Vitamin D deficiency can quite easily be diagnosed on the basis of a simple blood test, 25-OH Colecalciferol (25OH Vitamin D) with a value less than 10 mcg/l (25 nmol/l) indicating deficiency and a value below 20 mcg/l indicating insufficiency (1).

Treatment of vitamin D deficiency and insufficiency is associated with improvements in many of
the above symptoms and studies suggest that in the elderly there is a 22% statistically significant
reduction in falls in the elderly (NNT of 15 to prevent 1 fall) associated with doses above 700iu/d
(2). As yet, there is little data available for the impact of vitamin D on reduced fracture risk although
there is evidence of improved bone mineral density.

With regard to treatment itself, guidelines advocate the use of vitamin D to treat vitamin D
deficiency (1). This is important as, on many occasions, prescribers will employ combined calcium
and vitamin D preparations to treat vitamin D deficiency. This is unnecessary and expensive, as
combined preparations are often unpalatable, being rather chalky, so reducing compliance. Also the
dose of vitamin D within the preparations is insufficient to produce adequate replacement. Thus,
the advice is to treat with pure vitamin D with the preference being Colecalciferol (Vitamin D3). In
general, a dose of 1000iu/d raises plasma vitamin D concentrations by 10 mcg/l (25nmol/l).

Treatment was previously problematic due to the absence of a licensed vitamin D formulation.
However, more recently, the MHRA have licensed Fultium-D3 for the treatment of vitamin D
deficiency (3). Fultium-D3 comes in 800iu capsules with the dose being 3200iu/d (4 capsules)
for treatment of deficiency and 1600iu/d (2 capsules) for insufficiency and long term maintenance.

Vitamin D treatment is extremely with evidence revealing that doses up to 10000 units per day are
tolerated and toxicity is not apparent until plasma 25OH-Vitamin D concentrations exceed 200 mcg/l (500 nmol/l).

References:

1. http://www.wadeandersonpt.com/vitamind/articles/diagnosis-vitdd.pdf
2. http://www.ncbi.nlm.nih.gov/pubmed/15113819
3. http://www.mhra.gov.uk/home/groups/par/documents/websiteresources/con137942.pdf

Cushing’s syndrome is an endocrine rarity with an incidence of 1-2 per million of the population. Accurately diagnosing the condition can be very rewarding and clinically it is important so as to avoid the high morbidity and mortality. Yet, the features of Cushing’s are often multisystem and non-specific being difficult to distinguish from pseudo-Cushing’s syndrome due to obesity, alcohol excess and depression. Clinical features that help to distinguish include thin skin, ease of bruising and proximal myopathy and clinical suspicion require biochemical confirmation through appropriate screening tests.

There are a number of screening tests that have high sensitivity and specificity in the diagnosis of Cushing’s syndrome. Measuring random cortisol is not a screening tool and should not be performed. In my opinion, timed cortisol collections whilst often cited as useful are often impractical in primary care as they require sampling typically at midnight and 9am. I think these are unnecessary in the context of modern screening investigations.

The 1mg Overnight Dexamethasone Suppression Test (ODST) involves the patient taking 1mg of Dexamethasone at 11pm – midnight and then having a 9am cortisol measured. A normal response is a cortisol below 50nmol/l. The test has high sensitivity and specificity, in excess of 90% but is probably less practical in primary care.

Measurement of a timed urine free cortisol is a very useful screening test with again high sensitivity and specificity (above 90%). This test is also very usefully employed in primary care as the patient collects urine for a 24hr period (eg 10am til 10am the following day) and this is assayed for free cortisol. There are established reference ranges for 24hr urine free cortisol; ours is

Late night salivary cortisol is also a useful screening test, with again high sensitivity and specificity. The patient merely produces saliva into a universal container at midnight. The sample can then be processed with normal midnight salivary cortisols (again dependent on quoted lab reference values) being

In summary, 24hr urine free cortisol is a very useful test that can be employed in primary care in subjects in whom Cushing’s syndrome is suspected. Other good screening tests include salivary cortisol as well as the 1mg-ODST but the applicability of these tests in primary care may be impaired by complexity of the test and/or lab processing.

Further reading

Cushing’s research and support foundation http://csrf.net/page/diagnostic_testing_for_cushings_syndrome.php

Hi, I am Samit Ghosal from Kolkata, India. I graduated from Calcutta National Medical
College in 1996 and did my post-graduation in Internal Medicine from Chennai in 2001.
Since then I started private practice in my own diagnostic center come Nursing Home. I
always had a special interest in Diabetes & Endocrinology, however never received the
recognition for this. Several friends suggested I should forgo my practice and join either
the doctorate course in Endocrinology or MRCP. However, it was a difficult scenario for me
since my practice was well established.

This was the time I came across an online Postgraduate Diploma in Diabetes. This was a
wonderful opportunity to sharpen my skills, get a special status for the medical area of
interest as well as carry on with my normal clinical practice. It was in 2009 I completed
my diploma and was immediately absorbed as a tutor for the same course. It was an honor
to interact in this period with the likes of Prof. David Owens, Dr. Steve Davies, Dr. Dean
Jenkins and many others. Suddenly, there was a change in the atmosphere at the home
front. I started getting recognition from the major medical bodies and was invited to speak
in their CME programs as well as becoming a part of their organization. It also gave me the
confidence to expand my Nursing Home facility, which is now a 100 bedded Hospital.

Early this year, I decided to take things further and joined the MSc in Diabetes as well
as the Postgraduate Diploma in Endocrinology course at University of Glamorgan. The
MSc is about to finish and it has been a very satisfying experience. I learned vital facts
about statistics not taught well in our medical curriculum. It has become impossible to
understand medical articles as well as giving lectures without understanding the intricate
details about statistics. I learned valuable facts from this course and even had our group
project published as evidence of the high standards of the course.

I think this is an opportunity for many like me, who want to upgrade their professional
status without disrupting their established clinical practice. I am continuing with the
courses of my interest, along with teaching students, a dream come true for most
physicians.

» Article: “Critically appraise the recent data published, on the link between insulins and cancer.”

If you would like to download a .PDF of the programme(s) then you can do so by clicking on the following links:

» Diploma Lecture programme (.PDF)

» MSc Lecture programme (.PDF)

University of Glamorgan (Glyntaf Campus)
Diploma Lecture Programme

University of Glamorgan (Glyntaf Campus)
MSc Lecture Programme

If you would like to download a .PDF of the programme(s) then you can do so by clicking on the following links:

» Diploma Lecture programme (.PDF)

» MSc Lecture programme (.PDF)

The dates for the March intake of the Diploma in Diabetes course are as follows:

March Course dates

Diploma lectures UK 16th – 17th March 2012

Online

• Module 1 – 19th Mar – 27th Apr 2012
• Module 2 – 14th May – 22nd Jun 2012
• Module 3 – 9th Jul – 17th Aug 2012
• Module 4 – 3rd Sept – 12th Oct 2012
• Module 5 – 29th Oct – 7th Dec 2012
• Module 6 – 2nd Jan – 8th Feb 2013

*Applicants for bursaries must be UK-based and submit a letter of recommendation from their LHB/SHA with their application.

Gaynor Jones qualified as a Registered General Nurse in 1985 with South Glamorgan Area Health Authority following attainment of N.N.E.B qualification at Bridgend College. For two years she followed an in-service training scheme at Llandough Hospital that allowed her to gain wide experience in all fields of general nursing. Following a career break she returned to surgical nursing closely followed by general practice nursing where her interest in diabetes developed. In 2004 Gaynor was employed as a Diabetes Nurse Facilitator for Caerphilly Local Health Board, initially to implement the Inequalities in Health project for diabetes following the Wanless report. This post involved clinical mentoring and support for GP practices, assessing performance through clinical audit, providing information and facilitating education for both professionals and patients.

To expand her diabetes experience Gaynor returned to secondary care in 2009 to work as a Diabetes Specialist Nurse at University Hospital of Wales, Cardiff where she currently works with other members of the multi-disciplinary team to deliver both inpatient and outpatient care. Through this period she has also provided out-reach services to GPs through a Welsh Government scheme to support the Agenda for Health and other Welsh Government initiatives.

Her interest in education began with becoming an XPERT educator in 2005 (which was enhanced in 2009 by XPERT Insulin). She then went on to complete a degree in Promoting Health and Wellbeing.

As well as being a tutor for the Postgraduate Diploma in Diabetes, she is an Undergraduate Lecturer with University of Glamorgan and is currently undertaking the MSc in Diabetes.

Gaynor is a former student of the PG Diploma course and as such has a full insight into the course both from the perspective of a student and a tutor.

Outside diabetes, her interests include travel, hill walking and sugarcraft.

Course dates

Diploma

Lectures UK

16th – 17th March 2012

Online

Module 1 – 19th Mar – 27th Apr 2012

Module 2 – 14th May – 22nd Jun 2012

Module 3 – 9th Jul – 17th Aug 2012

Module 4 – 3rd Sep – 12th Oct 2012

Module 5 – 29th Oct – 7th Dec 2012

Module 6 – 2nd Jan – 8th Feb 2013

MSc

Lectures UK

17th March 2012

Online

Module 1 – 2nd Apr – 23rd June 2012

Module 2 – 16th July – 4th Jan 2013

To understand the purpose and way to construct your portfolio it may be helpful to firstly explain that it is not just a summary of the case/group discussions and module readings.

With each entry you make to the portfolio you should build upon your previous entries, treating it as a process. N.B. you should not be deleting your previous entries when you make new ones, as the previous entries are key to your process of learning. The portfolio can be motivational to your learning, and can also challenge and guide you through exploring yourself, your coursework and your professional experience.

In your portfolio, you may wish to include notes on the following:

• Readings from the module that interest you and any material that you wish to learn more about.
• Questions, thoughts and reflections that have come to your mind after reading up on a particular subject.
• Reflections on (not repetition of) the case discussions with the other students in your group and your tutor.
• Whether you are able to put into practice what you have learnt on the course in your professional environment. Has the knowledge you have gained from the course altered the way you have approached diabetes in your place of work?
• Your reflections on this course and how well it is meeting your needs.
• What key areas you may feel that you need to reflect on within the module materials in order to further your understanding or knowledge of aspects you were unfamiliar with.
• Changes in your perceptions on certain areas of the subject that may develop over the course of writing your portfolio. Contrasting your previous knowledge with present.

Remember that there is no set structure to the portfolio as every student’s learning process will be different. What is important is that the reflective journal assists your understanding and progression through the course.

The most notable benefits from post graduate qualifications in medicine are the financial, career-based and personal development gains. Postgraduates can earn between 20-30% more than their equivalents with an undergraduate degree, according to recent surveys. Gaining a further qualification subsequently increases your value as you acquire new skills and knowledge, and this can lead to financial rewards and career progression.

Some career paths may require that a healthcare professional has further experience beyond a first degree level, especially if the position demands a detailed knowledge and understanding of a particular field of medicine, such as diabetes. Additionally when applying for new jobs, the employers will look for an applicant that stands apart from their peers. A postgraduate qualification in a specialised field of medicine is an obvious attribute that will enable the candidate to differentiate themselves from other applicants providing a competitive advantage at interview. In secondary care, for instance, the formal process of clinical Specialist Training has seen the shift away from MD and PhD projects. Yet, the competitive advantage offered by such qualifications at interview remains. In consequence, many are taking the opportunity to study for a postgraduate qualification such as a MSc and Diploma in their spare time.

Throughout the career pathway, there is an expectation on practitioners to provide training for their students and trainees. Arguably, how can a senior healthcare professional teach a student in areas such as publications and research without having done this themselves? Thus postgraduate qualifications are important in providing the necessary education and teaching skills to develop trainees.

Given the great variety of postgraduate courses in medicine now available, it is very easy to find one that caters to your specific requirements. There are numerous online courses, such as the Diabetes Diploma and MSc courses, that allow you to study part time while continuing with a full time career. In addition, the completion of one course may inspire you to do another, e.g. progressing from a postgraduate diploma to a MSc in a chosen area of study, furthering your personal and professional gain and increasing your prospects for further career development. Whichever discipline of medicine you choose to pursue in a postgraduate qualification, the work load will be challenging, especially when studying part-time alongside a full time job, but the benefits are clearly worth the time and effort.

Factors to appreciate when selecting a postgraduate qualification in medical specialities:

1. Fully understand the reasons why you want to do a postgraduate course.
2. Decide on the type of course that suits you –

• Which speciality?
• To what level – certificate/Diploma/MSc/MD/PhD?
• Which teaching style – Residential, distance learning, online or a mixture of all three?

3. Realise the time commitments required to complete the course.
4. Recognise the cost implications of the courses. Costs vary but may range from £3000 to £10000+ annually.
5. Put the support structure in place by fully discussing the course with colleagues and family.
6. The course organisers are usually very happy to talk the course over, so why not take time to discuss your issues directly with the people that run the course. How do they deal with you? Are you impressed by them?

Examples of medical postgraduate courses available (2011/12):

• University of Glamorgan Diploma/MSc in Diabetes and Endocrinology: http://www.diploma-msc.com/
• Online Cosmetic Courses: http://www.cosmetic-courses.co.uk/
• Nursing and Midwifery Courses e.g. University of Aberdeen: http://www.abdn.ac.uk/
• Imperial University Clinical, Science-based or Research MSc Courses: http://www1.imperial.ac.uk/medicine/teaching/postgraduate/
• MSc in Physiotherapy, e.g. University of Hertfordshire: http://www.herts.ac.uk/
• Courses in Dermatology:http://www.dermatology.org.uk/
• http://www.findamasters.com/