Last Day of ENDO 2013 Already!

First off, I want to thank everyone who visited my blog over the past few days. I tried to present my thoughts on a few of the best sessions that I attended from the view of a pediatric endocrinologist. I also hope that everyone had a least a little bit of time to explore the city of San Francisco. It truly is a wonderful place and certainly deserves another trip if your time was too limited. 

Unfortunately I had an afternoon flight the impeded my ability to go to more sessions on day 4 of ENDO2013. I did get a chance to hear about the genetics of obesity and insulin resistance. Thankfully the two sessions were right across the hall from each other. The first talk related to epigenetic changes that occur in relation to obesity in subcutaneous versus visceral adipose tissue. The next talk focused on the sympathetic nervous system  activation in obesity. The next talk focused on the FTO gene and the browning of adipose tissue. I was able to catch some of the talk next door on carotid intimal thickness in adolescents. The session closed with CRP and its association with fracture risk in adults. All the presenters showed some very interesting data that I hope lead to further studies in the fight against obesity. 

I am glad that some of these studies explored adolescents as unfortunately this population has shown an alarming increase in obesity rate. We certainly need as much research as possible to try and prevent obesity in the adolescent period, which is certainly correlated with later obesity.

I hope everyone has a safe trip back home wherever that may be and see you next year in Chicago! 

Day 3 @ ENDO2013

Today started for this Endo Blogger with a jam packed session on food addiction. It was so full that the audience was being let in one person at a time! I think anyone that is interested in a better understanding of the major players that drive food intake would have enjoyed the session. There were 3 excellent talks from Dr. Ralph DiLeone, Dr. Gina Leinninger, and Dr. Susanne La Fleur. The first 2 talks were related in that they both looked at hypothalamic control over food intake. More specifically, each speaker discussed different aspects of the dopaminergic projections from the lateral hypothalamic area (LHA). The first talk described the dopaminergic projections themselves and the second talk explained some of details about the less well known molecule, neurotensin. The session closed with a talk by Dr. La Fleur which tried to tease out importance of both elevated fat and sugar on food intake. In short, the combination of high fat and high sugar diets limited rats ability to down regulate their food intake. This is contrast to with the substances alone, the ability was maintained. She also studied a small amount of healthy humans which also explored the impact of increased sugar and fat both at meals and at snacks. Those with high fat and high sugar intake at snacks showed decreased liver sensitivity and serotonin receptor binding, which is also known to play a role in food intake. Excellent work across the board.

I finally got a chance today to get a good look at some of the amazing ENDO posters. There were a lot of really interesting and rare cases from the world of the adrenal, thyroid, and pituitary glands. I definitely learned a thing or two perusing the posters. The last academic highlight of the day for me involved exercise and diabetes. I love hearing different physicians' views on how to tackle a potentially difficult issue with a lot of my patients. I certainly left with a some new ideas that I will implement in diabetes clinic.

On the ligher side, thankfully the higher ups at ENDO2013 allowed us to spin the wheel twice because of the evacuation yesterday. Sadly, I did not hit any of the big prizes, but I am certainly happy with my notebook and ear buds. There is always next year!

Onward to the last day of ENDO2013, my how the time flew!

Meet the Professor Continues to Please

Bright and early at ENDO2013 and the Meet the Professor series started things off well with a session on pediatric lipid disorders. Unfortunately because of the gas leak, other meet the professor sessions were missed today. I have to say that I was pleased to sit through a talk in which I did not get up saying, wow that was really interesting, but none of the potential therapeutics can help the children that I see in clinic. Dr. Morrison did a wonderful job simplifying a potentially confusing topic. In my training experience, I have found a lot of uncomfortability in pediatric lipid disorders. This probably largely stems from it being mostly viewed as an adult problem and there being a great deal of time since the previous NHLBI guideline (23 years). We now have additional medications and diagnostic tools available to us to treat lipid disorders. Unfortunately, the rise of childhood obesity has made a once rare problem increasingly more common. 

The talk started with the new recommendations as far as treatment strategies and lipid cutoff values. We were all reminded that a non-fasting non HDL level should be obtained on all children from age 9-11. Also, we were reminded that screening can begin as early as 1 year of age for those children at the highest risk (e.g. family history of premature coronary artery disease). Important secondary causes of hyperlipidemia were reviewed as well, such as hypothyroidism and liver disease. Now, the most interesting part of the talk was discussing management strategies. Clearly diet and exercise are a cornerstone of treatment. Even a "perfect diet", however, will often not lower LDL to goals in patient with familial hyperlipidemia which stresses the importance of follow up. A goal of restriction to less than 7% of calories from saturated fat and cholesterol less than 200 mg/day. There is also evidence that plant sterol/stanol esters can result in more LDL reduction. A therapy discussion cannot be complete without a discussion about statins. They are recommended for patients greater than 10 years of age with familial hypercholesterolemia (LDL>190 with no risk factors or >160 with risk factors) after 6 months of diet interventions. One must also be careful to counsel female patient about its teratogenicity. The talk touched on hypertrigyceridemia treatment with niacin, fibrates, and omega 3s.  It closed with a couple of cases for discussion of management of children with abnormal lipid profiles.

I certainly left with a better practical understanding of the subject and hope to bring this knowledge into our endocrine clinic. If you were not able to catch the second lecture because of the evacuation, check your case management book for a well-written summary. 

Time to rest up for day 3...

ENDO2013 Back up and Running

Things are back up and running at ENDO2013 and happening at their normal times. Sadly, the Expo is closed for the rest of the day. Another day without spinning the wheel for me, but there is always tomorrow!

Gas Leak?

Looks like the bomb squad is on the scene! ENDO2013 is getting more interesting by the minute. Stay tuned for more information! Stay safe everybody. 

Meet the Professor gets an A+

Since I am a first year clinical fellow attending ENDO for the first time, I have heard a lot about how to spend my time at the conference. The comment that I heard most from my elders was not to miss the "Meet the Professor" sessions. It was great advice. I went to my first one today about Premature Adrenarche by Dr. Oberfield. I found it very well organized and informative. It is also good to hear different physician's approaches to certain clinical scenarios which were discussed during the session. I purchased the case management book so that I can go through some of the cases from sessions that I am not able to attend. Try your best not the miss "Meet the Professor" and get your learn on!

Obesity Treatments from the Point of View of a Pediatrician

For those of you who missed the first obesity therapeutics talk on day 1 of ENDO2013, you certainly missed a great review on the past, present, and exciting future of obesity treatment. It was wonderful to hear about the history of where obesity treatment has come from. It started with the first sympathomimetic medications and progressed to present day treatments. Because obesity was first thought of as a problem of will power and less as an organic disease, most of the treatments were only designed for a short-term duration. Today, we certainly know much more about obesity. It is much more than a short-term problem and a problem of will power! Despite knowing so much more about the molecular pathophysiology, there are not a lot of therapeutic options for the pharmacologic treatment of obesity. This is in contrast to type 2 diabetes, for which there are a multitude of choices. Interestingly, it was pointed out that safety is an even more significant factor for the dearth of obesity drugs because of the large numbers of patients that suffer from obesity. Three relatively new medications were discussed in some detail.

1.) Lorcaserin (Belviq)  - A serotonin 2C receptor agonist which was developed out of the failure of Fen-phen. Thus far it has shown impressive results with 2 published, randomized, placebo controlled trials (BLOOM trial N Engl J Med 2010;363:245-56./Blossom trial J Clin Endocrinol Metab, October 2011, 96(10):3067–3077.)

2.) Phentermine/topiramate (Qsymia) -  The combination of phenteramine (sympathomimetic) and topiramate (anti-seizure and migraine medication) that has shown >10% weight loss in 2 randomized studies. One does have to keep in mind birth defect and tachycardia risks.

3.) Bupropion/naltrexone (Contrave) - The mixture of bupropion, a dopamine/norepinephrine reuptake inhibitor used for depression and smoking cessation, and naltrexone, an opiate antagonist, has also shown great promise as a weight loss medication. It is currently in phase 3 trials. Hypertension is a known side effect with bupropion and the FDA has required a study of cardiovascular safety outcomes prior to approval because of prior concerns for an increase in cardiovascular mortality.

As already described, there is not much else out there, except maybe metformin, which has limited results and its own side effects. Pharmaceutical companies are logically very interested in developing drugs because of the huge potential population and a few examples were discussed. There seems to be a lot of excitement around a GLP-1/glucagon mixed agonist and will hopefully see them on the shelves in the near future. 

In closing, as a pediatric endocrinologist, I have even less tools in the treatment toolbox compared to adult providers. None of the new treatments are currently available for children and the statistics for children are no better than for adults. In fact, approximately 1 in 3 children in the US are overweight or obese and there is  data that the damage in terms of cardiovascular risk is done far earlier than we first thought. As a result, I eagerly await the results of trials on younger patients so that we can do more than diet and exercise counseling for treatment for pediatric obesity. 

Updates from pediatric endocrinology to come...

So it begins...

Arrived at the meeting and ready to learn!

Official ENDO 2013 Blogger

Thank you to the Endocrine Society for giving me the opportunity to blog about the upcoming ENDO 2013 conference in San Francisco. I am  lucky in that I arrived in San Francisco about 365 days ago to start my fellowship, so I have gathered a lot of experience about the city in preparation for the conference. As a result, I can say 5 things for certain about San Francisco:

1.) Yes, it really is cold even in June, so pack accordingly!

2.) The city is unique and beautiful. I know the conference is going to be great, but be sure to give yourself a little time to explore the area.

3.) Yes, wine country is just up the road.

4.) The Ferry Building at the end of Market Street (moderate walk from Moscone Center) has an amazing Farmer's Market on Saturday.

5.) The hills can be brutal, so bring your walking shoes

On a more serious note, I have been assigned to blog about pediatric endocrinology and "obesity, adipocyte biology, and appetite." I will be writing on these subjects each day and tweeting as well! Be sure to follow me @FightChildDM

See you in San Fran!

Asthma and Metabolic Syndrome?

Happy June to everyone!

There was a recent release of an article in the journal Inflammation that was trying to see if the Metabolic Syndrome was a risk factor for asthma. The term "metabolic syndrome" is thrown around a lot, but it is a clustering of impaired glucose tolerance with obesity, high cholesterol, and hypertension (need 2 of these 3). Scientists have put forth pretty good evidence that obesity is a state of chronic, low-grade inflammation and it would not be surprising that this may in fact play a role in another common inflammatory disease, asthma. The study looked a cohort of post-menopausal women with and without asthma and then looked at various metabolic parameters. Interestingly, they found that those women with asthma had higher indices of insulin resistance, but did not find that link between asthma and obesity. That being said, causation is difficult to prove. They also found higher levels of certain inflammatory cytokines and adipokines in the asthma patients compared to their controls. A problem here is that it may be a bit like the chicken or the egg. Are patients with asthma more sedentary and therefore develop obesity/metabolic syndrome/more inflammation, or is the obesity related inflammation actually causing the asthma? I think those are great questions that warrant future research.

How best to curb obesity?

Here is a recent post in the New England Journal about the recent soda ban in New York City Ruling. A wonderful view that I personally share. 100% freedom has failed in this circumstance. If we let everyone eat whatever they want, you get the obesity rates that we currently see. We live in the greatest country in the world and we can do better!

http://www.nejm.org/doi/full/10.1056/NEJMp1303706?query=endocrinology 

Microbes and Obesity ?!

A truly facininating side to the obesity story is the relationship of gut flora to potential weight gain. Many believe that having an abnormal balance of gut bacteria can contribute to obesity through a multitude of mechanisms. One of the simplest explanations is that gut bacteria allow for more substrates (e.g. glucose or fatty acids) to be absorbed. Here is a summary of a recent study that came out in the JCEM: http://www.medscape.com/viewarticle/781943. The question that I always have is, are we looking at the chicken or the egg? Or does being obese eventually change your gut microbes? What we need is a study that can track people closely both before, during, and after developing obesity. Maybe then we can see a significant change in flora that precedes the obesity.

Just my thoughts...

New Era

The new era of this blog has begun! Since I am training to become a physician that specializes in childhood obesity, I will try and share new an exciting news on that front whenever I can. I will kick things off with a bit of good news. Apparently, some rates of childhood obesity are starting to fall, but I don't think that it is time to let our guard down. The fact of the matter is that we have only begin to scrape the surface of the obesity problem from the policy side and sadly there are few option on the "drug side." So, I guess that leaves diet and exercise right?

Concussions and Head Trauma

Sorry for the absence from the blog world! Clearly, residency has been making it tough to write! Anyway, I have been working in the outpatient world lately and I saw a teenager after being released from the ER after sustaining a head injury. It was a head to head collision in which the child started slurring his words and had neurological signs! No imagining was done and he was sent home after being watched for about 6 hours.  I think this management is debatable and could be talked about below.

I think we have all noticed an increase in the amount of press coverage of head trauma over the past few years. I thought about writing this article after seeing the following story: College Athlete Died of Head Trauma, Father SaysWe as pediatricians are much more careful about return to play now and in fact all patients should return to play in a step-wise fashion after first taking a full week off. It is sad to see another person die because of possible mismanagement and/or under appreciation of the severity of head trauma.

Happy New Year!

Happy New Year to all Followers! I know I have had very little activity lately, but as the year goes on, I should have more time as I have been through the meat of my schedule. We have seen a very interesting year in the medical field, especially with the H1N1 affair. It seems that we have been spared/done a wonderful job with the vaccination program. In fact, there is a wonderful Times article on this very subject:Swine Flu.  I urge anyone out there that would like me to cover any specific subject to drop me a line. Happy New Year again to you all!!

Cash and Money

You sometimes I just wonder about people and what has happened to healthcare. I saw a nice family this week who's child had an allergic rash. When I came back to the room to talk about our plan and told her that she was going to need to get some over the counter steroid cream she responded.."wait, wait, I am going to have to pay for something?!?!" I honestly didn't know what to say and we are certainly not talking about an expensive item that is likely going to take the rash away. Is that how the public thinks healthcare should work? All the care should be free and all the medications free? Let's see what healthcare reform has in store for us.

90%?

While this post is not about the rumored Apple tablet PC, I do find it pretty cool and maybe it would even have possible benefits to the healthcare industry. Today in the ER, I asked one of the financial experts and she claimed that 90%, yes 90% of the ER visits to our Pediatric ER get paid for! I was shocked by this number...could it actually be this high? I do think that it is good that the hospital is actually getting paid when kids come in with nothing, there needs to be a line drawn. Maybe you should be charged for ER visits that could be seen at your community MD. I still am amazed by how many people actually have primary doctors and yet they do not actually go to them! They only go for well child visits. I don't know, once again it all seems wrong to me.

ER Continues!

Yes I am still in the ER!! The Monday's are always crazy around here...my muzing for the day has to be the visit to the ER for "coordination of care." 2 patients came in for this today. What is this you ask? It is when people come to the ER not for any complaint, but in order to get hooked up to the referring service. The scary thing is that patients are often actually referred from their primary doctor! Now this is instead of the way I would think to go to a specialist...I would go to my primary doctor and have them refer me. I sometimes just don't get it. I would love to hear people's thoughts. Happy Monday!

The Emergency Room!!

Talk about the front lines of medicine! This is where people go when the healthcare system fails. It really is amazing as 90% of the families that I see come for a fever for 2 hours...and at 3am! Go figure! Hey, it is often free because it is an emergency right. I do not know what the answer is, but we will see what ObamaCare brings us!

A large problem where I work is immigrant care and what to do about it. It certainly is costing America and arm and a leg, but will the new and improved system that is going through Congress do anything for the problem? It remains to be seen. Any thoughts on this internet world: Undocumented Immigrant Care.

Stay tuned for future healthcare related posts!

Back in New York and Happy Mother's Day

So I have started spreading the news (you know the song)! So the big day is finally near and graduation is this Friday! I started my first night back in NYC like anyone would with hitting the town! It was the latest that I stayed out in like 6 months, wow. So I am still like out of money! So sad that a 28 year old guy still has to ask his parents for money. Well, hopefully those times are nearing and end. But hey, if anyone is looking for a bright minded, young lad with some medical knowledge..then this is the place. Oh yes, you can follow me on twitter, my tag is sharkoff. Happy Mother's Day mom!

p.s. don't forget to at least call you mom