International consensus on the diagnosis and management of dumping syndrome

Dumping syndrome is a common but underdiagnosed complication of gastric and oesophageal surgery. We initiated a Delphi consensus process with international multidisciplinary experts. We defined the scope, proposed statements and searched electronic databases to survey the literature. Eighteen experts participated in the literature summary and voting process evaluating 62 statements. We evaluated the quality of evidence using grading of recommendations assessment, development and evaluation (GRADE) criteria. Consensus (defined as >80% agreement) was reached for 33 of 62 statements, including the definition and symptom profile of dumping syndrome and its effect on quality of life. The panel agreed on the pathophysiological relevance of rapid passage of nutrients to the small bowel, on the role of decreased gastric volume capacity and release of glucagon-like peptide 1. Symptom recognition is crucial, and the modified oral glucose tolerance test, but not gastric emptying testing, is useful for diagnosis. An increase in haematocrit >3% or in pulse rate >10 bpm 30 min after the start of the glucose intake are diagnostic of early dumping syndrome, and a nadir hypoglycaemia level <50 mg/dl is diagnostic of late dumping syndrome. Dietary adjustment is the agreed first treatment step; acarbose is effective for late dumping syndrome symptoms and somatostatin analogues are preferred for patients who do not respond to diet adjustments and acarbose.

SAT-444 Pituitary Function and the Response to GH Replacement Therapy in Patients with Histiocytosis: Analysis of the Pfizer International Metabolic Database (KIMS)

Introduction: Langerhans Cell Histiocytosis (LCH) is a rare infiltrative disease with granulomatous deposits sometimes involving the hypothalamus-pituitary axis, with endocrine manifestations that includes diabetes insipidus (DI) and growth hormone deficiency (GHD) as the most prevalent consequences in both adult- and childhood onset patients. Anterior pituitary dysfunction, although well recognized, has been reported in only 5-20% of patients and most clinical information is primarily described in pediatric patients (Kaltsas G et al. JCEM 85: 1370-1376, 2000) with little information on pituitary function in adults with LCH. Objective: To analyze the safety and effectiveness of GH replacement treatment in adult patients with GHD and LCH. Patients and Methods: Patients with LCH naïve/semi-naïve to GH replacement therapy with baseline (BL) and at least 1 year of follow-up data, enrolled in KIMS were studied. Data are presented as mean (SD) or percentage (%). Effectiveness GH data are presented as change after 1 year treatment (mean, 95% CI). P<0.05 was considered as statistically significant. Results: At BL, 57 adults with LCH (27 with childhood onset), 54% women, mean age at GHD onset 30 (15) yr, at KIMS entry 35 (12) yr; IGF-I SDS and total cholesterol (mmol/L) were -2.3 (1.8) and 5.7 (1.2), respectively; BMI kg/m², 28.5 (7.3) and waist circumference, 93.8 (16.5) cm. DI was diagnosed in 87% of LCH patients and additional pituitary deficiencies included LH/FSH (64%), TSH (56%), and ACTH (47%). One yr cross-sectional values for GH dose (n=37; mg/d) was 0.39 (0.21) and for IGF-I SDS -0.5 (-1.2 to 0.2). First yr delta for patients with LCH included total cholesterol (mmol/L) -0.9 (-1.5 to -0.3; p<0.05); AGHDA-Quality of Life (QoL) score (reduction indicating improved QoL; n=24) was -2.8 (-5.3 to -0.3; p<0.05) and change in waist circumference was -0.7 cm (-3.1 to 1.6; not statistically significant). Twenty-two serious adverse events (SAEs) were reported in 11 patients during 297 patient-years (74.1/1000 pyrs), 14 of these 22 SAEs were associated with hospitalization (7 out of 11 patients), 4 reports indicated no hospitalization and 4 reports had missing value on hospitalization. No new safety signals were reported. Conclusion: Pituitary deficiencies were more frequently observed in patients with LHC and concomitant GHD than previously recognized supporting a systematic hormonal evaluation in these patients. GH replacement therapy (for 1 year) was safe and improved metabolic variables and quality of life.

A rebreathing method to determine carbon monoxide diffusing capacity in children: reference values for 6- to 18-year-olds [corrected] and validation in adult volunteers

The diffusing capacity of carbon monoxide (D(L,CO)) and its value normalized to alveolar volume (D(L,CO)/V(A)) are usually estimated with the single breath method at total lung capacity (TLC). Severely ill patients and small children are not able to deliver a satisfactory vital capacity (VC) or hold their breath for 10 s at TLC. The aim of this study was to develop a rebreathing procedure in which diffusing capacity can be determined during spontaneous tidal breathing. The conventional rebreathing method during hyperventilation was modified so that rebreathing volume and gas concentrations were kept constant by CO2 absorption and O2 supplementation. In adult healthy volunteers and in patients who were able to perform both tests, the diffusion indices obtained with this rebreathing method during resting ventilation were compared with those obtained by the single breath method. Predicted (reference) values for rebreathing D(L,CO) and D(L,CO)/V(A) for children were determined. D(L,CO)/V(A) decreased with alveolar volume (V(A)) and increased with alveolar ventilation (V'(A)). In adults at V'(A) above 35 L x min(-1) rebreathing D(L,CO)/V(A) was similar to single breath D(L,CO)/V(A) at similar alveolar volumes. The D(L,CO)/V(A) relative to their corresponding reference values were the same for both methods in adult patients, irrespective of ventilation distribution disturbances. In children the newly described diffusing capacity obtained by the rebreathing method during resting ventilation can serve as a valuable index to assess and follow a diffusion disorder.

Samarium-153-EDTMP for palliation of ankylosing spondylitis, Paget's disease and rheumatoid arthritis

Samarium-153-EDTMP is an effective agent for palliation of widespread skeletal metastases because it concentrates in bone metastases which have an osteoblastic component. Similar concentration in areas of osteoblastic activity in ankylosing spondylitis, Paget's disease and rheumatoid arthritis suggests a possible new treatment approach. Three patients with ankylosing spondylitis, one patient with Paget's disease and one patient with rheumatoid arthritis were treated with 153Sm-EDTMP. Objective and subjective improvement was noted, especially in ankylosing spondylitis patients. Samarium-153-EDTMP has disease-modifying potential in ankylosing spondylitis and Paget's disease and has palliative value in resistant rheumatoid arthritis. Further trials to determine optimal dose, treatment scheduling, long-term disease-modifying potential and toxicity are needed.