Pooja Sachdev

Bariatric surgery in severely obese adolescents: a single-centre experience

Background Increasing numbers of severely obese young people undergo bariatric surgery in the USA with reports of substantial weight loss after 1 year. National Institute for Clinical Excellence 2006 suggests considering surgery for young people in ‘exceptional circumstances’. We present six patients operated upon 2004–2012 at our centre in the UK. Case series Six patients (4 male) aged 14–16 years (mean age 15.10) underwent surgery. Mean preoperative body mass index (BMI) was 62.7 kg/m2 and BMI SDS +4.4. Comorbidities included hypertension, insulin resistance, obstructive sleep apnoea, limited mobility, benign intracranial hypertension and psychosocial issues. All six patients had prior involvement with local lifestyle weight management services and had pharmacological intervention. Four laparoscopic gastric bypass procedures, one laparoscopic gastric banding (patient had a gastric balloon prior to band) and one laparoscopic sleeve gastrectomy were performed. Results There were no major postoperative procedural complications (one patient had a port rotation). Mean percentage of weight loss, as a percentage of total body weight at 6 and 12 months, was 22 and 27%, respectively. Average absolute weight loss at current follow-up is 54 kg. Mean BMI at 12 months postprocedure was 46.5 kg/m2—a mean fall of 16.2 kg/m2. Mean BMI SDS fell from +4.4 to +3.8 at 12 months and +3.1 at 2 years. Resolution of hypertension, improved school attendance and no progression to T2DM were the benefits noted. Conclusions Recent systematic reviews and meta-analyses suggest that bariatric surgery results in sustained and clinically significant weight loss in paediatric populations. The surgical option should continue to be exercised with extreme caution only in severely obese adolescents and done so in appropriate case results in positive outcomes.

The short Synacthen test: a questionnaire survey of current usage

Background Supported by meta-analyses, the low-dose Synacthen test (LDST) has gained in popularity, with many believing it to be more sensitive than the supraphysiological standard (250 µg) short ST (SSST), particularly when assessing children prescribed high-dose inhaled corticosteroids (HDICS). However, consensus is lacking about its specific clinical application, what is considered ‘low dose’ and how that dose is made up. Methods To ascertain current use of the short Synacthen test (SST), a questionnaire was emailed to members of the British Society of Paediatric Endocrinology and Diabetes in the UK and Ireland (N=257), requesting a response from each department (N=92). A reminder was sent a month later to members of departments which had not responded. Results The authors received 39 replies, giving a response rate of 42%. All departments use the SST: 82% use an LDST, 87% use the SSST and 69% use both. The 1 µg dose was used by 44% of hospitals, with the other 56% using seven different doses based on age, weight and body surface area. There were 14 different methods of preparing the low dose test. Additionally, variations in the timings of cortisol sampling and the diagnostic cut-offs for adrenal insufficiency were found. Increased requests for SSTs in children with asthma prescribed HDICS were noted by 44% of respondents, with 67% reporting the detection of adrenal suppression in this group. Conclusion Standardisation of the SST is required to address the considerable variation in the methodology and application of this test in the UK and Ireland.

Intra-gastric balloon as an adjunct to lifestyle support in severely obese adolescents; impact on weight, physical activity, cardiorespiratory fitness and psychosocial well-being

Background:Severe adolescent obesity (body mass index (BMI) >99.6th centile) is a significant public health challenge. Current non-invasive treatments, including community-based lifestyle interventions, are often of limited effectiveness in this population, with NICE guidelines suggesting the use of bariatric surgery as the last line of treatment. Health professionals are understandably reluctant to commission bariatric surgery and as an alternative, the use of an intra-gastric balloon as an adjunct to a lifestyle programme might offer a reversible, potentially safer and less invasive option.Objectives:Explore the use of an intra-gastric balloon as an adjunct to a lifestyle support programme, to promote weight loss in severely obese adolescents. Outcomes included weight loss, waist and hip measurements, psychosocial outcomes including health-related quality of life (HRQoL) and physical self perceptions, physical activity and cardiorespiratory fitness.Method:Non-randomised pilot study.Results:Twelve severely obese adolescents (5 males, 7 females; mean age 15 years; BMI >3.5 s.d.; puberty stage 4 or more) and their families were recruited. Mean weight loss at 12 months (n=9) was 3.05 kg±14.69; d=0.002, P=0.550, and a BMI Z-score (n=12) change of 0.2 s.d.; d=0.7, P=0.002 was observed at 6 months with a large effect, but was not sustained at 12 months (mean change 0.1 s.d.; d=0.3, P=0.146). At 24 months (n=10), there was a weight gain from baseline of +9.9 kg±1.21 (d=0.4; P=0.433). Adolescent and parent HRQoL scores exceeded the minimal clinical important difference between baseline and 12 months for all domains but showed some decline at 24 months.Conclusion:An intra-gastric balloon as an adjunct to a lifestyle support programme represents a safe and well-tolerated treatment approach in severely obese adolescents, with short-term effects on weight change. Improvements in psychosocial health, physical activity and cardiorespiratory fitness were maintained at 12 months, with varying results at 24 months.

Protocol for: The Use of Intra-Gastric Balloons as an Adjunct to a Lifestyle Support Programme to Promote Weight Loss in Severely Obese Adolescents

Background: Severe childhood and adolescent obesity (BMI>3.5SD) remains a significant public health priority with an increasing incidence and is associated with significant morbidity including immediate and long-term cardiovascular, metabolic and psychological consequences. Current non-invasive treatments including lifestyle modification and pharmaceutical intervention are of limited effectiveness in this population, which leaves permanent bariatric surgery as the only viable option. As an alternative, intra-gastric balloons offer a reversible, potentially safer and less invasive option for severely obese adolescents for whom all other available treatments have been exhausted. Methods/design: BOB is a non-randomised pilot study. A cohort of 12 obese adolescents (BMI > 3.5SD, puberty stage 4 or more) aged 13 - 16 years, will be recruited to the study, where an intragastric balloon (ORBERA – inflated to 500-700ml) will be inserted into the stomach for 6 months, whilst receiving intense, weekly, behavioural support for the family. Follow-up will continue for 18 months after balloon removal with reduced behavioural support. The primary outcome measure will be the change in body weight and BMI standard deviation score from baseline following six months with the intragastric balloon and lifestyle therapy. Secondary outcome measures include the assessment of weight maintenance at 18 months post balloon removal, biomedical outcomes including blood glucose levels, physical activity and physical fitness, and psychosocial outcomes such as paediatric health-related quality of life.

International survey on high- and low-dose synacthen test and assessment of accuracy in preparing low-dose synacthen

The short synacthen test (SST) is widely used to assess patients for adrenal insufficiency, but the frequency and protocols used across different centres for the low‐dose test (LDT) are unknown. This study aimed to survey centres and test the accuracy of ten different synacthen preparation strategies used for the LDT.

Intragastric balloon as an adjunct to lifestyle programme in severely obese adolescents: impact on biomedical outcomes and skeletal health

Intragastric Balloons are a temporary, reversible and safer option compared to bariatric surgery to promote significant weight loss, leading to improved metabolic outcomes. However, due to subsequent weight regain, alternative procedures are now preferred in adults. In adolescents, more amenable to lifestyle change, balloons may be an alternative to less reversible procedures. Our aim was to assess the tolerability and efficacy of the intragastric balloon in severely obese adolescents and the impact of associated weight loss on biomedical outcomes (glucose metabolism, blood pressure, lipid profiles) and bone density. A 2-year cohort study of 12 adolescents (BMI >3.5 s.d., Tanner stage >4) following 6 months intragastric balloon placement was carried out. Subjects underwent anthropometry, oral glucose tolerance test, and DEXA scans at 0, 6 and 24 months. The results showed clinically relevant improvements in blood pressure, insulin: glucose metabolism, liver function and sleep apnoea at 6 months. Changes were not sustained at 2 years though some parameters (Diastolic BP, HBA1c, insulin AUC) demonstrated longer-term improvement despite weight regain. Despite weight loss, bone mass accrual showed age appropriate increases. In conclusion, the intragastric balloon was safe, well tolerated and effective in supporting short-term weight loss and clinically relevant improvement in obesity-related complications, which resolved in some individuals. Benefits were not sustained in the majority at 2 years.

Monogenic diabetes mellitus in cystic fibrosis

We present a non-consanguineous family of three siblings who presented with diabetes mellitus (DM), two of whom had genetically confirmed cystic fibrosis (CF), with one pancreatic-sufficient mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene (ΔF508/R117H;IVS8-5T). A detailed history revealed family members from three successive generations diagnosed with ‘type 1’ or ‘type 2’ diabetes, leading to genetic investigations for monogenic DM. A heterozygous frameshift mutation in the hepatocyte nuclear factor 1 homeobox alpha (HNF1A) gene (c.404delA) was subsequently confirmed in all three siblings, which is known to cause monogenic diabetes and is exquisitely sensitive to sulfonylurea therapy. Following this diagnosis, both siblings with CF and HNF1A monogenic diabetes were started on gliclazide therapy, while their older brother who had been wrongly diagnosed with type 1 diabetes was switched from insulin to gliclazide, all with excellent therapeutic responses.

G175(P) Current dilution methods cause large variations and inaccuracies when making up 1MCG synacthen dose

Aims The low-dose Short Synacthen test is a popular diagnostic test of adrenal insufficiency in children. It is employed by 82% of UK paediatric endocrinologists. Although various dosing strategies exist, 1 mcg is most commonly employed, however none of the low-dose forms of Synacthen are commercially available. A ‘British Society for Paediatric Endocrinology and Diabetes’ survey revealed 14 different methods for diluting 250 mcg/ml ampoules. We investigated whether the various dilution strategies result in differences in the resultant Synacthen dose administered. Methods The ten most popular dilution methods were tested, encompassing different diluents (0.9% saline n=9, 5% dextrose n=1), single (n=6) and double (n=4) dilution strategies and varying initial quantities of Synacthen (0.1 to 1 ml). Each method was made up five times under simulated ward conditions and three samples were taken from different parts of the bag of resultant solution. Samples were frozen then batch-analysed on an hACTH radioimmunoassay validated for Synacthen. All samples were diluted to 250 pg/ml (most sensitive part of the assay measuring range) and the coefficient of variation (CV) calculated. Results There was marked variation in Synacthen detected from the three samples taken from the same solution (CV 13.4%– 194.6%) suggesting inadequate mixing, the five preparations of the same method, suggesting batch to batch variation, and between the ten different preparation methods (CV range 24.2%–163.7%) suggesting divergence between methods. Estimates of the likely Synacthen dose, if administered to patients, ranged from less than 0.04 mcg to more than 2 mcg. Conclusion Considerable variation was observed both within and between dilution methods. Variables, which may affect the actual dose of Synacthen administered, include: poor dilution technique, inappropriate dilution strategies, pharmaceutical manufacturer variation, use of inaccurate ward equipment, volume inconsistencies, lack of adequate mixing and lack of a controlled environment. We recommend low-dose Synacthen be made up under laboratory conditions and call for a commercial preparation of 1 mcg Synacthen.

G194(P) Delayed diagnosis of Type 1 Diabetes Mellitus (T1DM)in children

Background There are around 3000 new paediatric diagnoses of T1DM a year in the UK with around 25% presenting in DKA (Diabetic ketoacidosis). Cerebral oedema remains the most common cause of mortality in DKA, particularly in children and adolescents, and is more likely to occur in newly diagnosed T1DM. Guidelines for the management of suspected T1DM in primary care recommends that patients presenting to the GP with symptoms suggestive of T1DM (polydipsia, polyuria, thirst, lethargy, weight loss) should have an immediate random finger prick capillary glucose test. If positive (>11.1mmol/L), the child should be referred to specialist diabetes services in secondary care the same day. Aim The aim of this study is to analyse cases of delayed presentation to secondary care in an attempt to ascertain reasons for this delay. The ultimate aim is to increase awareness, amongst primary care professionals, of the guidance surrounding the diagnosis of T1DM and consequently decrease morbidity and mortality in newly diagnosed T1DM. Methods A retrospective case series analysis of patients presenting with a delayed or missed diagnosis of T1DM between 2012–2015. Results 12 cases (2 female, age range 1.5–15 years) of delayed presentation of T1DM to hospital were identified over a 3 year span. This number represents 10% of new diagnoses over this period. These patients presented to primary care with core signs and symptoms of T1DM. None had an immediate capillary blood glucose check. 1/12 (8%) had a blood glucose checked but this was sent to the laboratory, this was then not actioned appropriately. The mean delay between presentation to the GP and to hospital was 4.6 days (range 12 h-21 days). 6/12 (50%) of children presented to hospital in DKA. 2 of these children had prolonged stays in intensive care and have significant long-term sequelae. Conclusion 10% of children presenting with new diagnoses of T1DM have a delayed presentation to hospital. Prompt recognition and referral of children with suspected diabetes is vital to prevent life-threatening DKA. Reasons for delayed presentations include: failure to recognise signs and symptoms of diabetes; failure to perform immediate finger prick blood glucose and failure to take appropriate action when an abnormal result is detected.