR LETTER BELOW.
More Consultant members If you would like to be involved with the STC please do contact Nicky Leech ASAP.
ARCP (RITA) The next round is due on Weds 12th, Thurs 13th & Fri 15th May 2010. Trainees please keep these dates free as possible.
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. 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. The e-portfolio for DM&ENDO is available now for StRs.
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.
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.
Case Based Discussions (CbD) The pilot form is available from the JRCPTB website. It is a must for trainers to use as a tool to document feedback in clinic. This has always been done informally, but now there is a method to formally document it. It can be used for when a SpR presents a new case in clinic.
Documenting CCU and ITU experience It is essential that trainees document their CCU and ITU experience. This is best done by keeping a summary log of the cases seen on CCU and ITU and linking it with reflection or assessment. This should then be signed off by your Educational Supervisor to be of any use at the Acute Medicine PYAs.
Audit Assessment tool This is now available in draft form on the JRCPTB website. Its use is highly recommended.
General Internal Medicine Curriculum is now updated and available on www.jrcptb.org.uk. All trainees appointed ST3 from August 2009 will be offered entry to train for this CCT. Trainees before this date can easily apply to train in this CCT (i.e. dual accredit), again detailed in the website. Reviewing the new curriculum for G(I)M each trainee will need 6 ACATs, 4-CBDs and 4 Mini-CEXs in G(I)M as well as the specialty work based assessments. The publication of this curriculum and the formation of a National SAC in G(I)M separate from the Acute Medicine SAC really does mean that in practical terms the 2 specialties will be split entirely in 5-10 yrs. Our current G(I)M/Acute Medicine STC is preparing for this split, but will continue to have a dual function up to the point when there are enough Acute Medicine trained Physicians in the region to allow the formation of 2 different STCs. What this space.......................................................................................
MRCP Diabetes & Endocrinology This exam has to be completed and passed by all trainees appointed after August 2007 before their PYA. We recommend sitting it ASAP and well before your PYA.
Personal Development Plans Each trainee should use their ARCP/RITA report to construct a PDP and discuss with their Educational Supervisor. A copy of the PDP should be sent to Nicky Leech by 26th Nov 2009.
INFORMATION for QA Could each individual trainer send the following to Simon Pearce: educational qualifications, any training positions held and any educational courses attended.
MORE INFORMATION for QA Could each unit’s Training Lead please send to Simon Pearce a completed training unit information report and an updated SpR/StR job description as per Nicky Leech’s e-mail.
Trainers & Trainees meeting The next T&T is on 24th June 2010. Details to be confirmed nearer the time, but please note in your diary.
Training Committee Chair- Simon Pearce,; Regional Speciality Advisor- Shaz Wahid; Programme Director- Nicky Leech Consultant member (SAC rep)- Richard Quinton, Consultant member-Jean MacLeod,; Consultant member-Vacant; Consultant member-Simon Eaton,; SpR representative- Vacant; SpR representative- Jeevan Mettayil
NEWS FROM THE NORTHEAST
· Congratulations to Arut on appointment to a Consultant post at James Cook University Hospital in Diabetes&Endo. He already has his feet under the table.
· Congratulations to Jeevan Mettayil on being appointed the Regional Rep for the Young Diabetologists Forum.
· Congratulations to Ravi on his PhD “Postprandial metabolism in health and type 2 diabetes”.
· ABCD is coming to town. Please note that this excellent national meeting will be visiting the region on 6-7th May 2010 at the Hilton in Gateshead. See above.
· Simon Pearce is the new Chair of the STC.
· Keep an eye out for the annual RCP Acute Medicine Symposium on 28th April 2010 at FRH. Yours truly will be presenting with the title “Sugar and Hormones in the Acute Unit”.
· There are a number of new trainees on the scene, welcome to you all: Catherine Napier, Hamza Ali Khan, Naveen Aggarwal, Munir, Sajid Ethol Kalathil, Nimanth De Alwis. Please excuse, any spelling errors. The “drums” are not quite that accurate just yet.
· Congratulation s to Rohana Wright on her recent marriage.
LETTERS
The 8th Habit-From Effectiveness to Greatness-Shaz Wahid
I did warn you I would be writing about this and this is not at all about becoming a megalomaniac! This excellent book by Stephen Covey is a must read once you have read about the 7 habits of effectiveness and more importantly after practicing them for at least 1 year. It is all about finding your own voice and then helping others to find their voice. I have found the principles of the 8th habit very useful in my professional activities of late. I have been involved in a major change project within the Trust. As ever such a project has resulted in much angst, frustration and confrontation. I clearly found my voice in relation to this major project a long time ago and based it on sound principles of quality patient care, safe patient care, cost-effective patient care and quality training all rolled into a MISSION STATEMENT in the form of a VISSION. My organization is aligned towards this vision and the task of getting others aligned towards this vision has begun with everyone accepting the VISSION. The challenge is keeping everyone aligned towards the vision along the curvy path. This is best done by helping others to find their voice in relation to the vision and helping the alignment towards it. I have deliberately kept this description general. Those of you who know me have probably worked out this is about my activities around shaping emergency care at South Tyneside. However, I am also using the same principles in reshaping Diabetes care in the District in negotiations with the commissioners. Once you have got to grips with the 7-habits the 8th habit is a must do.
The dark side-Shaz Wahid
I think I shocked Petros when I met him at the RITAs and let it slip I will be going towards management! I have grown up with a healthy dollop of mistrust when it comes to the management. So what has changed my mind. Well it has all got to do with instituting change. Knowing the workings within my Trust has helped me institute change, although some would say or get what I want or Empire Build. But, to truly effect change and help others in contributing to change I need to be a in a position of influence. So the first steps have started with:
-getting onto the Executive Board as Clinical Lead for the Emergency Care Pathway
-getting onto and actively participating in governance groups such as the Clinical Incident Review Group and Mortality Review Group
-plans to attend a conference titled “Effective Clinical Director”, covering areas such as revalidation, measuring & monitoring clinical outcomes and PROMs, lean thinking, quality metrics and managing poor performance & dealing with difficult Drs
-Subscribing to the Health Service Journal
-Joining the British Association of Medical Managers (BAMM)
They are all first steps and I guess watch this space……………….. Although, it is important to have an escape route otherwise the trap door looms large. This route is the full retirement of an Everton supporter in 2011! For more information visit bamm.co.uk and for you yunguns, here is a plug for BAMMbino:
In recent years, it has become increasingly apparent that the medical profession needs to develop high quality leadership and management skills in order to effectively participate in the great healthcare debate. Work by the Royal Colleges, NHS Institute for Innovation and Improvement and BAMM has called for these skills to be nurtured from an early stage in doctor's careers, but there is little support and advice for those who wish to be the Clinical Directors, Medical Directors and Chief Medical Officers of the future.
At BAMMbino, we intend to create a living network of enthusiastic Junior Doctors who see medical management and leadership as an intrinsic part of their future careers. By acting as a portal for information, advice and support we will be building on the ethos of BAMM to help create a new generation of doctors who will be able to work proactively in and with the ever-changing healthcare environment.
Our intention is to deliver a service that will guide our members through the latest hot topics, encourage their own attempts to improve services for patients, and help mentor them through the ups and downs of their individual careers.
If you are a keen medical student, F1, F2, SHO or SpR who shows an interest in the ‘bigger picture' then let us know by sending their details to BAMMbino@bamm.co.uk This e-mail address is being protected from spam bots, you need JavaScript enabled to view it
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and we will try to make their journey a little smoother than those who have gone before.
GOSSIP FROM THE TPD-Nicky Leech
Congratulations to Arut Arutchelvum on his appointment as a consultant at James Cook University Hospital. This leaves a vacancy for an SPR on the Specialist training committee. This is a position of great responsibility representing the views and needs of Diabetes & Endocrinology trainees across the NE, working with consultant members of the committee to continue to develop training in the NE Deanery. Application is by e-mail . You need to submit a 300 word maximum answer on the question ---
What recommendation would you make to the STC regarding developing the training programme to better prepare trainees for Consultanthood?
Application should be sent by e-mail to me on .. Nicola.leech@nuth.nhs.uk
Closing date: October 30th 2009. The entries will be judged and scored by the STC and the results announced at NEERAG on 18th November 2009.
Also…
I am interested in hearing from any trainees interested in training in and working towards a diploma or MSc in public Health. We have an opportunity to secure funding and supervision through “Darzi” Money for part-time training in public Health. It may be possible to combine this with clinical diabetes but the details of the job may be customised around the wishes and needs of the applicant . Therefore anyone interested at this stage should contact me personally and I will discuss it further with them.
Summer Camp for Kids with Diabetes at Marrick Priory-A Santhakumar
Attending the paediatric diabetes outpatient clinics at James Cook University hospital I got the wonderful opportunity to be a part of their annual kids camp at Marrick Priory and wish to share my experience. Set in the scenic Yorkshire Dales , the Marrick Priory has been hosting this immensely popular children’s camp for years. The enthusiasm of the children and their parents at the diabetes outpatient clinics led me to sign up as part observer/counsellor at this year’s activities camp for children with diabetes. The summer camp had 30-35 kids aged between 9-13 years and for some of them it was the first time away from their parents. The camp staff and counsellors included the camp warden, senior and junior medical officers, diabetes nurses, dieticians, psychologists and junior leaders who had diabetes themselves.
I arrived at the camp early Friday morning to find children being lined up into 4 groups. My group had 8 children and as counsellors the group had a senior paediatrician, a paediatric registrar, an adult diabetes registrar (yours truly) and a dietician. At the camp the staff to kids ratio was maintained at around 1:2 and there was close supervision during all sports and outings. To ensure safety and optimal diabetes management, multiple blood glucose determinations were made throughout each 24-h period
Attempts were made to follow the home insulin regimen of each camper as closely as possible. However, most camps have found it advisable to decrease the home insulin dosage by 10–20% (or more) on arrival at camp, especially in those children under good control who were not active before the camp session.
The day was jam packed with activities like kayaking, archery, rock climbing and obstacle courses to name just a few. The enthusiasm and the excitement of the kids were infectious and we had to remind ourselves that all these kids had type 1 diabetes and could potentially have a hypoglycaemic episode atop a tree or in a kayak!
Meal times provided an excellent opportunity to educate and encourage children about insulin adjustments and carbohydrate counting. Many of the kids gave their first independent insulin shots at the camp. The camp also provided these youngsters an opportunity to help out younger campers and learn to be responsible. Using the active camping environment as a teaching opportunity was an extremely useful way for children with diabetes to gain skills in managing their disease within the supportive camp community. It was all about having a positive experience learning how to manage their diabetes. In fact most of the kids who attend these camps frequently return and often volunteer as counsellors themselves which is indicative of how much they value their time spent in these camps.
On the whole (apart from a terrifying personal moment during a free fall exercise!) it was a thoroughly enjoyable and an extremely enriching experience for me. It gave me a whole new perspective on management of diabetes in the young and I would recommend my fellow registrars to try and attend a similar camp at least once .
What these camps offer the kids
· Diabetes camp is one of the best experiences that a child with diabetes can have. It is a place where the norm is to have diabetes and they no longer feel ‘different’.
· A fun and safe camping experience. Many will meet new friends with whom they will keep in touch for years to come.
· An emphasis on achieving good control of diabetes while adjusting to daily activities.
· Opportunity to develop self confidence and independently manage their diabetes.
· Diabetes education in an informal setting.
· It is an opportunity to gain independence from mom and dad, to be with other kids with diabetes, and simply to have a great time.
· It's also an excellent opportunity for mom and dad to take a break from diabetes!
What the camps can offer us
· Fun practical experience in insulin management during exercise.
· Insight and a whole new perspective into what it means to live with diabetes.
· Opportunity to educate in an informal environment far removed from the clinic setting and to be creative when imparting skills and knowledge!
· Understand the pathos that comes from being responsible for a young person with diabetes.
· Amazing eye opener in how quickly kids grasp new knowledge, accept change and just get on with it!
· Useful tips to incorporate informal teaching techniques in the management of young people in the adult diabetes service.
Diabetes UK has been organizing holidays for children since 1930s with about 500 kids participating each year. Details about similar camps in our region is available on their website. http://www.diabetes.org.uk/Professionals/Resources-for-patients/Care-events/
The Firbush Project, run by Perth Royal Infirmary provides a similar annual adventure camp for 16-21 year olds on Loch Tay. Details are available on NHS Tayside website http://www.diabetes-healthnet.ac.uk/HandBook/DiabetesAndTeenagers.aspx
RECENT PUBLICATIONS FROM THE NORTHEAST
1. Kamaruddin MS, Quinton R, Leech N. 2009 Inpatient diabetes care: first do no harm? Clinical Services Journal. 6: 37-40.
2. Arun CS, Al-Bermani A, Stannard KS, Taylor R. Long term impact of retinal screening upon significant diabetes related visual impairment in the working age population. Diabetic Medicine 26:489-492, 2009.
3. Jovanovic A, Leverton E, Solanky B, Snaar JEM, Morris PEG, Taylor R. The second meal phenomenon is associated with enhanced muscle glycogen storage. Clin Sci 117:119–127, 2009.
4. Al-Ozairi E, Waugh JJS, Taylor R. Termination is not the treatment of choice for severe hyperemesis gravidarum: Successful management using prednisolone. Obstetric Medicine 2: 34-37, 2009.
5. Lim EL, Burden T, Marshall SM, Davison JM, Blott MJ, Waugh JJS, Taylor R. Intrauterine Growth Rates in Pregnancies Complicated by Type 1, Type 2 and Gestational Diabetes. Obstetric Medicine 2: 21-25, 2009.
6. Jovanovic A, Gerrard J, Taylor R. The second meal phenomenon in type 2 diabetes. Diabetes Care 32:1199-1201, 2009.
7. L. Sibal, A. Aldibbiat, S. C. Agarwal, G. Mitchell, C. Oates, S. Razvi, J. U. Weaver, J. A. Shaw and P. D. Home. Circulating endothelial progenitor cells, endothelial function, carotid intima–media thickness and circulating markers of endothelial dysfunction in people with type 1 diabetes without macrovascular disease or microalbuminuria. Editors choice August 09 Diabetologia www.diabetologia-journal.org
8. Wright R J, Frier B M, Deary I J. Effects of acute insulin-induced hypoglycemia on spatial abilities in adults with type 1 diabetes. Diabetes Care 2009; 32: 1503-1506.
RECENT PUBLICATIONS IN DIABETES & ENDOCRINOLOGY THAT HIT THE NEWS OR THAT MAY HAVE A SIGNIFICANT IMPACT ON MANAGEMENT
Denosumab in men receiving androgen-deprivation therapy for prostate cancer. Smith MR, Egerdie B, Hernández Toriz N et al N Engl J Med. 2009 Aug 20;361(8):745-55. Androgen-deprivation therapy is well-established for treating The authors investigated the effects of denosumab, a fully human monoclonal antibody against receptor activator of nuclear factor-kappaB ligand (RANKL) that blocks its effect on the RANK receptor reducing osteoclast activity and hence bone resorption with an intendent increase in bone mineral density, on bone mineral density and fractures in men receiving androgen-deprivation therapy (which increases fracture risk) for nonmetastatic prostate cancer. 734 patients were randomized to receive denosumab 60 mg subcutaneously every 6 months and 734 patients received placebo . The primary end point was percent change in bone mineral density at the lumbar spine at 24 months and secondary end points included percent change in bone mineral densities at the femoral neck and total hip at 24 months and at all three sites at 36 months, as well as incidence of new vertebral fractures. At 24 months, lumbar spine BMD increased by 5.6% in the denosumab group as compared with a loss of 1.0% in the placebo group (P<0.001); Denosumab therapy was also associated with significant increases in BMD at the total hip, femoral neck, and distal third of the radius at all time points. Denosumab reduced the incidence of new vertebral fractures at 36 months by 62% (1.5%, vs. 3.9% with placebo; relative risk, 0.38; 95%CI 0.19 to 0.78; p=0.006). Rates of adverse events were similar between the two groups. In this trial Denosumab was associated with increased bone mineral density at all sites and a reduction in the incidence of new vertebral fractures.
Denosumab for prevention of fractures in postmenopausal women with osteoporosis. Cummings SR, San Martin J, McClung MR N Engl J Med. 2009 Aug 20;361(8):756-65. The investigators enrolled 7868 women between the ages of 60 and 90 years with a BMD T score of < -2.5 but not <-4.0 at the lumbar spine or total hip and randomly assigned them to receive either 60 mg of denosumab or placebo subcutaneously every 6 months for 36 months. The primary end point was new vertebral fracture with secondary end points of nonvertebral and hip fractures. Compared to placebo denosumab reduced the risk of new radiographic vertebral fracture by 68% (cumulative incidence of 2.3% vs 7.2%; risk ratio, 0.32: 95%CI 0.26-0.41; p<0.001). Denosumab reduced the risk of hip fracture by 40% (cumulative incidence of 0.7% vs 1.2%; hazard ratio, 0.60: 95% CI, 0.37-0.97; p=0.04). Denosumab also reduced the risk of nonvertebral fracture by 20% (cumulative incidence of 6.5% vs 8.0%; hazard ratio, 0.80: 95% CI, 0.67-0.95; p=0.01). There was no increase in the risk of cancer, infection, cardiovascular disease, delayed fracture healing, or hypocalcaemia, and there were no cases of osteonecrosis of the jaw and no adverse reactions to the injection of denosumab. The above two trials clearly demonstrate the effectiveness of targeting RANKL to treat osteoporoses in both men and women. Denosumab is an exciting new tool for treating osteoporoses. The accompanying editorial by Sundeep Khosla (NEJM 2009;361:818-820) is well worth a read. The challenge now is construct cost effective pathways for utilising the therapies available for osteoporoses.
Recent developments in hyperthyroidism. Julia Kharlip and David S Cooper. Lancet 2009;373:1930-1932. A reasonable editorial that will point you to the true goodies to read.
Eradication of insulin resistance. Imai J, et al. Lancet 2009;374:264. An excellent case report.
Hyperparathyroidism. William D Fraser. Lancet 2009;374:145-158. An excellent review well worth a read.
A reason to panic in pregnancy. Pearson GAH et al. Lancet 2009;374:756. An excellent case report exploring catecholamine excess in pregnancy.
Insulin glargine and malignancy: an unwarranted alarm. Stuart J Pocock & Liam Smeeth. Lancet 2009;374:511-513. AND Insulin glargine and cancer: another side to the story? Edwin AM Gale. Lancet 2009;374:521. An editorial and correspondence that I think provide food for thought, pause and appraisal............
Rosiglitazone evaluated for cardiovascular outcomes in oral agent combination therapy for type 2 diabetes (RECORD): a multicentre, randomised, open-label trial. Home PD, Pocock SJ, Beck-Nielsen H, et al Lancet. 2009;373:2125-35. The investigators randomized 4447 patients with type 2 diabetes on metformin or sulfonylurea monotherapy with mean HbA1c of 7.9% to the addition of rosiglitazone (n=2220) or to a combination of metformin and sulfonylurea (active control group, n=2227). The primary endpoint was cardiovascular hospitalisation or cardiovascular death. The latter occurred in 321 people in the rosiglitazone group and 323 in the active control group during a mean follow-up of 5.5 years. The Hazard Ratio[95%CI] was 0.84[0.59-1.18]for cardiovascular death, 1.14[0.80-1.63] for MI, and 0.72[0.49-1.06] for stroke. Hospital admission for heart failure or death occurred in 61 people in the rosiglitazone group and 29 in the active control group (HR 2.10[1.35-3.27]) Upper (Risk Ratio[95%CI] 1.57[1.12-2.19], p=0.0095)and distal lower limb (2.6[1.67-4.02], p<0.0001) fracture rates were increased mainly in women assigned to rosiglitazone. Mean HbA1c was lower in the rosiglitazone group than in the control group at 5 years, mean[SE] HbA1c rosiglitazone vs sulfonylurea -0.28[0.03] vs 0.01[0.04], p<0.0001; rosiglitazone vs metformin -0.44[0.03] vs -0.18[0.04], p<0.0001. This trial really does confirm my working practice that glitazones are effective therapy for improving glycaemic control in patients with Type 2 DM, but they should not be used in patients with heart failure or at significant risk of heart failure; the fracture risk of all patients should be assessed before starting therapy AND that they do not increase overall cardiovascular mortality or morbidity. Their use really is guided by discussion with the patient. The generic advice in guidelines or to GPs of a glitazone of your choice remains for me.
The venous thrombotic risk of oral contraceptives, effects of oestrogen dose and progestogen type: results of the MEGA case-control study. van Hylckama Vlieg A, Helmerhorst FM, et al BMJ. 2009 Aug 13;339:b2921. doi: 10.1136/bmj.b2921. This population based case-control study assessed the thrombotic risk associated with oral contraceptive use with a focus on dose of oestrogen and type of progestogen of oral contraceptives in premenopausal women <50 years old who were not pregnant, not within four weeks postpartum, and not using a hormone excreting intrauterine device or depot contraceptive, with a population of 1524 patients and 1760 controls. Currently available oral contraceptives increased the risk of venous thrombosis fivefold compared with non-use (odds ratio 5.0, 95%CI 4.2 to 5.8). The risk clearly differed by type of progestogen and dose of oestrogen. The use of oral contraceptives containing levonorgestrel was associated with an almost fourfold increased risk of venous thrombosis (odds ratio 3.6, 2.9 to 4.6)compared to non-users, whereas the risk of venous thrombosis compared with non-use was increased 5.6-fold for gestodene (5.6, 3.7 to 8.4), 7.3-fold for desogestrel (7.3, 5.3 to 10.0), 6.8-fold for cyproterone acetate (6.8, 4.7 to 10.0), and 6.3-fold for drospirenone (6.3, 2.9 to 13.7). The risk of venous thrombosis was positively associated with oestrogen dose. There was a high risk of venous thrombosis during the first months of oral contraceptive use irrespective of the type of oral contraceptives. Reviewing the results of this study and another study (Hormonal contraception and risk of venous thromboembolism: national follow-up study. Lidegaard O, et al. BMJ 2009;339:b2890doi10.1136/bmj.b2890) along with an excellent review (Contraception for women: an evidence based overview. Jean-Jacques Amy & Vrijesh Tripathi. BMJ 2009;339:b2895 doi10.1136/bmj.b2895) in the same issue of the BMJ show that when discussing oral contraception with women we should recommend those containing levonorgestrel or norethisterone with as low a dose of oestrogen as possible. The accompanying editorial by Nick Dunn (BMJ 2009;339:b3164doi:10.1136/bmj.b3164) is well worth a read.
NEXT NEWSLETTER Due out beginning of February 2009 so keep the gossip coming.
Endodiabology.blogspot.com
NORTHEAST
NEWSLETTER
FOR SPRs AND BOSSES TRAPPED
IN THE NORTHERN DEANERY
OCTOBER 2009
Editors: Shaz Wahid and
Petros Perros and Arut Vijayaraman
Associate Editors: Shafie Kamarrudin, Ravi Erukulapati
SpR PLACEMENTS (NTN year of training from 1st October 2008)
· Newcastle- Ravi Erukalapati(5), Sudeep Manohar (3), Nimanth De Alwis (1), Arif Ullah (3), Srikanth Mada(3) Naveen Siddaramaiha (2), Sarah Steven (2)
· North Tyneside/Wansbeck- Anjali Santhakumar (3), Kathryn Stewart (3)
· South Tyneside- Rohanna Wright (2),
· Gateshead- Preeti Rao (3)
· Sunderland- Beas Bhattacharya (5) then Naveen Aggarwal (1), Chandima Idampitiya (5)
· North Tees/Hartlepool- Shafie Kamarrudin (4), Hamza Ali Khan (1)
· Middlesbrough- Freda Razvi (5), Dr Munir (1), Sajid Ethol Kalathil (1), Catherine Napier (1)
· Carlisle-
· Bishop Auckland Khaled Mansur-Dukhan (5)
· Durham- Jeevan Mettayil (4)
· NGH/QEH- Vacant
· Research with numbers (supervisor)- Eelin Lim(5-Prof Taylor); Stuart Little (2-Dr Shaw) & Asgar Madathil (4-Dr Weaver)
MEETINGS / LECTURES / ANNOUNCEMENTS
· 12th October 2009 Northern Endocrine & Diabetes Autumn CME, JCUH, Middlesbrough
· 23rd October 2009 Diabetic Foot Teaching day-for medical and surgical trainees. Freeman Hospital
· 31st October 2009 Association of Physicians, Darlington Memorial Hospital.
· 2nd-4th November 2009 Society for Endocrinology Clinical Update 2009, Manchester. Contact www.endocrinology.org
· 2nd November 2009 GIM training ½ day, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 3rd November 2009 RCPL Medicine Update, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247
· 11th November 2009 North East Obesity Forum, 1600-1830, Newcastle University. Contact
· 19th November 2009 1st Joint Meeting of The British Thyroid Association and British Association Of Endocrine and Thyroid Surgeons, St Thomas Hospital. Contact www.british-thyroid-association.org
· 19th-20th November 2009 ABCD autumn meeting, London. Contact www.diabetologists.org.uk followed by SpRs meeting 21-22nd November 2009.
· 25th November 2009 Northern Endocrine Region Research and Audit Group annual meeting, Lumley Castle, Durham 2pm-8pm. Contact
· 26th & 27th November 2009 Middlesbrough insulin pump course. Contact
· 4th December 2009 Society for Endocrinology regional cases meeting, Edinburgh. Contact www.endocrinology.org
· 26th January 2010 Northern Endocrine & Diabetes Winter CME, Freeman Hospital. Contact
· 26th January 2010 Diabetes-A Hospital Perspective, RCPL. Contact conferences@rcp.ac.uk
· 23rd February 2010 SfE National Clinical Cases meeting, venue TBC. Contact www.endocrinology.org
· 3rd- 5th March 2010 DUK Annual Professional Conference, Liverpool. Contact www.diabetes.org.uk
· 15th – 18th March 2010 BES 2010, Manchester. Contact www.endocrinology.org.
· 28th April 2010 RCP Acute Medicine symposium, Freeman Hospital. Contact Lorraine Waugh 0191 223 1247 Lorraine.waugh@tfh.nuth.northy.nhs.uk.
· 6th-7th May 2010 ABCD Spring Meeting, The Hilton, GATESHEAD. Contact www.diabetologists.org.uk
· 8th June 2010 Northern Endocrine & Diabetes Spring CME, Freeman Hospital. Contact mshafie_kamaruddin@yahoo.co.uk
· 19th – 22nd June 2010 ENDO 2010, San Diego, USA. Contact endostaff@endo-societ.org or www.endo-society.org/scimeetings .
· 25th – 29th June 2010 American Diabetes Association 70th Annual Scientific Sessions, Orlando, Florida, USA. Contact meetings@diabetes.org .
TRAINING ISSUES
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.
A new Trainee Rep With Arut now having his CCT AND Consultant post an opportunity for a new trainee rep has arisen on the STC. SEE OUR TPDs REGULAR LETTER BELOW.
A novel training opportunity Any one interested in working towards a diploma or MSc in Public Health? If yes, SEE OUR TPDs REGULAR LETTER BELOW.
More Consultant members If you would like to be involved with the STC please do contact Nicky Leech ASAP.
ARCP (RITA) The next round is due on Weds 12th, Thurs 13th & Fri 15th May 2010. Trainees please keep these dates free as possible.
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. 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. The e-portfolio for DM&ENDO is available now for StRs.
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.
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.
Case Based Discussions (CbD) The pilot form is available from the JRCPTB website. It is a must for trainers to use as a tool to document feedback in clinic. This has always been done informally, but now there is a method to formally document it. It can be used for when a SpR presents a new case in clinic.
Documenting CCU and ITU experience It is essential that trainees document their CCU and ITU experience. This is best done by keeping a summary log of the cases seen on CCU and ITU and linking it with reflection or assessment. This should then be signed off by your Educational Supervisor to be of any use at the Acute Medicine PYAs.
Audit Assessment tool This is now available in draft form on the JRCPTB website. Its use is highly recommended.
General Internal Medicine Curriculum is now updated and available on www.jrcptb.org.uk. All trainees appointed ST3 from August 2009 will be offered entry to train for this CCT. Trainees before this date can easily apply to train in this CCT (i.e. dual accredit), again detailed in the website. Reviewing the new curriculum for G(I)M each trainee will need 6 ACATs, 4-CBDs and 4 Mini-CEXs in G(I)M as well as the specialty work based assessments. The publication of this curriculum and the formation of a National SAC in G(I)M separate from the Acute Medicine SAC really does mean that in practical terms the 2 specialties will be split entirely in 5-10 yrs. Our current G(I)M/Acute Medicine STC is preparing for this split, but will continue to have a dual function up to the point when there are enough Acute Medicine trained Physicians in the region to allow the formation of 2 different STCs. What this space.......................................................................................
MRCP Diabetes & Endocrinology This exam has to be completed and passed by all trainees appointed after August 2007 before their PYA. We recommend sitting it ASAP and well before your PYA.
Personal Development Plans Each trainee should use their ARCP/RITA report to construct a PDP and discuss with their Educational Supervisor. A copy of the PDP should be sent to Nicky Leech by 26th Nov 2009.
INFORMATION for QA Could each individual trainer send the following to Simon Pearce: educational qualifications, any training positions held and any educational courses attended.
MORE INFORMATION for QA Could each unit’s Training Lead please send to Simon Pearce a completed training unit information report and an updated SpR/StR job description as per Nicky Leech’s e-mail.
Trainers & Trainees meeting The next T&T is on 24th June 2010. Details to be confirmed nearer the time, but please note in your diary.
Training Committee Chair- Simon Pearce,; Regional Speciality Advisor- Shaz Wahid; Programme Director- Nicky Leech Consultant member (SAC rep)- Richard Quinton, Consultant member-Jean MacLeod,; Consultant member-Vacant; Consultant member-Simon Eaton,; SpR representative- Vacant; SpR representative- Jeevan Mettayil
NEWS FROM THE NORTHEAST
· Congratulations to Arut on appointment to a Consultant post at James Cook University Hospital in Diabetes&Endo. He already has his feet under the table.
· Congratulations to Jeevan Mettayil on being appointed the Regional Rep for the Young Diabetologists Forum.
· Congratulations to Ravi on his PhD “Postprandial metabolism in health and type 2 diabetes”.
· ABCD is coming to town. Please note that this excellent national meeting will be visiting the region on 6-7th May 2010 at the Hilton in Gateshead. See above.
· Simon Pearce is the new Chair of the STC.
· Keep an eye out for the annual RCP Acute Medicine Symposium on 28th April 2010 at FRH. Yours truly will be presenting with the title “Sugar and Hormones in the Acute Unit”.
· There are a number of new trainees on the scene, welcome to you all: Catherine Napier, Hamza Ali Khan, Naveen Aggarwal, Munir, Sajid Ethol Kalathil, Nimanth De Alwis. Please excuse, any spelling errors. The “drums” are not quite that accurate just yet.
· Congratulation s to Rohana Wright on her recent marriage.
LETTERS
The 8th Habit-From Effectiveness to Greatness-Shaz Wahid
I did warn you I would be writing about this and this is not at all about becoming a megalomaniac! This excellent book by Stephen Covey is a must read once you have read about the 7 habits of effectiveness and more importantly after practicing them for at least 1 year. It is all about finding your own voice and then helping others to find their voice. I have found the principles of the 8th habit very useful in my professional activities of late. I have been involved in a major change project within the Trust. As ever such a project has resulted in much angst, frustration and confrontation. I clearly found my voice in relation to this major project a long time ago and based it on sound principles of quality patient care, safe patient care, cost-effective patient care and quality training all rolled into a MISSION STATEMENT in the form of a VISSION. My organization is aligned towards this vision and the task of getting others aligned towards this vision has begun with everyone accepting the VISSION. The challenge is keeping everyone aligned towards the vision along the curvy path. This is best done by helping others to find their voice in relation to the vision and helping the alignment towards it. I have deliberately kept this description general. Those of you who know me have probably worked out this is about my activities around shaping emergency care at South Tyneside. However, I am also using the same principles in reshaping Diabetes care in the District in negotiations with the commissioners. Once you have got to grips with the 7-habits the 8th habit is a must do.
The dark side-Shaz Wahid
I think I shocked Petros when I met him at the RITAs and let it slip I will be going towards management! I have grown up with a healthy dollop of mistrust when it comes to the management. So what has changed my mind. Well it has all got to do with instituting change. Knowing the workings within my Trust has helped me institute change, although some would say or get what I want or Empire Build. But, to truly effect change and help others in contributing to change I need to be a in a position of influence. So the first steps have started with:
-getting onto the Executive Board as Clinical Lead for the Emergency Care Pathway
-getting onto and actively participating in governance groups such as the Clinical Incident Review Group and Mortality Review Group
-plans to attend a conference titled “Effective Clinical Director”, covering areas such as revalidation, measuring & monitoring clinical outcomes and PROMs, lean thinking, quality metrics and managing poor performance & dealing with difficult Drs
-Subscribing to the Health Service Journal
-Joining the British Association of Medical Managers (BAMM)
They are all first steps and I guess watch this space……………….. Although, it is important to have an escape route otherwise the trap door looms large. This route is the full retirement of an Everton supporter in 2011! For more information visit bamm.co.uk and for you yunguns, here is a plug for BAMMbino:
In recent years, it has become increasingly apparent that the medical profession needs to develop high quality leadership and management skills in order to effectively participate in the great healthcare debate. Work by the Royal Colleges, NHS Institute for Innovation and Improvement and BAMM has called for these skills to be nurtured from an early stage in doctor's careers, but there is little support and advice for those who wish to be the Clinical Directors, Medical Directors and Chief Medical Officers of the future.
At BAMMbino, we intend to create a living network of enthusiastic Junior Doctors who see medical management and leadership as an intrinsic part of their future careers. By acting as a portal for information, advice and support we will be building on the ethos of BAMM to help create a new generation of doctors who will be able to work proactively in and with the ever-changing healthcare environment.
Our intention is to deliver a service that will guide our members through the latest hot topics, encourage their own attempts to improve services for patients, and help mentor them through the ups and downs of their individual careers.
If you are a keen medical student, F1, F2, SHO or SpR who shows an interest in the ‘bigger picture' then let us know by sending their details to BAMMbino@bamm.co.uk This e-mail address is being protected from spam bots, you need JavaScript enabled to view it
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and we will try to make their journey a little smoother than those who have gone before.
GOSSIP FROM THE TPD-Nicky Leech
Congratulations to Arut Arutchelvum on his appointment as a consultant at James Cook University Hospital. This leaves a vacancy for an SPR on the Specialist training committee. This is a position of great responsibility representing the views and needs of Diabetes & Endocrinology trainees across the NE, working with consultant members of the committee to continue to develop training in the NE Deanery. Application is by e-mail . You need to submit a 300 word maximum answer on the question ---
What recommendation would you make to the STC regarding developing the training programme to better prepare trainees for Consultanthood?
Application should be sent by e-mail to me on .. Nicola.leech@nuth.nhs.uk
Closing date: October 30th 2009. The entries will be judged and scored by the STC and the results announced at NEERAG on 18th November 2009.
Also…
I am interested in hearing from any trainees interested in training in and working towards a diploma or MSc in public Health. We have an opportunity to secure funding and supervision through “Darzi” Money for part-time training in public Health. It may be possible to combine this with clinical diabetes but the details of the job may be customised around the wishes and needs of the applicant . Therefore anyone interested at this stage should contact me personally and I will discuss it further with them.
Summer Camp for Kids with Diabetes at Marrick Priory-A Santhakumar
Attending the paediatric diabetes outpatient clinics at James Cook University hospital I got the wonderful opportunity to be a part of their annual kids camp at Marrick Priory and wish to share my experience. Set in the scenic Yorkshire Dales , the Marrick Priory has been hosting this immensely popular children’s camp for years. The enthusiasm of the children and their parents at the diabetes outpatient clinics led me to sign up as part observer/counsellor at this year’s activities camp for children with diabetes. The summer camp had 30-35 kids aged between 9-13 years and for some of them it was the first time away from their parents. The camp staff and counsellors included the camp warden, senior and junior medical officers, diabetes nurses, dieticians, psychologists and junior leaders who had diabetes themselves.
I arrived at the camp early Friday morning to find children being lined up into 4 groups. My group had 8 children and as counsellors the group had a senior paediatrician, a paediatric registrar, an adult diabetes registrar (yours truly) and a dietician. At the camp the staff to kids ratio was maintained at around 1:2 and there was close supervision during all sports and outings. To ensure safety and optimal diabetes management, multiple blood glucose determinations were made throughout each 24-h period
Attempts were made to follow the home insulin regimen of each camper as closely as possible. However, most camps have found it advisable to decrease the home insulin dosage by 10–20% (or more) on arrival at camp, especially in those children under good control who were not active before the camp session.
The day was jam packed with activities like kayaking, archery, rock climbing and obstacle courses to name just a few. The enthusiasm and the excitement of the kids were infectious and we had to remind ourselves that all these kids had type 1 diabetes and could potentially have a hypoglycaemic episode atop a tree or in a kayak!
Meal times provided an excellent opportunity to educate and encourage children about insulin adjustments and carbohydrate counting. Many of the kids gave their first independent insulin shots at the camp. The camp also provided these youngsters an opportunity to help out younger campers and learn to be responsible. Using the active camping environment as a teaching opportunity was an extremely useful way for children with diabetes to gain skills in managing their disease within the supportive camp community. It was all about having a positive experience learning how to manage their diabetes. In fact most of the kids who attend these camps frequently return and often volunteer as counsellors themselves which is indicative of how much they value their time spent in these camps.
On the whole (apart from a terrifying personal moment during a free fall exercise!) it was a thoroughly enjoyable and an extremely enriching experience for me. It gave me a whole new perspective on management of diabetes in the young and I would recommend my fellow registrars to try and attend a similar camp at least once .
What these camps offer the kids
· Diabetes camp is one of the best experiences that a child with diabetes can have. It is a place where the norm is to have diabetes and they no longer feel ‘different’.
· A fun and safe camping experience. Many will meet new friends with whom they will keep in touch for years to come.
· An emphasis on achieving good control of diabetes while adjusting to daily activities.
· Opportunity to develop self confidence and independently manage their diabetes.
· Diabetes education in an informal setting.
· It is an opportunity to gain independence from mom and dad, to be with other kids with diabetes, and simply to have a great time.
· It's also an excellent opportunity for mom and dad to take a break from diabetes!
What the camps can offer us
· Fun practical experience in insulin management during exercise.
· Insight and a whole new perspective into what it means to live with diabetes.
· Opportunity to educate in an informal environment far removed from the clinic setting and to be creative when imparting skills and knowledge!
· Understand the pathos that comes from being responsible for a young person with diabetes.
· Amazing eye opener in how quickly kids grasp new knowledge, accept change and just get on with it!
· Useful tips to incorporate informal teaching techniques in the management of young people in the adult diabetes service.
Diabetes UK has been organizing holidays for children since 1930s with about 500 kids participating each year. Details about similar camps in our region is available on their website. http://www.diabetes.org.uk/Professionals/Resources-for-patients/Care-events/
The Firbush Project, run by Perth Royal Infirmary provides a similar annual adventure camp for 16-21 year olds on Loch Tay. Details are available on NHS Tayside website http://www.diabetes-healthnet.ac.uk/HandBook/DiabetesAndTeenagers.aspx
RECENT PUBLICATIONS FROM THE NORTHEAST
1. Kamaruddin MS, Quinton R, Leech N. 2009 Inpatient diabetes care: first do no harm? Clinical Services Journal. 6: 37-40.
2. Arun CS, Al-Bermani A, Stannard KS, Taylor R. Long term impact of retinal screening upon significant diabetes related visual impairment in the working age population. Diabetic Medicine 26:489-492, 2009.
3. Jovanovic A, Leverton E, Solanky B, Snaar JEM, Morris PEG, Taylor R. The second meal phenomenon is associated with enhanced muscle glycogen storage. Clin Sci 117:119–127, 2009.
4. Al-Ozairi E, Waugh JJS, Taylor R. Termination is not the treatment of choice for severe hyperemesis gravidarum: Successful management using prednisolone. Obstetric Medicine 2: 34-37, 2009.
5. Lim EL, Burden T, Marshall SM, Davison JM, Blott MJ, Waugh JJS, Taylor R. Intrauterine Growth Rates in Pregnancies Complicated by Type 1, Type 2 and Gestational Diabetes. Obstetric Medicine 2: 21-25, 2009.
6. Jovanovic A, Gerrard J, Taylor R. The second meal phenomenon in type 2 diabetes. Diabetes Care 32:1199-1201, 2009.
7. L. Sibal, A. Aldibbiat, S. C. Agarwal, G. Mitchell, C. Oates, S. Razvi, J. U. Weaver, J. A. Shaw and P. D. Home. Circulating endothelial progenitor cells, endothelial function, carotid intima–media thickness and circulating markers of endothelial dysfunction in people with type 1 diabetes without macrovascular disease or microalbuminuria. Editors choice August 09 Diabetologia www.diabetologia-journal.org
8. Wright R J, Frier B M, Deary I J. Effects of acute insulin-induced hypoglycemia on spatial abilities in adults with type 1 diabetes. Diabetes Care 2009; 32: 1503-1506.
RECENT PUBLICATIONS IN DIABETES & ENDOCRINOLOGY THAT HIT THE NEWS OR THAT MAY HAVE A SIGNIFICANT IMPACT ON MANAGEMENT
Denosumab in men receiving androgen-deprivation therapy for prostate cancer. Smith MR, Egerdie B, Hernández Toriz N et al N Engl J Med. 2009 Aug 20;361(8):745-55. Androgen-deprivation therapy is well-established for treating The authors investigated the effects of denosumab, a fully human monoclonal antibody against receptor activator of nuclear factor-kappaB ligand (RANKL) that blocks its effect on the RANK receptor reducing osteoclast activity and hence bone resorption with an intendent increase in bone mineral density, on bone mineral density and fractures in men receiving androgen-deprivation therapy (which increases fracture risk) for nonmetastatic prostate cancer. 734 patients were randomized to receive denosumab 60 mg subcutaneously every 6 months and 734 patients received placebo . The primary end point was percent change in bone mineral density at the lumbar spine at 24 months and secondary end points included percent change in bone mineral densities at the femoral neck and total hip at 24 months and at all three sites at 36 months, as well as incidence of new vertebral fractures. At 24 months, lumbar spine BMD increased by 5.6% in the denosumab group as compared with a loss of 1.0% in the placebo group (P<0.001); Denosumab therapy was also associated with significant increases in BMD at the total hip, femoral neck, and distal third of the radius at all time points. Denosumab reduced the incidence of new vertebral fractures at 36 months by 62% (1.5%, vs. 3.9% with placebo; relative risk, 0.38; 95%CI 0.19 to 0.78; p=0.006). Rates of adverse events were similar between the two groups. In this trial Denosumab was associated with increased bone mineral density at all sites and a reduction in the incidence of new vertebral fractures.
Denosumab for prevention of fractures in postmenopausal women with osteoporosis. Cummings SR, San Martin J, McClung MR N Engl J Med. 2009 Aug 20;361(8):756-65. The investigators enrolled 7868 women between the ages of 60 and 90 years with a BMD T score of < -2.5 but not <-4.0 at the lumbar spine or total hip and randomly assigned them to receive either 60 mg of denosumab or placebo subcutaneously every 6 months for 36 months. The primary end point was new vertebral fracture with secondary end points of nonvertebral and hip fractures. Compared to placebo denosumab reduced the risk of new radiographic vertebral fracture by 68% (cumulative incidence of 2.3% vs 7.2%; risk ratio, 0.32: 95%CI 0.26-0.41; p<0.001). Denosumab reduced the risk of hip fracture by 40% (cumulative incidence of 0.7% vs 1.2%; hazard ratio, 0.60: 95% CI, 0.37-0.97; p=0.04). Denosumab also reduced the risk of nonvertebral fracture by 20% (cumulative incidence of 6.5% vs 8.0%; hazard ratio, 0.80: 95% CI, 0.67-0.95; p=0.01). There was no increase in the risk of cancer, infection, cardiovascular disease, delayed fracture healing, or hypocalcaemia, and there were no cases of osteonecrosis of the jaw and no adverse reactions to the injection of denosumab. The above two trials clearly demonstrate the effectiveness of targeting RANKL to treat osteoporoses in both men and women. Denosumab is an exciting new tool for treating osteoporoses. The accompanying editorial by Sundeep Khosla (NEJM 2009;361:818-820) is well worth a read. The challenge now is construct cost effective pathways for utilising the therapies available for osteoporoses.
Recent developments in hyperthyroidism. Julia Kharlip and David S Cooper. Lancet 2009;373:1930-1932. A reasonable editorial that will point you to the true goodies to read.
Eradication of insulin resistance. Imai J, et al. Lancet 2009;374:264. An excellent case report.
Hyperparathyroidism. William D Fraser. Lancet 2009;374:145-158. An excellent review well worth a read.
A reason to panic in pregnancy. Pearson GAH et al. Lancet 2009;374:756. An excellent case report exploring catecholamine excess in pregnancy.
Insulin glargine and malignancy: an unwarranted alarm. Stuart J Pocock & Liam Smeeth. Lancet 2009;374:511-513. AND Insulin glargine and cancer: another side to the story? Edwin AM Gale. Lancet 2009;374:521. An editorial and correspondence that I think provide food for thought, pause and appraisal............
Rosiglitazone evaluated for cardiovascular outcomes in oral agent combination therapy for type 2 diabetes (RECORD): a multicentre, randomised, open-label trial. Home PD, Pocock SJ, Beck-Nielsen H, et al Lancet. 2009;373:2125-35. The investigators randomized 4447 patients with type 2 diabetes on metformin or sulfonylurea monotherapy with mean HbA1c of 7.9% to the addition of rosiglitazone (n=2220) or to a combination of metformin and sulfonylurea (active control group, n=2227). The primary endpoint was cardiovascular hospitalisation or cardiovascular death. The latter occurred in 321 people in the rosiglitazone group and 323 in the active control group during a mean follow-up of 5.5 years. The Hazard Ratio[95%CI] was 0.84[0.59-1.18]for cardiovascular death, 1.14[0.80-1.63] for MI, and 0.72[0.49-1.06] for stroke. Hospital admission for heart failure or death occurred in 61 people in the rosiglitazone group and 29 in the active control group (HR 2.10[1.35-3.27]) Upper (Risk Ratio[95%CI] 1.57[1.12-2.19], p=0.0095)and distal lower limb (2.6[1.67-4.02], p<0.0001) fracture rates were increased mainly in women assigned to rosiglitazone. Mean HbA1c was lower in the rosiglitazone group than in the control group at 5 years, mean[SE] HbA1c rosiglitazone vs sulfonylurea -0.28[0.03] vs 0.01[0.04], p<0.0001; rosiglitazone vs metformin -0.44[0.03] vs -0.18[0.04], p<0.0001. This trial really does confirm my working practice that glitazones are effective therapy for improving glycaemic control in patients with Type 2 DM, but they should not be used in patients with heart failure or at significant risk of heart failure; the fracture risk of all patients should be assessed before starting therapy AND that they do not increase overall cardiovascular mortality or morbidity. Their use really is guided by discussion with the patient. The generic advice in guidelines or to GPs of a glitazone of your choice remains for me.
The venous thrombotic risk of oral contraceptives, effects of oestrogen dose and progestogen type: results of the MEGA case-control study. van Hylckama Vlieg A, Helmerhorst FM, et al BMJ. 2009 Aug 13;339:b2921. doi: 10.1136/bmj.b2921. This population based case-control study assessed the thrombotic risk associated with oral contraceptive use with a focus on dose of oestrogen and type of progestogen of oral contraceptives in premenopausal women <50 years old who were not pregnant, not within four weeks postpartum, and not using a hormone excreting intrauterine device or depot contraceptive, with a population of 1524 patients and 1760 controls. Currently available oral contraceptives increased the risk of venous thrombosis fivefold compared with non-use (odds ratio 5.0, 95%CI 4.2 to 5.8). The risk clearly differed by type of progestogen and dose of oestrogen. The use of oral contraceptives containing levonorgestrel was associated with an almost fourfold increased risk of venous thrombosis (odds ratio 3.6, 2.9 to 4.6)compared to non-users, whereas the risk of venous thrombosis compared with non-use was increased 5.6-fold for gestodene (5.6, 3.7 to 8.4), 7.3-fold for desogestrel (7.3, 5.3 to 10.0), 6.8-fold for cyproterone acetate (6.8, 4.7 to 10.0), and 6.3-fold for drospirenone (6.3, 2.9 to 13.7). The risk of venous thrombosis was positively associated with oestrogen dose. There was a high risk of venous thrombosis during the first months of oral contraceptive use irrespective of the type of oral contraceptives. Reviewing the results of this study and another study (Hormonal contraception and risk of venous thromboembolism: national follow-up study. Lidegaard O, et al. BMJ 2009;339:b2890doi10.1136/bmj.b2890) along with an excellent review (Contraception for women: an evidence based overview. Jean-Jacques Amy & Vrijesh Tripathi. BMJ 2009;339:b2895 doi10.1136/bmj.b2895) in the same issue of the BMJ show that when discussing oral contraception with women we should recommend those containing levonorgestrel or norethisterone with as low a dose of oestrogen as possible. The accompanying editorial by Nick Dunn (BMJ 2009;339:b3164doi:10.1136/bmj.b3164) is well worth a read.
NEXT NEWSLETTER Due out beginning of February 2009 so keep the gossip coming.
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