Impact of an educational intervention combining clinical obesity preceptorship with electronic networking tools on primary care professionals: a prospective study.

BACKGROUND: Primary care providers' (PCPs) attitude toward obesity is often negative, and their confidence level for helping patients manage their weight is low. Continuing professional development (CPD) on the subject of obesity is often based on a single activity using a traditional passive approach such as lectures known to have little effect on performance or patient outcomes. The aim of this study was to evaluate the impact of an educational intervention for obesity management on PCPs' attitude, self-efficacy, practice changes and patient-related outcomes. METHODS: Prospective interventional study with 12 months follow-up. A two-day clinical obesity preceptorship was offered where participants were actively involved in competence building using real-life situations, in addition to electronic networking tools, including a discussion forum and interactive monthly webinars. Thirty-five participants (12 nurses and 23 physicians) from seven Family medicine groups were enrolled. Questionnaires were used to evaluate the impact on primary care nurses' and physicians' attitudes and self-efficacy for obesity management. Practice changes and patient outcomes were evaluated using clinical vignettes, de-identified electronic patient records and qualitative analyses from group interviews. RESULTS: Physicians' general attitude towards patients with obesity was improved (61 ± 22 mm vs 85 ± 17 mm, p <  0.001). Self-efficacy for obesity management and lifestyle counselling were also improved immediately and 1 year after the intervention (all Ps <  0.05). De-identified patient records and clinical vignettes both showed improvement in recording of weight, waist circumference and evaluation of readiness to change lifestyle (all Ps <  0.05) that was confirmed by group interviews. Also, 15% of patients who were prospectively registered for weight management had lost more than 5% of their initial weight at the time of their last visit (P <  0.0001, median follow-up of 152 days). CONCLUSION: A multimodal educational intervention for obesity management can improve PCPs'attitude and self-efficacy for obesity management and lifestyle counselling. This translates into beneficial practice changes and patient-related outcomes. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01385397 . Retrospectively registered, 28 June 2011.

[Factors associated with breastfeeding continuation in young Canadian mothers]. / Les facteurs associés à la poursuite de l'allaitement maternel chez les jeunes mères canadiennes.

OBJECTIVES: Breastfeeding continuation rates are lower among young mothers, while few studies have specifically focused on this population. This study describes the factors related to continued breastfeeding beyond two months among young Canadian mothers. METHODS: A descriptive and correlational design was used to identify and quantify the impact offactors affecting continued breast-feeding beyond two months. Data were derived from a selection of mothers 15-19 years who responded to The Maternity Experiences Survey. RESULTS: The difference between subgroups (15-18 vs 19 years old) in terms of breastfeeding continuation was not significant, but non-smoking (OR 2.78, 95% C, 1.351 - 5.682), living with a partner (OR 1.96, 95% CI, 1.087 to 3.597), vaginal delivery (OR 2.22, 95% CI, 1.012 to 4.878) and experiencing a large number of stressful situations (RC 0.42, 95% CI, 0.221 to 0.788) promotes continued breastfeeding beyond two months. No significant relationship wasfound with pregnancy planning, prenatal preparation, the violence suffered, depressive symptoms and the availability of social support. CONCLUSION: Some factors related to pre-and postnatal periods, in addition to sociodemographic factors influence the choice of young Canadian mothers to continue or not continue breastfeeding beyond two months. Our results will be used to guide specific interventions for young mothers in breastfeeding protection, promotion and support programmes.

Comparison of Intranasal and Injectable Glucagon Administration Among Pediatric Population Responders.

Aims: Ease of use and acceptability of nasal versus injectable glucagon (IG) among pediatric responders have been little investigated. This study compared the performance of administering nasal and IG in parents of youth with type 1 diabetes (T1D) and in school workers. Enablers and barriers associated with each glucagon and preferred glucagon administration learning modality were also evaluated. Methods: Three months after watching short pedagogical videos, 30 parents and 30 school workers performed simulated scenarios where they administered both glucagon. Completion time and successful execution of critical steps were collected. Interviews assessed preferred learning modalities, barriers, and enablers associated with each glucagon. Results: Both groups administered nasal glucagon faster than IG (median [interquartile range]: parents 19 [12-29] vs. 97 [71-117] s, P < 0.001; school workers 24 [16-33] vs. 129 [105-165] s, P < 0.001). A lower proportion of participants successfully executed all critical steps for injectable versus nasal glucagon (significant difference for school workers [53% vs. 90%; P = 0.007] but not for parents [68% vs. 83%; P = 0.227]). Nasal glucagon was preferred for ease of use and acceptability. Preferred learning modalities were a combination of videos and workshops, but videos alone could suffice for nasal glucagon. Conclusions: Nasal glucagon is faster to use, more likely to be successfully administered, and more acceptable than IG for parents of children with T1D and school workers. Nasal glucagon training with videos could improve school workers' involvement in severe hypoglycemia management. Clinical Trial number, URL to the registration: NCT05395000, https://clinicaltrials.gov/ct2/show/NCT05395000.

Leydig cell tumors in children: contrasting clinical, hormonal, anatomical, and molecular characteristics in boys and girls.

OBJECTIVE: To analyze the clinical, hormonal, anatomical, and molecular characteristics of Leydig cell tumors, a very rare cause of progressive hyperandrogenism in children. STUDY DESIGN: Description of a 9-year-old boy with isosexual precocious pseudopuberty, and of a 12-year-old girl with rapidly progressive virilization, both due to a pure Leydig cell tumor. Review of all cases of pediatric Leydig cell tumors published since 1999 (when the first somatic mutations of the luteinizing hormone receptor were described) and reporting hormonal and/or molecular data. RESULTS: Boys (n = 24) are younger than girls (n = 12) at diagnosis (median 6.5 vs 13.0 years, P = .04). Plasma gonadotrophins are more often completely suppressed in boys (6 cases) than in girls (2 cases). Pure Leydig cell tumors are exceedingly rare in girls (2 cases), who most often have Sertoli-Leydig tumors. These tumors affect either testis equally (11 left, 13 right) but occur more often in the left ovary (8 left, 3 right). Activating mutations of the alpha-subunit of the G(s) stimulatory protein have not been found in either boys or girls and activating mutations of the luteinizing hormone receptor have only been found in boys. CONCLUSIONS: Leydig cell tumors in children display clinical, hormonal, anatomical, and molecular sexual dimorphism.

Insulin sensitivity and secretion in children and adolescents with hypothalamic obesity following treatment for craniopharyngioma.

BACKGROUND: Craniopharyngioma (CP), a tumour occurring in the hypothalamic-pituitary area, results in morbid obesity in 25-60% of affected children. It has been suggested that abnormalities of insulin secretion and/or insulin action due to hypothalamic injury may be associated with weight gain and the metabolic syndrome in this population. AIM: To evaluate: (i) insulin secretion (IS) and insulin sensitivity (Si); (ii) features of the metabolic syndrome (MS) and (iii) factors involved in risk for diabetes and heart disease in obese youth treated for CP. METHODS: Obese subjects treated for CP were compared to BMI-matched control subjects. All subjects underwent anthropometric, blood pressure, resting energy expenditure and body fat assessment. Cholesterol and inflammatory markers, oral glucose tolerance test (OGTT) and frequent sampling intravenous glucose tolerance test (FSIGT), with calculation of IS and Si, were performed. RESULTS: Fifteen CP subjects and 15 controls (C) were studied. There were no differences between CP and C for age, gender, BMI or pubertal status. MS was present in 10/15 CP and 3/15 C (P = 0.03), including impaired glucose tolerance (IGT) in 6/15 CP and 0/15 C (P = 0.02). Measures of IS, including first and second phase IS, and insulin area-under-the-curve (AUC(ins)) during OGTT, were significantly higher in CP. Si, measured by frequent sampled intravenous glucose tolerance test (Si-FSIGT), was significantly lower in CP subjects (0.96 +/- 0.34 vs. 1.67 +/- 0.7; P = 0.01). AUC(ins) was negatively correlated with Si-FSIGT (r = -0.62; P = 0.003). CONCLUSION: Children with CP and hypothalamic obesity have more features of MS, increased IS and IGT prevalence and lower Si compared with BMI-matched controls.

Integrated obesity care management system -implementation and research protocol.

BACKGROUND: Nearly 50% of Canadians are overweight and their number is increasing rapidly. The majority of obese subjects are treated by primary care physicians (PCPs) who often feel uncomfortable with the management of obesity. The current research proposal is aimed at the development and implementation of an innovative, integrated, interdisciplinary obesity care management system involving both primary and secondary care professionals. METHODS: We will use both action and evaluative research in order to achieve the following specific objectives. The first one is to develop and implement a preceptorship-based continuing medical education (CME) program complemented by a web site for physicians and nurses working in Family Medicine Groups (FMGs). This CME will be based on needs assessment and will be validated by one FMG using questionnaires and semi structured interviews. Also, references and teaching tools will be available for participants on the web site. Our second objective is to establish a collaborative intra and inter-regional interdisciplinary network to enable on-going expertise update and networking for FMG teams. This tool consists of a discussion forum and monthly virtual meetings of all participants. Our third objective is to evaluate the implementation of our program for its ability to train 8 FMGs per year, the access and utilization of electronic tools and the participants' satisfaction. This will be measured with questionnaires, web logging tools and group interviews. Our fourth objective is to determine the impact for the participants regarding knowledge and expertise, attitudes and perceptions, self-efficacy for the management of obesity, and changes in FMG organization for obesity management. Questionnaires and interviews will be used for this purpose. Our fifth objective is to deliver transferable knowledge for health professionals and decision-makers. Strategies and pitfalls of setting up this program will also be identified. CONCLUSION: This project is relevant to health system's decision-makers who are confronted with an important increase in the prevalence of obesity. It is therefore critical to develop strategies allowing the management of obesity in the 1st line setting. Results of this research project could therefore influence health care organization in the field of obesity but also eventually for other chronic diseases.

Reversible metaphyseal dysplasia, a novel bone phenotype, in two unrelated children with autoimmunepolyendocrinopathy-candidiasis-ectodermal dystrophy: clinical and molecular studies.

We report the association of an undescribed, reversible metaphyseal dysplasia (RMD) with autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) in two patients, one homozygous and one heterozygous for a 13-bp deletion in exon 8 of the autoimmune regulator (AIRE) gene. One patient also had a novel deletion in exon 6, resulting in a frameshift mutation and introduction of a STOP codon in exon 10. Their APECED phenotypes differed, but both patients developed progressive skeletal deformities and growth failure from early childhood. Radiological examination suggested a generalized abnormality of endochondral ossification, with irregular, flared, radioopaque regions in the metaphyses, subjacent to the growth plates. Histopathology in patient 1 showed islands of calcified cartilage within bone, consistent with impaired coupling of cartilage resorption with vascular invasion and ossification. Despite discordance for puberty, both patients experienced radiological resolution of their bone disease in their mid-teens, with improvement in histopathology in patient 1. RMD may constitute a rare phenotypic variation of APECED, possibly resulting from autoimmunity directed against skeletal proteins. We also demonstrated AIRE expression in chondrocytes derived from human fetal growth plates, primary culture of human chondrocytes, and two chondrosarcoma cell lines, suggesting a potential role for abnormal AIRE expression in the development of RMD.

Adipose tissue insulin resistance in peripubertal girls with first-degree family history of polycystic ovary syndrome.

OBJECTIVE: To assess metabolic and endocrine defects in girls genetically predisposed to polycystic ovary syndrome (PCOS). DESIGN: Controlled cross-sectional study. SETTING: University hospital. PATIENT(S): Nine girls, aged 8-14 years, having a first-degree relative diagnosed with PCOS (PCOSr) and 10 age-matched girls without a family history of PCOS. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Insulin sensitivity (IS(FSIVGTT)) determined by frequently sampled IV glucose tolerance testing (GTT) and insulin-induced nonesterified fatty acid (NEFA) suppression, estimated by the log-linear slope of NEFA levels during the first 20 minutes of GTT. RESULT(S): In comparison to controls, PCOSr had higher body mass index (BMI) Z-score, waist circumference, and waist-to-height ratio. Levels of the androgen 17α-hydroxyprogesterone (17-OHP) were significantly increased in PCOSr, independent of adiposity, and inversely correlated with IS(FSIVGTT). The IS(FSIVGTT) was decreased and the NEFA suppression was less steep in PCOSr compared with controls, independent of BMI and 17-OHP. The NEFA suppression was more pronounced with increasing IS(FSIVGTT), independent of adiposity. CONCLUSION(S): Girls at high risk of developing PCOS display increased adiposity and 17-OHP levels, but are mainly characterized by global insulin resistance and resistance to insulin-induced suppression of lipolysis that were independent of adiposity and 17-OHP levels. Therefore, genetic predisposition to PCOS may be related to early insulin resistance and adipocyte dysfunction.

Delayed ghrelin suppression following oral glucose tolerance test in children and adolescents with hypothalamic injury secondary to craniopharyngioma compared with obese controls.

Ghrelin, released from the stomach, acts at the hypothalamus and is associated with initiation of food intake. We hypothesised that patients with craniopharyngioma and hypothalamic obesity (CRHO) would have ghrelin abnormalities. Fifteen CRHO patients and 15 BMI-matched controls underwent oral glucose tolerance test with dynamic ghrelin measurement. From 0-30 minutes, ghrelin (pg/ml) decreased less (43.4 ? 38.8 vs. 70.8 ? 35.8, p < 0.05) and insulin (pmol/l) increased more (1 669.2 ? 861.7 vs. 1 049.1 ? 560.4, p = 0.04) in CRHO compared with controls, respectively. Insulin area-under-the-curve was a weak negative predictor of the 0?30 minutes ghrelin decrease (r(2) = 0.29, p = 0.02). Delayed ghrelin suppression may contribute to obesity in CRHO.

Sleep-disordered breathing is increased in obese adolescents with craniopharyngioma compared with obese controls.

CONTEXT: Retrospective studies suggest that adolescents with craniopharyngioma and hypothalamic obesity have increased sleep-disordered breathing (SDB). OBJECTIVES: The objectives of this study were to compare the prevalence of SDB in adolescents with craniopharyngioma-related obesity compared with body mass index (BMI)-matched controls and to explore possible relationships between SDB, insulin resistance, and adipocytokines. DESIGN: This was a cross-sectional study of obese craniopharyngioma and obese control adolescents. SETTING: Subjects were evaluated in the clinical investigation unit at the Hospital for Sick Children, Toronto. PATIENTS: Fifteen patients with craniopharyngioma-related obesity and 15 BMI-matched controls were recruited and tested. INTERVENTIONS: Each subject underwent fasting blood work, frequent sampled iv glucose tolerance test, polysomnography, and abdominal magnetic resonance imaging with calculation of visceral and sc adipose tissue. MAIN OUTCOME MEASURES: Main measures included insulin sensitivity, sleep efficiency, and fragmentation. RESULTS: Insulin sensitivity was lower in craniopharyngioma subjects compared with control subjects (0.96 +/- 0.34 vs. 1.67 +/- 0.7, P = 0.01). Sleep-onset latency (19.3 +/- 27.8 vs. 31.9 +/- 23.4, P = 0.03) and oxygen saturations (rapid eye movement sleep: 89.0 +/- 5.1 vs. 94.2 +/- 2.3, P < 0.001; non-rapid eye movement sleep: 88.4 +/- 5.6 vs. 94.3 +/- 1.5, P < 0.001) were lower in craniopharyngioma. Obstructive apnea-hypopnea index (OAHI) (7.5 +/- 9.0 vs. 1.5 +/- 1.5, P = 0.03) was higher in craniopharyngioma. Respiratory distress index and OAHI correlated negatively with adiponectin concentrations (r = -0.61, P = 0.03, r = -0.71, P = 0.006, respectively) in craniopharyngioma. On multiple regression, TNF-alpha and craniopharyngioma were independent positive predictors of sleep-onset latency and adiponectin and craniopharyngioma were significant predictors (negative and positive, respectively) of OAHI. CONCLUSIONS: SDB is increased in adolescents with craniopharyngioma-related obesity compared with BMI-matched controls. Routine polysomnography should be considered in obese patients with craniopharyngioma and appropriate treatment initiated.