Welcome to issue 21 Dear FrIeNDS aND colleaGueS, Time is passing fast and the next eSPe meeting, the 2013 Joint meeting in milan, is already approaching. The Joint meetings lend a unique flavour to our academic life. New friends and colleagues from different countries all over the world, broader perspectives from different societies, and a busier and tighter schedule… We wish every success to the President of the milan meeting, Franco chiarelli, and the organising committee, built from the different societies, who have compiled an excellent scientific programme. See Franco chiarelli’s message to you all on page 3, and please reserve space on your calendars to be in milan on 19–22 September. We continue to introduce the national societies to you in the newsletter, and this issue features news from the British Society (page 6). We thank our British colleagues for sharing their information with us. Please volunteer to tell us what is happening in your own national society. Welcome continued from page 1 News about other eSPe activities includes the very successful eSPe Summer School (page 1), the clinical Fellowship Programme (page 4), paediatric endocrinology in India (page 6), and an update from the eSPe Working Group for Turner syndrome (page 5). make sure you don’t miss the interviews with younger and senior paediatric endocrinologists on page 7, where you can learn what eSPe has brought to their academic lives. The Yearbook of Pediatric Endocrinology is greatly appreciated by eSPe members, and on page 8 we are delighted to include a further preview from the editors, ze’ev hochberg and ken ong, to whom we extend our cordial thanks. We, as the editorial Board, will do our best to continue to maintain the quality of the newsletter and try to enrich it with feedback from all members. Do send your news and information to firstname.lastname@example.org. Yours sincerely, Professor Feyza Darendeliler Editor, ESPE Newsletter email@example.com eDITorIal BoarD Indi Banerjee, manchester, uk George P chrousos, athens, Greece Gabriel martos moreno, madrid, Spain
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IN 2013, IFcah (International Fund-raising for congenital adrenal hyperplasia) is launching
its third call for proposals, in collaboration with eSPe.
academic groups working directly or indirectly on congenital adrenal hyperplasia are
encouraged to submit a project, if the expected results could aid the understanding of the
pathophysiology and improve the management of the disease. Projects focused on gene or/and
cellular therapy will be given particular consideration.
Information about IFcah and this call for grant applications is available on IFcah’s website
(www.ifcah.org). The deadline for application is 25 march 2013. We hope that you will
consider this opportunity with great interest
19–22 September 2013, Milan, Italy
Dear colleaGueS aND FrIeNDS,
The Joint Programme organising committee is hard at
work finalising the schedule of an exciting meeting in
milan this September. Internationally renowned
experts, invited from all over the world, will offer
perspectives on the theme of ‘Predictive medicine to
improve the care of children,’ by exploring and sharing the latest
developments in research on growth, endocrine disrupters, obesity and
type 1 diabetes, in a prestigious plenary lecture programme.
Interaction and discussion will be the essence of this meeting, and
the free oral communications in 20 scheduled platform sessions will
enable all participants to benefit from this expertise. Together with 16
themed symposia, 12 meet the expert sessions, 4 sessions covering
‘controversies’, 3 yearbook events and 2 new perspective sessions, it
goes without saying that this reunion of eSPe with the Pediatric
endocrine Society (PeS), australasian Paediatric endocrine Group
(aPeG), asia Pacific Paediatric endocrine Society (aPPeS), african
Society for Pediatric and adolescent endocrinology (aSPae), Japanese
Society for Pediatric endocrinology (JSPe), and Sociedad
latinoamericana de endocrinología Pediátrica (SleP) is a unique
opportunity to share the latest developments in research, as well as to
renew old friendships.
The 2013 eSPe Summer School (see page 1) follows the meeting
and will be a significant and stimulating opportunity that symbolises
eSPe’s commitment to the future care of children with endocrine
disorders. It will provide a fitting conclusion to the 9th Joint meeting.
For further information about the meeting, contact
I look forward to seeing you all in milan!
Professor Franco Chiarelli firstname.lastname@example.org
President, European Society for Paediatric Endocrinology (ESPE)
Chairman of the Joint Programme Organising Committee (JPOC)
<The SuBcommITTee IS WorkING to update the existing european Training Syllabus in Paediatric endocrinology and Diabetes and to develop plans for accreditation of paediatric endocrine centres in europe. once agreed by eSPe, our proposal will be submitted to the european academy of Paediatrics (eaP) for approval. To advertise the syllabus and reach more members, a poster was exhibited at the eSPe booth at the 2012 meeting in leipzig. We also wrote to members and circulated a questionnaire to learn whether different countries use the eSPe syllabus or a national alternative. The results revealed that training in paediatric endocrinology is quite variable across eu countries. In the eaP’s Tertiary care Working Group, made up of representatives from each subspecialty, it has been noted that there is great heterogeneity among the training programmes of european paediatric subspecialties in terms of format and duration. Furthermore, among the training programmes accepted by eaP, fewer than 25% have been updated in the past 5 years. uemS (the european union of medical Specialists) proposes that the training requirements of the subspecialties should be developed under the subtitles: • training requirements for trainees • organisation of training • training requirements for trainers • training requirements for training centres once the training programme is established, visits, evaluation and specialist certification will follow. uemS recommends that visits to centres are performed to gain better visibility of training quality, with the aim of accrediting 1–2 centres per country. eaP should set european standards that can be used by national organisations. If eu standards are met in a country, eaP can endorse national accreditation. european Board exams are held in 39 specialities such as urology, radiology and paediatric subspecialties like paediatric allergology, but not yet in paediatric endocrinology. a subgroup of the accreditation and Syllabus Subcommittee, including Feyza Darendeliler, Sten Drop, Stefano cianfarani, Wilma oostdijk, Giorgio radetti, Stefan riedl, Jan lebl and lars Savendahl, is working to update the paediatric endocrinology training programme, based on the recommendations of the eaP and european Board of Paediatrics, with the aim of presenting it to the larger group and the eSPe council. Feyza Darendeliler Chair, Accreditation and Syllabus Subcommittee
Bringing you recent highlights from the world of research
Why you should do it! This ESPE programme sponsors young paediatricians who wish to become paediatric endocrinologists but who lack specialised training opportunities at their home centres. It enables them to spend 3–12 months at a recognised European centre with established training opportunities for paediatric endocrinology and diabetology. A fellow’s perspective... I am aN INDIaN NaTIoNal WorkING in abu-Dhabi, uae, taking care of both general paediatric and paediatric endocrinology and diabetes cases. Paediatric endocrine cases in uae are usually handled by adult endocrinologists, or referred to Western countries, as there are few trained paediatric endocrinologists. India, to which I intend to return, has a similar lack of trained paediatric endocrinologists for its mammoth population. I acquired my basic training and skills in paediatric endocrinology and diabetes through a diligent 18-month research cum-clinical fellowship at the all India Institute of medical Sciences (a tertiary care university hospital) in Delhi, India. I then became an active member of aPPeS, ISPae and eSPe, and undertook their training courses, as well as attending and presenting papers at various international paediatric endocrine forums. Despite having immense interest and basic training in paediatric endocrinology and diabetes, I always felt the need to upgrade my clinical skills and expertise at an advanced tertiary care centre of paediatric endocrinology in a developed country. eSPe awarded me this golden opportunity to work as a clinical fellow under Professor Jean claude carel at hospital robert Debré, in Paris, France, in September 2011. I could even choose my own time-frame, in consultation with my host and to fit my family and work commitments. I successfully finished in February 2012 (with thanks to my family for their great support). I had a wonderful time learning and interacting with the great team of clinicians. each member of the team contributed in their own way to my learning process. It was a phenomenal experience to do practically what I used to read in books: following the protocols, performing the ...and a host’s receNTlY, ekaTerINe (eka) kvaraTSkelIa from Tbilisi, Georgia, spent 3 months at our centre. It was a wonderful experience for us both. We had met at the eSPe Winter School 2010 in ankara, Turkey. We both think that the Winter School is a great opportunity to get intensive training in basic paediatric endocrinology and diabetology, to meet people with the same interests and to network with teachers – the specialists in the field. Then, it is extremely helpful to consolidate knowledge and broaden clinical expertise, either in general paediatric endocrinology or in any specific topic, with a 3- to 12-month fellowship. To plan a successful fellowship, you must identify your training needs and expectations to find state of the art investigational and genetic work and then giving the appropriate management. It has added to my patient management skills. I used to think how I would tackle the same issue in my own setting, and it was heartening to realise that so much could be done despite the limited resources. I even undertook a research project, and have published a paper in Hormone Research in collaboration with the team at my host centre. The icing on the cake was networking with the best in the field, which will help me manage problem cases needing an expert opinion. The eSPe meeting in leipzig, where I also participated in the eSPe Summer School, felt like a home-coming when I met the robert Debré team there. Paris also gave me the experience of a lifetime in terms of its rich culture, warm people and wonderful cuisine. I wish my French had been better to start with, but everyone was very supportive, including the patients, who tried their best to communicate with me in english and got so excited about my countries of origin and abode, which was both humbling and touching. regarding everyday issues, I would recommend accommodation near the hospital for future fellows. Staying in the chic heartland of the city provided for a great experience, but the cost and uncertainties were not for the faint-hearted. anyway, if wisely spent, the eSPe grant can meet your living expenses, even in a costly city like Paris. I have built a solid foundation on which to develop my career and so benefit scores of patients in paediatric endocrinology and diabetes. Potential candidates should use this eSPe learning opportunity to enhance their skills and build bridges to narrow the gap in today’s truly global world. Deepti Chaturvedi Burjeel Hospital, Abu-Dhabi, UAE the ‘perfect’ host centre. eka, for instance, wanted to spend 3 months consolidating her skills in general paediatric endocrinology. as she knows both english and German very well, she was able to choose from several european centres that host fellows. Initially, she hoped to bring her family (including two children), but practical issues such as lack of short term accommodation and day-care meant this was not possible. eka became part of our clinical team within days of her arrival, and saw patients under supervision, just as our own fellows do. She also participated actively in grand-round discussions and laboratory meetings. eka visited our routine endocrine laboratory and our research aboratories to get an insight into the laboratory world of endocrinology. We both felt that 3 months was too short to embark upon a research project. I think if this had been the aim, some planning would have been necessary beforehand. our team also learned from eka, when she presented her difficult patients and told us about the limited resources she has for diagnosing, testing and treating them. We also enjoyed her very enthusiastic and open-minded personality and are convinced that with all her efforts eka will improve the medical care for children and adolescents with endocrine disorders in Georgia. We will certainly remain in touch. The eSPe clinical Fellowship Programme benefits both fellows and hosts. compared with other programmes, it is also quite cheap. I hope eSPe keeps this programme running and that sponsors will continue to support it. Christa E Flück University Children’s Hospital Bern, Switzerland Read an interview with another Clinical Fellowship recipient in this issue's 'Fellowship in Focus' feature on page 7 chrISTa e Flück & eka kvaraTSkelIa E
ESPE Clinical Fellowship Programme:
The eSPe TurNer SYNDrome WorkING GrouP (TSWG) includes paediatric endocrinologists involved in the care of subjects with Turner syndrome and associated clinical research. This condition causes multi-faceted problems, and an interdisciplinary team is required for the diagnosis, follow-up and treatment of these patients. The paediatric endocrinologist is the co-ordinator of the team, following paediatric patients until they are young adults, and responsible for managing their transition to adult health care. Informing a patient and her family about the diagnosis of Turner syndrome is a delicate matter, because of the psychological impact, even in later life. consequently, ‘Talking about Turner syndrome’ was chosen as the topic of the eSPe TSWG meeting in leipzig in 2012. The meeting was very interesting, as many different aspects of the communication of a diagnosis of Turner syndrome were discussed. Geneticist Bruno Dallapiccola (Italy) reported on communication during pregnancy, when a baby can’t be seen, but only imagined. The presence of a Y-chromosome in the karyotype was given particular consideration by martine cools (Belgium). The problem of gonadectomy due to the risk of developing gonadoblastoma was treated exhaustively. The painful prospective of infertility with its potential harmful relationship with femininity was part of the talk given by psychologist angelika Bock (Germany). a questionnaire on communication of Turner syndrome diagnosis had been prepared by Siska verlinde and aneta Gawlik and submitted to eSPe members. The results were reported during the TSWG meeting in leipzig and also discussed with the Turner syndrome support groups. This workshop included space for the support groups, which was a good opportunity for everyone to understand the point of view of the subjects that we care for, and to reflect on how best to talk about this diagnosis. a large randomised european study to optimise pubertal replacement therapy (androgen and oestrogen) in Turner syndrome with a treatment protocol that combines different formulations (transdermal and oral) and times of introduction (early, late or very early) is one of the most important aims of the TSWG. a proposal was prepared by Theo Sas, principal investigator, helped by Jean-claude carel. anyone interested in the project can contact him at T.c.J.Sas@asz.nl. ‘controversies in the care of Turner syndrome’ will be the topic of the next Joint TSWG meeting in milan next September. Some aspects of the care of subjects with Turner syndrome, which remain controversial, will be discussed with experts. These include ovarian failure and hormone replacement therapy (optimal type, dose, route and time of oestrogen replacement induction); perspectives on all aspects of fertility preservation, including ovarian cryopreservation and oocyte donation, as well as the risks associated with pregnancy; heart monitoring strategies; and the transition from paediatrics to adulthood, as the proper framework for transition has not yet been established. how much responsibility do doctors and Turner syndrome patients have in deciding transition time? What is the limit of our liability? We hope that this programme will be of interest to paediatric endocrinologists, in facing the most relevant problems in Turner syndrome. Laura Mazzanti, Co-ordinator, TSW
DeSPITe INDIa’S larGe population (1.2 billion), there are only 287 paediatric endocrinologists affiliated to the Indian Society of Pediatric and adolescent endocrinology (ISPae). eSPe has partnered ISPae since its first meeting in mumbai in 2007, and helped organise the first Pediatric endocrine Training (PeT) course in 2009 in New Delhi. We are delighted to welcome Indian delegates to our annual meetings, with 16 travelling to Glasgow in 2011, including one invited speaker, and 6 visiting leipzig in 2012. eSPe successfully contributed to the last ISPae meeting and PeT course in calicut, kerala. The course design was very similar to that of the eSPe Summer School, with small group discussions, interaction around cases and formal lectures. The high level of enthusiasm and the strong academic background of the fellows were very clear. The interaction around complex cases was very informative, even for the faculty, as some of the cases discussed were rather extreme in their presentation, compared with those in europe. The ISPae meeting was well attended, with more than 300 delegates. It covered a broad range of topics. Several eSPe members were invited to speak, including ze’ev hochberg (hypothalamic obesity), olaf hiort (disorders of sex development and G proteins) and Jean-claude carel (precocious puberty and type 2 diabetes). overall, eSPe members were greatly impressed by the enthusiasm and dedication of our Indian colleagues, who are in the process of establishing a network of paediatric endocrinologists, often working in difficult conditions with limited resources In November 2013, ISPae is organising a biannual meeting and PeT course in Bangalore, karnakata. eSPe will be present and communicate on disorders of sex development (olaf hiort), hypoglycaemia (khalid hussain), bone disorders (Nick Bishop) and growth hormone in small for gestational age individuals (Jean-claude carel). eSPe faculty members will also participate in the PeT course, in order to further promote the close links with ISPae. You can learn more about ISPae at www.ispae.org.in.
BSPeD, the British Society for Paediatric endocrinology and Diabetes, was founded in 1979. It currently has 400 members, and is chaired by Professor mehul Dattani. along with the executive committee and the Programme organising committee, which are in charge of running the Society and planning the annual meeting respectively, the clinical Subcommittee is one of the cornerstones of the BSPeD. This committee was established in 2009 and its main aims are to respond to and give opinion on matters in clinical paediatric endocrinology and diabetes; to develop guidelines for optimal management of these pathologies; to participate in the development and maintenance of national audit; to facilitate peer review of paediatric endocrine centres; and to provide an interface with patient support groups. The clinical Subcommittee includes representatives from the Society for endocrinology and the association of children’s Diabetes clinicians. among the on-going and future working groups, special interest groups on sexual differentiation disorders and adolescent transition stand out. You can find BSPeD’s clinical guidelines and publications at The 41st annual meeting of BSPeD will be held in Brighton, uk, on 13-15 November 2013, and BSPeD also annually supports a wide range of grants (travel, research, nursery). currently, the national accreditation in paediatric endocrinology is the GrID training for tertiary endocrinologists, with the eSPe syllabus used for national training posts, whereas the diabetes training curriculum is currently in progress. For further information or to contact the co-ordinator of the working groups, visit the BSPeD website at www.bsped.org.uk or contact the BSPeD team at email@example.com
ESPE is now more than 50 years old. Your Society has been uniting paediatric endocrinologists ever since its formation,
aiding communication and education and improving patient care. In this article, we look back at the Society's formative
Deconstruction of a neural circuit for hunger atasoy D, Betley JN, Su hh & Sternson Sm Nature 2012 488 172–177 coNTexT: hunger is a complex behavioural state that elicits intense food seeking and consumption. These behaviours are rapidly recapitulated by activation of starvation-sensitive agouti-related peptide (aGrP) neurones, which present an entry point for reverse engineering neural circuits for hunger. meThoDS: here they mapped synaptic interactions of aGrP neurones with multiple cell populations in mice and probed the contribution of these distinct circuits to feeding behaviour using optogenetic and pharmacogenetic techniques. reSulTS: an inhibitory circuit with paraventricular hypothalamus (Pvh) neurones substantially accounted for acute aGrP neurone evoked eating, whereas two other prominent circuits were insufficient. Within the Pvh, they found that aGrP neurones target and inhibit oxytocin neurones, a small population that is selectively lost in Prader Willi syndrome, a condition involving insatiable hunger. coNcluSIoNS: By developing strategies for evaluating molecularly defined circuits, this paper shows that aGrP neurone suppression of oxytocin neurones is critical for evoked feeding. These experiments reveal a new neural circuit that regulates hunger state and pathways associated with over-eating disorders. COMMENTARY by Ze’ev Hochberg It was known that stimulation of the agouti-related peptide (aGrP) neurones evokes hunger and its behavioural responses: an intense search for food and hedonic eating. If starvation-sensitive neurones and behaviours can be elicited by a single molecule, aGrP, then genetic manipulation allows for ‘reverse engineering’ of the neural circuit for hunger. Stimulation of aGrP-expressing neurones by optogenetics and pharmacogenetics is shown here to suppress oxytocin-releasing neurones. It was previously reported that oxytocin-releasing neurones are lost in Prader-Willi syndrome. It follows that the inhibitory circuit involving oxytocin neurones is a prerequisite for aGrP-expressing neurone-evoked eating. Thus, here we have a previously unknown neural circuit in the regulation of hunger and its behavioural responses, which may be associated with over-eating disorders that we now call hypothalamic obesity. Efficacy and safety of lorcaserin in obese adults: a meta-analysis of 1-year randomised controlled trials (RCTs) and narrative review on short-term RCTs chan eW, he Y, chui cS, Wong aY, lau Wc & Wong Ic Obesity Reviews 2013 Jan 21. doi: 10.1111/obr.12015. coNTexT: lorcaserin is a new anti-obesity drug recently approved by the uS Food and Drug administration. meThoDS: This was a systematic review and meta-analysis of randomised controlled trials (rcTs) to evaluate the association of lorcaserin therapy with weight loss and adverse events in obese adults (18-65 years old). reSulTS: Weight loss of 3.23 kg (95% confidence interval [cI]: 2.70, 3.75) and body mass index reduction of 1.16 kg m-2 (95% cI: 0.98, 1.34) was observed compared with placebo in rcTs of 1 year duration. The use of lorcaserin for 8 and 12 weeks reduced weight by 1.60 kg (95% cI: 0.34, 2.86) and 2.9 kg (95% cI: 2.2, 3.5) respectively. In comparison with placebo, lorcaserin decreased waist circumference, blood pressure, total cholesterol, low-density lipoprotein-cholesterol and triglycerides. however, it did not statistically affect heart rate or high-density lipoprotein-cholesterol. headache, nausea and dizziness were found to be significantly higher in the patients receiving lorcaserin than in patients receiving placebo, whereas diarrhoea is no more likely than in patients receiving placebo. coNcluSIoN: lorcaserin achieves modest weight loss and appears to be well-tolerated. clinical and pharmacovigilance studies with longer study duration are needed to inform us of the long-term efficacy and safety of lorcaserin. COMMENTARY by Ze’ev Hochberg In spite of the growing burden of obesity worldwide, anti-obesity drug development and approval have lagged behind. lorcaserin has been in trials for several years now, and is suggested to induce satiety by a selective agonistic effect on the serotonin 5-hT2c receptor. It deserves special attention as it was recently approved by the uS Food and Drug administration (FDa). It was previously rejected by the FDa because of evidence that it increased cancer incidence in rats, and because of its modest efficacy (loss of 3% body weight after 1 year of treatment). The FDa advisory panel has now concluded that the cancer findings did not apply to humans, and our desperation has reached a state when even modest efficacy is welcome. Since the 2012 Yearbook, the FDa has also approved Qsymia, a combination of two older drugs, phentermine and topiramate, that reduces hunger by targeting different neurotransmitter systems, mainly norepinephrine but also dopamine and serotonin. Qsymia is more potent that lorcaserin (an average of 8.9% at the highest dose compared with placebo), yet it may cause more serious side effects, including an increased heart rate and increased risk of birth defects. The FDa was convinced that the benefits outweigh the risks. These are not perfect drugs. a healthy lifestyle and low carbohydrate diets work better when they are introduced; it is only that we fail to introduce them Training for North Africa The eSPe maGhreB School PromoTeS the training of young paediatric endocrinologists in the French-speaking countries of North africa and from other parts of africa such as cameroon. The scheme was founded in recognition of the underdevelopment of paediatric endocrinology in these countries, and because the language barrier makes it difficult for paediatricians in these areas to attend eSPe educational activities such as the Winter and Summer Schools. The eSPe maghreb School began a 3-year teaching programme in october 2011 in morocco. Subsequently, 6 students spent between 10 weeks and 1 year training in paediatric endocrinology at european centres during 2012 (by means of eSPe clinical Fellowships), while paediatric endocrinologists from the maghreb School also successfully presented at the eSPe annual meeting. The 2nd eSPe maghreb School was held in Tunisia in December 2012 with 26 students (50% of whom had attended the 1st eSPe maghreb School). The 4½ day course had an extended programme, including topics that were not covered in detail previously, such as growth, thyroid, disorders of sex development, diabetes mellitus, obesity, pituitary and adrenals. The teaching comprised interactive lectures, case presentations from the students and teachers, a small group of workshops on proposal research projects from students, and presentation of selected projects to the plenum. all participants worked hard from 8.00 am to 8.30 pm! The programme was supported by a faculty consisting of six members of eSPe and teachers from the three maghreb countries, algeria, morocco and Tunisia. maghreb School participants also have access to a web-based French educational programme, where they can refer to slides of the conferences and case presentations. The next eSPe maghreb School will be in algeria (20–25 November 2013). application details are at www.eurospe.org/education/ education_maghrebProject.html. We are extremely grateful to Pfizer, who have funded the programme, and have kindly agreed to sponsor another 3-year cycle of teaching. The eSPe maghreb project will have huge benefits in terms of developing a paediatric endocrine infrastructure, with effective networks for research and development, in the North african countries