The inaugural Joint Irish-UK Endocrine Meeting, which took place in the International Cultural Centre, Belfast, from 13-14 October, welcomed a host of leading national and international experts, clinicians, and guest speakers to a rich and diverse scientific programme, the latest updates in endocrine-related research, and opportunities for multidisciplinary collaboration.
Multiple plenaries, symposia, lectures, and posters covered a substantial array of specialist and general areas, ranging from the management of adrenal insufficiency, to pituitary health, diabetes and metabolism, thyroid disease, and polycystic ovary disease, among many other areas of endocrine-related health.
The endocrinologist’s role along the cancer journey
The Hadden Lecture was among the many highlights during the Joint Irish-UK Endocrine 2024 Meeting; described by Irish Endocrine Society (IES) President Prof Fidelma Dunne, Professor in Medicine at the National University of Ireland, Galway, Consultant Endocrinologist at Galway University Hospital, as the “highest honour the IES can bestow on a colleague in our field”.
The lecture is given in memory of Prof David Hadden, who was a Consultant Physician at the Royal Victoria Hospital and Honorary Professor of Endocrinology at Queen’s University, Belfast. Prof Hadden was instrumental in uncovering the role of diet in type two diabetes, among many other contributions to his field, before his death is 2014, and was as a founding member of the IES.
Prof Maralyn Druce, Consultant Endocrinologist at Barts Health NHS Trust, Professor of Endocrine Medicine at Barts and the London School of Medicine and Dentistry, and Senior Editor of Clinical Endocrinology, delivered the Hadden Lecture with a talk entitled: ‘The endocrinologist’s role along the patient cancer journey – from pre-diagnosis to survival and vitality and beyond’. She began with a personal and professional tribute to Prof Hadden, adding that he “inadvertently got me started on my journey as an endocrinologist”, when he co-edited a book for which Prof Druce had written a chapter on diabetes in her early career. Quoting his obituary in The Lancet, she said Prof Hadden “was always a gentleman, very open to talk to, and a pleasure to work with”.
The endocrinologist’s role in cancer care
Moving on to her presentation, Prof Druce examined the complexity of the endocrinologist’s role throughout the cancer trajectory and said that overall, “listening, thinking, explaining options to patients, and linking with different members of the multidisciplinary team are perhaps the greatest contribution we can make”. She discussed the different ways that endocrinologists might interface with a cancer journey, such as managing patients with an increased risk of cancer in endocrine organs, patients with proven cancer in endocrine organs, and patients at risk of endocrine injury because of either their cancer or cancer treatment.
Attendees heard several direct quotes from the lived experiences of patients before Prof Druce discussed the limitations of existing guidelines and the “explosion of data” in the literature. “It’s not always the cancer itself that impacts life,” she emphasised, adding that many cancer therapies result in “direct and intended acute toxicities to the endocrine system”, as well as long-term effects. “We need to be literate, not just in the management of long-term sequalae such as bone health, but also increasingly in the management of symptoms associated with them,” she said.
Prof Druce then presented data on persistent and later toxicities in childhood cancer, highlighting the substantial increases in survivorship of “patients living beyond cancer”. “Mortality is not the only issue,” she noted, before focusing on the range of morbidities “that can stack up over time”.
The conference heard that survivors of childhood cancers have significantly higher risks of developing morbidities when compared to their siblings and that notably high rates of late endocrine effects exist among this population.
“There’s a high prevalence of endocrinopathy, but not necessarily high mortality, from late endocrine effects in general,” Prof Druce said, and discussed the various post-cancer pathologies that can affect the thyroid, the hypo-pituitary-axis, bone health, obesity, metabolism, and other endocrine processes, and what this means for endocrinologists.
“What is clear from some of these long-term cohort studies is that the impact of endocrine late effects is not just on the endocrine system…. We might think that if we replace the hormones everything will be fine. In fact, endocrine late effects, excluding weight-based effects, track with life morbidity, such as depression, PTSS (post-traumatic stress syndrome), emotional regulation, and social function; even when well managed.”
Concluding, Prof Druce said “we don’t yet have the data on late effects” and acknowledged the existence of many clinical, economic, and practical “unanswered questions”. Regarding the role of the endocrinologist, she said “we are there to guide our patients to the roadblocks with the information and knowledge that we have”, and advocated supporting the patient “through their chronic ill-health, keeping them optimal both in terms of their psychological and quality of life, and also in terms of their endocrine health”.
ADOPTing AI to facilitate timely bone care
The Joint Irish and UK Endocrine Annual Scientific Meeting 2024 was presented with a practical and clinically-grounded overview of the UK ADOPT (AI-enabled Detection of OsteoPorosis for Treatment) study from lead author Prof Kassim Javaid, Professor of Osteoporosis and Adult Rare Bone Diseases, University of Oxford, UK.
ADOPT uses artificial intelligence (AI) to review hospital computed tomography (CT) scans and identify appropriate patients, who are not critically unwell or in the final stages of life, that will benefit from a prompt bone health assessment. In his talk, he provided insight into AI algorithms in clinical practice, how healthcare systems and clinicians “can use them intelligently”, and why he and his team now include the technology in their osteoporosis pathway.
Undetected fractures and high-risk patients
Prof Javaid began by presenting the empirical data and a patient case study to show that while patients undergo CT scans for many reasons, up to 50 per cent of moderate to severe vertebral fractures on images that include the spine are not detected. “This has led to a tsunami of AI models that look at different [radiological] modalities to automate the detection of bone fractures,” he said, and added that healthcare systems “don’t have the manpower” required to do so in the same manner.
Discussing the available technologies, Prof Javaid detailed “ensemble AI”– which involves training several AI models to achieve optimal fracture prediction and detection. “Why use one model when you can use four?” he said, explaining that agreement between the separate models provides “a much higher performance rate”, and diminishes dependence on just one system.
“CT has a lot more information than just the shape of the bone,” Prof Javaid continued, and went on to describe the “valuable” data AI can produce and analyse regarding muscle, age, and other demographics. Attendees then heard that the technology can improve fracture prediction even without analysing radiological images or bone parameters, instead using “very old” and other data sets, such as ICD [International Classification of Diseases] 10 codes. He then presented evidence to show that AI is “quite impressive” when compared to the traditional mode of osteoporosis detection, the DXA (dual-energy x-ray absorptiometry)scan. “There is a massive amount of [AI] models in the literature,” he said, and told his colleagues that they did not need to “keep up” with the ongoing advances, and should instead just wait for those that are granted regulatory approval, as most will “drop off” during the process.
Practical insight from ADOPT
Prof Javaid proceeded to share some of the practical knowledge he gained while successfully implementing a “very simple AI pathway way using CT data” in five hospitals during ADOPT. “We did this in four work packages,” he explained. “Does AI actually work in the hospital setting? What are the regulatory pathways for deployment? Do we actually improve the number of patients we manage? And finally, do we prevent fractures?”
Prof Javaid then gave a step-by-step description of the methodology, approval, and implementation phases of the study, as well as an overview of practical issues, tips for adoption, litigation considerations, and “lessons learned”. He emphasised the importance of identifying “humans in the loop”, as well as the “massive IT requirements”, and described carrying out a shadow test before going live “to see what happens” within a clinical context and identify areas to be fixed.
“AI is going to revolutionise healthcare in coming years,” Prof Javaid told the room. “The good news is that after 2,000 patients, we’ve only had positive feedback. Most patients are delighted that AI is now helping them achieve bone health.” Concluding, he emphasised the necessity of “human review”, multidisciplinary collaboration, particularly with general practice, and patient follow-up after the AI has identified those at risk.
“I would suggest you spend 90 per cent of your time thinking about the patient and 10 per cent thinking about AI, because the AI will work. You’ll get lots of patients and your AI implementation group has to focus on what happens once they get confirmed.”
Developments in bariatric surgery
Attendees at the Joint Irish and UK Endocrine Annual Scientific Meeting 2024 received a tour de force presentation from Prof Helen Heneghan, Consultant Bariatric Surgeon, St Vincent’s University Hospital, Dublin, on the latest advances, findings, and outcomes in bariatric surgery in a talk entitled: ‘Metabolic surgery: Which to choose and new developments’.
The gastric band is “becoming a redundant procedure” and has the highest rates of long-term complications, Prof Heneghan began with the current trends, adding that the approach is also the least effective in terms of weight loss and comorbidity resolution when compared to the commonest operations performed – sleeve gastrectomy and gastric bypass.
Delegates received a detailed overview of each procedure, noting that bypassing the foregut (duodenum and proximal jejunum) leads to “a lot of the gut hormone benefits responsible for metabolic improvements”. Prof Heneghan also stated that sleeve gastrectomy “leads the way in terms of volume”, accounting for over 60 per cent of bariatric surgeries performed worldwide.
Describing her own practice and experiences, Prof Heneghan talked about the value of “enhanced recovery after surgery”, which she described as a “bundle of things done before, during, and after surgery” to enhance safety, get people out of hospital sooner, and reduce risks, including a simple laprascopic approach and early resumption of mobility post-operatively. Prof Heneghan told the conference that bariatric surgery carries a mortality rate equal to cholecystectomy, which is less than one-in-1,000. Major complications arise in 1-2 per cent of cases, while one-in-10 patients will experience mild to moderate problems, she said.
Moving to the benefits of bariatric surgery, Prof Heneghan noted that “every organ affected by obesity can be improved”, and described an array of positive outcomes which also extend to mental health benefits and a reduced risk of cancer (excluding lung cancer).
The superiority debate: Choosing a procedure
Prof Heneghan explained that if patients do not have a preference regarding sleeve gastrectomy or bypass, “it’s not an easy decision.” She added that only around half of patients will have a preference, and that many come misinformed, particularly due to social media.
“There are pros and cons to both procedures,” she said. Benefits of sleeve gastrectomy include the fact it is simple and quick to perform, is relatively safe, and is effective for weight loss and obesity complications. On the other hand, it is not reversible and weight regain occurs in up to 70 per cent of patients. Gastro-oesophageal reflux disease (GORD) occurs in 20-30 per cent of patients, with one-in-five developing non-dysplastic Barret’s oesophagus, the conference heard.
“Bypass is also quick,” Prof Heneghan compared, adding that the procedure is also reversible, slightly more effective than sleeve gastrectomy, and reduces obesity complications. “There is a risk of ulcers and strictures at the first anastomosis,” she said, and noted the surgery carried a slightly higher risk of iron deficiency.
“There is some new data to help decide which procedure to choose,” Prof Heneghan presented the latest published, and some unpublished, findings to summarise current understanding that “bypass outperforms a sleeve, which outperforms a band”, and that gastric bypass achieved a better quality of life.
“Bypass is more clinically effective than a sleeve and a band in short- to medium-term. We need data beyond three years, particularly beyond five years. I think based on experience and non-randomised data, the bypass will outperform the sleeve…. The bypass is now as safe as a sleeve and as cost-effective, but that data has yet to be published.”
Novel therapies
A range of novel approaches are emerging in bariatric surgery, delegates heard, including the inter-gastric balloon; an endoscopic procedure that is “very safe for temporary weight loss or patients unsuitable for surgery”, but not for long-term results as “weight goes back on when [the balloon] is removed”.
Prof Heneghan also mentioned the EndoBarrier device, which is placed endoscopically in the duodenum to “mimic aspects of bypass”, and leads to 11 per cent weight loss and a notable HbA1C reduction in one year. “The device lost approval four or five years ago” due to a particularly high incidence of liver abscesses and gastro-intestinal bleeds, likely tied to the anchoring mechanism of the device, Prof Heneghan said, but added that the “second generation of that device will be interesting”.
“The most novel endoscopic device coming to market is the magnet anastamotic system,” she added, which “involves placing a magnet in the proximal jejunum using endoscopy and one in the terminal ileum using colonoscopy, let them meet each other, and compression will form an anastomosis in a really safe way”. Prof Heneghan also discussed selecting patients for the duodenal mucosal resurfacing procedure, which involves endoscopic ablation to resurface the mucosa, “takes less than one hour to perform, is really safe, and is associated with an improved A1C and weight loss of around 7 per cent at one year.”
Concluding her talk with a summary of current knowledge in the field, Prof Heneghan said: “Bariatric surgery is clinically- and cost-effective for the treatment of obesity. A gastric bypass is more effective and as safe as a sleeve gastrectomy. Patient choice is also important in determining which procedure people have. They have to be informed on the likely procedure outcomes. There are really exciting novel metabolic procedures on the way that I think combined with medications will transform the treatment of obesity in future.”
