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AimsWe aim to find the prevalence of overweight and obesity in children aged over the age 5 with type 1 diabetes who attend the tertiary referral clinic in our Lady’s Children’s Hospital Crumlin, Dublin.MethodsWe measured heights and weights of the children with type 1 diabetes attending the clinic. We entered the data into our electronic database (Diamond version 1, Hicom). The electronic database calculates the child’s body mass index (kg/m²). We exported the data to SPSS Version 24 IBM. We calculated the children’s BMI Z-score using the WHO Reference 2007 SPSS macros package. We used the WHO 2007 Reference normative data and the definition of overweight as BMI z-score for age more than 1 standard deviation away from the mean (represents 85th centile). We used the WHO definition of obesity as BMI z-score for age of more than 2 standard deviations away from the mean (represents 97th centile). We ran descriptive statistics. We analysed the relationship between BMI z-score and HbA1c using a linear regression model.Results541 children attended the diabetes clinic. 511 of these children were over the age of 5. Of these children 38.7% had a BMI z-score +1 SD away from the mean in the WHO reference data reflecting overweight. Of the 511 children 47 or 9.2% of them had a BMI z-score +2SD from the mean normative data reflecting obesity and 1.2% had a BMI z-score of +3SD away from the mean reflecting severe obesity. There was no statistically significant relationship between BMI z-score and HbA1c using linear regression.ConclusionOur results highlight the high prevalence of overweight and obesity in children with type 1 diabetes. The prevalence of overweight and obesity is nearly double that of the general population. This is a relatively new phenomena. Various causes have been postulated including intensive insulin therapy since the early 90s as well as the secular trend in overweight and obesity.

Introduction Adolescents with Type 1 diabetes are a cohort whose self‐management of their diabetes care often declines during adolescence which can lead to adverse health outcomes. Research indicates that providers find it challenging to engage adolescents in communication exchanges during triadic encounters in diabetes clinics. Our study aimed to explore adolescents, parents, and providers' experiences of clinic encounters. Methods A qualitative study was conducted with a convenience sample of 13 adolescents with Type 1 diabetes (aged 11–17), 14 parents, and seven providers. Participants were recruited from two outpatient diabetes clinics in two urban children's hospitals, Ireland. Data were obtained using a combination of interviews and focus groups. Data were analysed thematically. Results Adolescents and their parents appeared to hold both positive and negative experiences of diabetes clinic encounters. Providers reported challenges associated with engaging adolescents in communication exchanges. The structure, focus and style of clinic encounters created barriers that potentially led to suboptimal adolescent participation and impaired provider–adolescent communication during clinic visits. Conclusions The findings provide insights into the challenges associated with adolescents' engagement in communication encounters in diabetes clinics. Healthcare providers could encourage adolescents to be more actively involved in their diabetes management, by taking an adolescent‐centred approach and creating a nonjudgemental milieu. Focusing on adolescent's agenda could lead to more meaningful and relevant discussions between providers and adolescents and ensure more tailored education in the time available. Adolescence is a risky period for nonadherence and adverse health complications; therefore, it is critical that providers make every contact count in diabetes clinic encounters. Patient or Public Involvement The study's design and delivery were guided by two advisory groups, comprising (1) five adolescents living with Type 1 diabetes (T1D) and (2) five parents of an adolescent with T1D.

Introduction Limited research has investigated young people's opinions on health measures that are used in clinical and research settings. This study aimed to describe young people's views on research methods utilised in a longitudinal birth cohort. It also aimed to explore the feasibility of (i) blood pressure and a fitness assessment as a substitute for blood biomarkers; (ii) foot length as a substitute for maternal‐reported stage of puberty and (iii) neck and mid‐upper arm circumference as a substitute for body composition analysis in preteens (9–11‐year‐olds). Methods This is a mixed‐methods analysis of preteens (n = 408) who were born into the ROLO longitudinal birth cohort study. Weight, height, skinfold thickness, circumferences, body composition, blood pressure, fitness (shuttle run test score), blood biomarkers, stage of puberty and foot length were obtained at 9–11 years of age. A subgroup completed a Likert‐style acceptability questionnaire after their study visit and took part in public and patient involvement to gain further insight into opinions of health measures utilised. Statistical comparisons and linear regression models explored associations in the total group and stratified by child sex. Results were adjusted for multiple testing. Results Of 50 preteens who completed an acceptability questionnaire after their study visit, no participants rated the study measurements, exercises or questionnaires as unacceptable research methods, and only 5% rated providing a blood sample as unacceptable. Blood pressure percentiles and fitness scores were not strongly associated with blood biomarkers. In the total group, after adjustment for multiple testing, neck and mid‐upper arm circumference were positively associated with body mass index z‐score (Beta [B] = 0.42, 95% confidence interval [CI] = 0.34,0.49, p < 0.001, q = 0.015; B = 0.32, 95% CI = 0.29, 0.35, p < 0.001, q = 0.005), waist circumference (cm) (B = 2.83, 95% CI = 2.22, 3.45, p < 0.001, q = 0.016; B = 2.10, 95% CI = 1.78, 2.41, p < 0.001, q = 0.010) and body fat (%) (B = 2.26, 95% CI = 1.66, 2.87, p < 0.001, q = 0.018; B = 2.05, 95% CI = 1.80, 2.30, p < 0.001, q = 0.008), respectively. Conclusion Research methods were acceptable to preteens. Neck and mid‐upper arm circumference may serve as simple and less burdensome indicators of adiposity. Future research should explore minimally invasive blood sampling techniques. Patient or Public Contribution Preteens contributed to the manuscript analysis by sharing their insights and ideas related to health measurements used in a longitudinal birth cohort study. Their input provided important perspectives on the acceptability of health measures in this age group that may have important implications for researchers and clinicians conducting health research with youth.

Background Macrosomia (birthweight ≥ 4 kg or ≥ 4.5 kg) is strongly associated with a predisposition to childhood obesity, which in turn is linked with adverse cardiometabolic health. Despite this, there is a lack of longitudinal investigation on the impact of high birthweight on cardiometabolic outcomes in youth. The preteen period represents an important window of opportunity to further explore this link, to potentially prevent cardiometabolic profiles worsening during puberty. Methods This is a secondary analysis of 9–11-year-olds (n = 405) born to mothers in the ROLO longitudinal birth cohort study, who previously delivered an infant with macrosomia. Preteens were dichotomised into those born with and without macrosomia, using two common cut-off criteria (birthweight ≥ 4 kg (n = 208) and < 4 kg; ≥ 4.5 kg (n = 65) and < 4.5 kg). Cardiometabolic health was assessed using anthropometry, dual-energy x-ray absorptiometry, blood pressure, heart rate, cardiorespiratory endurance (20-m shuttle run test), and non-fasting serum biomarkers for a subgroup (n = 213). Statistical comparisons between the two groups were explored using independent t -tests, Mann–Whitney U tests, and Chi-square tests. Crude and adjusted linear regression models investigated associations between macrosomia and preteen cardiometabolic outcomes. Results In total, 29.3% (n = 119) of preteens had overweight/obesity based on their BMI z-score. Preteens born ≥ 4 kg had lower median (IQR) C3 concentrations (1.38 (1.22, 1.52) g/L vs. 1.4 (1.26, 1.6) g/L, p  = 0.043) and lower median (IQR) ICAM-1 concentrations (345.39 (290.34, 394.91) ng/mL vs. 387.44 (312.91, 441.83) ng/mL, p  = 0.040), than those born < 4 kg. Those born ≥ 4.5 kg had higher mean (SD) BMI z-scores (0.71 (0.99) vs. 0.36 (1.09), p  = 0.016), and higher median (IQR) lean mass (24.76 (23.28, 28.51) kg vs. 23.87 (21.9, 26.79) kg, p  = 0.021), than those born < 4.5 kg. Adjusted linear regression analyses revealed birthweight ≥ 4 kg was negatively associated with C3 concentration (g/L) (B = − 0.095, 95% CI = − 0.162, − 0.029, p  = 0.005) and birthweight ≥ 4.5 kg was positively associated with weight z-score (B = 0.325, 95% CI = 0.018, 0.633, p  = 0.038), height z-score (B = 0.391, 95% CI = 0.079, 0.703, p  = 0.014), lean mass (kg) (B = 1.353, 95% CI = 0.264, 2.442, p  = 0.015) and cardiorespiratory endurance (B = 0.407, 95% CI = 0.006, 0.808, p  = 0.047). Conclusion This study found no strong evidence to suggest that macrosomia is associated with adverse preteen cardiometabolic health. Macrosomia alone may not be a long-term cardiometabolic risk factor. Trial registration ISRCTN54392969 registered at  www.isrctn.com .

Macrosomia is associated with overweight and obesity across the life course. Most research to date has been based on cross-sectional analyses, and longitudinal investigations between macrosomia and developmental trajectories of growth throughout the first decade of life are lacking. This research aimed to examine associations between macrosomia and postnatal growth trajectories from birth to 10 years of age. Children (  = 337) from the ROLO longitudinal birth cohort, who were born to mothers with previous macrosomic delivery. Birthweight was recorded at delivery and dichotomised using the cut-off criteria for macrosomia (birthweight ≥ 4 kg and < 4 kg). Child weight, length/height, body mass index (BMI) and waist circumference were measured at birth, 6 months, 2, 5 and 10 years of age. Postnatal growth trajectories were developed using these longitudinal measurements from birth up to 10 years of age. Linear spline multilevel models were used to examine associations between macrosomia and postnatal trajectories with adjustment for confounders (maternal ethnicity, socioeconomic status, maternal age at delivery, maternal smoking in pregnancy, paternal BMI, adherence to gestational weight gain guidelines in pregnancy, sex of the child, original study group allocation, adherence to a special diet in pregnancy, maternal physical activity levels, metabolic complications in pregnancy and breastfeeding). In this cohort, 53.7% (  = 181) had a birthweight ≥ 4 kg. The median (IQR) early pregnancy BMI was 25.4 (23.1, 28.6) kg/m , and mothers were 33.1 (30.6, 35.3) years old at delivery. We found no strong evidence of associations between macrosomia and trajectories of childhood growth from birth to 10 years of age. Significant findings in crude and adjusted models were close to the null and provide limited evidence for a meaningful association. Macrosomia was associated with early, but not later, childhood growth trajectories. Associations were weak and varied according to definition and growth measurement. The lack of strong results indicates uncertain clinical relevance and warrant additional future research in a larger cohort.

Aims/hypothesisMucosal-associated invariant T cells (MAIT cells) are an abundant population of innate T cells. When activated, MAIT cells rapidly produce a range of cytokines, including IFNγ, TNF-α and IL-17. Several studies have implicated MAIT cells in the development of metabolic dysfunction, but the mechanisms through which this occurs are not fully understood. We hypothesised that MAIT cells are associated with insulin resistance in children with obesity, and affect insulin signalling through their production of IL-17.MethodsIn a cross-sectional observational study, we investigated MAIT cell cytokine profiles in a cohort of 30 children with obesity and 30 healthy control participants, of similar age, using flow cytometry. We then used a cell-based model to determine the direct effect of MAIT cells and IL-17 on insulin signalling and glucose uptake.ResultsChildren with obesity display increased MAIT cell frequencies (2.2% vs 2.8%, p=0.047), and, once activated, these produced elevated levels of both TNF-α (39% vs 28%, p=0.03) and IL-17 (1.25% vs 0.5%, p=0.008). The IL-17-producing MAIT cells were associated with an elevated HOMA-IR (r=0.65, p=0.001). The MAIT cell secretome from adults with obesity resulted in reduced glucose uptake when compared with the secretome from healthy adult control (1.31 vs 0.96, p=0.0002), a defect that could be blocked by neutralising IL-17. Finally, we demonstrated that recombinant IL-17 blocked insulin-mediated glucose uptake via inhibition of phosphorylated Akt and extracellular signal-regulated kinase.Conclusions/interpretationsCollectively, these studies provide further support for the role of MAIT cells in the development of metabolic dysfunction, and suggest that an IL-17-mediated effect on intracellular insulin signalling is responsible.

AimsPrimary intestinal lymphangiectasia (PIL) is a well-recognized congenital abnormality of the lymphatic system leading to protein-losing enteropathy (PLE). It is an uncommon disorder seldom seen in clinical practice. The prevalence is unknown. The objective of this case report is to describe the clinical presentation and diagnosis of PIL.MethodsA detailed chart review was performed. Data extracted from the medical records included presenting complaint, disease progression, laboratory results, imaging and clinical measurements.ResultsThe patient was a 4 month old boy, who presented to the emergency department in Our Lady‘s Children Hospital, Crumlin (OLCHC) with a 3 week history of bilateral lower limb swelling, easy bruising and a change in stool consistency. The baby was passing watery secretions prior to stool. Stool consistency was clay- like with mucous. Initial bloods showed a severe coagulopathy (PT 204.6 secs, APTT 80.4 secs), severe electrolyte disturbances (Na+128 mmol/l, K+ 2.6 mmol/l), mild transaminase elevation (AST 87 U/l, ALT 49 U/l), metabolic acidosis (pH 7.293, pCO2 4.75, HCO3- 16.9) and profound hypoalbuminemia (13 g/l). The patient was admitted for electrolyte replacement and for further investigation of the underlying cause of the hypoalbuminemia and oedema. Stool alpha- 1-antitrypsin (5.66 mg/g) was markedly elevated confirming protein-losing enteropathy. Further investigations including endoscopic biopsies and allergy testing excluded other enteropathies such as coeliac disease, inflammatory bowel disease, congenital enteropathies and allergic enteritis. As in this case PIL pathology is often mid small bowel and beyond the reach of endoscopic biopsies.ConclusionHypoalbuminemia can manifestation from a variety of clinical disorders. This patient had an extensive work-up to exclude other possible causes. Once PLE was confirmed, further investigations were required to identify the underlying cause. The main laboratory findings that supported the diagnosis of PIL included hypoproteinaemia, protein losing enteropathy, lymphopenia, panhypogammaglobulinemia, malabsorption of fat-soluble vitamins and, ultimately, response to a low long chain triglyceride containing diet.

AimsCyclic Cushing’s syndrome is an uncommon disorder, defined by intermittent episodes of excess cortisol secretion. These episodes occur sporadically. The fluctuating clinical picture and conflicting biochemical findings make Cyclic Cushing’s syndrome challenging to diagnosis. We report a case of Cyclic Cushing’s syndrome is a 6 year old boy and discuss the challenges in diagnosis.MethodsA detailed chart review was performed. Data extracted from the medical records included presenting complaint, disease progression, laboratory results, imaging and clinical measurements.ResultsAt 4 years of age the patient presented with a two week history of rapid weight gain, increased appetite, lethargy, polydipsia and polyuria. The child has a background history of speech delay, obesity (weight 29 kg, >99.6thcentile, BMI 23.3 kg/m2), macrocephaly (OFC 56cm, > 97thcentile), and facial freckling. During an in-patient stay, six hourly serum cortisol levels taken over a 48 hour period followed by a dexamethasone suppression test and a 24 hour urinary cortisol collection failed to support a diagnosis of Cushing’s Syndrome. His significant facial freckling -with lip sparing and no mucosal involvement - prompted a Clinical Genetics referral. A diagnosis of Carney Complex (CNC) with a mutation in the PRKAR1A gene was made.The patient continued to have episodes that would suggest episodic hyper-secretion of cortisol. Each episode lasted 3–4 weeks and then resolved. Parents reported 2 episodes in 2016, 1 episode in 2017 and 1 episode in 2018. In early 2018, the patient was admitted to hospital during an acute episode. A diagnosis of Cyclical Cushing’s syndrome was confirmed by very elevated serum cortisol levels, elevated 24 hour urine free-cortisols, failure to suppress to dexamethasone and a very suppressed ACTH level during this admission. MRI and CT of abdomen however failed to reveal any adrenal lesions. Following discussions at multidisciplinary team meetings and with colleagues in adult Endocrinology, a decision was made to proceed with a bilateral adrenalectomy. The patient tolerated the procedure well. His adrenal histology was consistent with subtle changes suggestive of a mild Primary pigmented nodular adrenocortical disease (PPNAD) picture. Following adrenalectomy his symptoms have completely resolved but he will require lifelong Hydrocortisone and Fludrocortisone replacement.ConclusionOur patient has a background history of CNC and PPNAD which has been linked in very occasional cases with Cyclical Cushing’s syndrome. PPNAD is the most common endocrine manifestation of CNC. This case report highlights the difficulty in diagnosing Cyclic Cushing’s syndrome.

Although the orchestrating role of Interleukin-36 cytokines in regulating inflammation at barrier tissue sites, is well established, whether they play a significant role in the settings of metabolic health and disease, has yet to be fully established. Several recent studies have demonstrated that IL-36 cytokine expression is elevated among adult patients with obesity, and can play roles in regulating both insulin sensitivity and driving inflammation. In this report, we have extended these analyses to paediatric patients and identified an association between elevated serum levels of expression of the specific Interleukin-36 subfamily member, IL-36β, among children with obesity displaying insulin sensitivity, compared to children with obesity who are insulin resistant. While these data further indicate a possible protective role for IL-36 in metabolic health, they also differ with previous findings from an adult patient cohort, where elevated levels of the related cytokine, IL-36γ, were found to occur in association with improved metabolic health. While highlighting important differences between paediatric and adult patient cohorts in the context of metabolic disease associated with obesity, these data underscore the need for a deeper mechanistic analysis of the role of IL-36 cytokines in disease.

Adolescents with Type 1 diabetes mellitus (T1DM) are a high risk group due to relatively poor metabolic control and infrequent attendance at healthcare appointments. Many have difficulty in establishing and maintaining self-care routines which can lead to serious complications and hospitalisations. Furthermore the transition from paediatric to adult services is a high-risk period associated with poor glycaemic control, disengagement with healthcare, and increased risk of complications. To improve the quality of care for adolescents they need to be prepared for self-management, to become wholly responsible for their treatment regimen, make autonomous healthcare decisions, and interact with their healthcare providers. Current guidelines emphasise that paediatric diabetes services need to be patient-centred and should promote self-management[1, 2]. The PACE (Promoting Adolescents Communication and Engagement) study aims to develop and test an intervention to promote adolescents’ active engagement and self-advocacy skills in clinic interactions with healthcare providers.For work package 1, we conducted separate focus groups with adolescents with T1DM, parents and providers from two clinics in Ireland. The objectives were: a) to obtain views of the educational needs of adolescents with T1DM; b) how to involve adolescents more during paediatric diabetes visits; c) identify content preferences for an educational video; d) and what to include in a question prompt list. All focus groups were audio-tape recorded and transcribed. Identifiers were removed and replaced with a numerical code. The qualitative analysis software package NVivo version 11.0 assisted in the data analysis. Ethical approval was obtained from the two relevant ethics committees.The data from the focus groups will inform the development of the intervention (video and question prompt sheet) which is based on Bandura’s Social Cognitive Theory, as self-efficacy is a central component of SCT. Self-efficacy is the belief that an individual has the ability to create change by personal actions. Enhanced diabetes self-efficacy has been linked to improved diabetes self-management and glycaemic control and is an important indicator of health behaviour changes in adolescents. The issues which arose from the focus groups will be outlined and discussed in terms of self-efficacy and development of the intervention.ReferencesSperling, M., et al., ISPAD Clinical Practice Consensus Guidelines 2014. Pediatric Diabetes, 2014. 15(Suppl 20): p. 1–290.National Clinical Programmes for Diabetes and Paediatrics, Model of Care for All Children and Young People with Type 1 Diabetes. 2015, Faculty of Paediatrics, Royal College of Physicians of Ireland Dublin