Reference: November 2025 | Issue 11 | Vol 11 | Page 3
Outstanding line-up of speakers and topics
The 49th Annual Meeting of the Irish Endocrine Society (IES) featured an outstanding line-up of national and international experts in their field assembled to discuss the current hot topics in endocrinology, network with colleagues, meet industry participants, and enjoy a range of excellent oral and poster presentations.
The event began with a trainees’ meeting and RCPI and sub-committees meetings, as well as a ‘Meet the Professor’ section. This was followed with case presentations by trainees, followed by a clinical discussion.
Prof Steven Hunter, IES President, and Consultant Endocrinologist, Royal Victoria Hospital, Belfast, officially opened the meeting. He introduced four oral presentations on original clinical and scientific content that were specially selected by the organisers.
One of the presenters, Dr Maria Tomkins, spoke on the topic of steroid metabolism in patients with chronic kidney disease (CKD) to shed light on renal determinants of adrenal steroid biosynthesis and metabolism.
“When we think of the kidney and adrenal steroids, the first one that comes to mind is aldosterone,” said Dr Tomkins. “When aldosterone is elevated in patients with CKD, it drives pro-inflammatory and fibrotic changes, which can then drive cardiovascular risk.”
Manipulating the renin-angiotensin system is the mainstay of treatment in patients with CKD, she explained. “ACE (angiotensin converting enzyme) inhibitors and ARBs (angiotensin 2 receptor blockers) are widely used in patients with CKD and mineralocorticoid receptor antagonist use is somewhat curtailed by the risk of hyperkalaemia, with newer agents with less risk of hyperkalaemia coming on the market.
“But what we sometimes fail to remember is that cortisol can also bind to the mineralocorticoid receptor… the mineralocorticoid receptor is exposed to far more cortisol than it is aldosterone.” Dr Tomkins presented data from studies conducted by herself and her colleagues and noted that steroid enzyme activity can be evaluated by looking at steroid ratios.
She also observed that patients with CKD share some of the clinical markers of Cushing’s syndrome, such as excess cardiovascular risk, bone disease, muscular atrophy, and a greater risk of liver disease. Dr Tomkins and colleagues set out to identify the effect renal dysfunction has on steroid metabolism and biosynthesis, particularly looking at glucocorticoids and mineralocorticoids.
“We can confirm that the kidneys do play a major role in adrenal regulation, and this goes beyond just aldosterone,” she said. “Where patients with CKD do have elevated aldosterone, which can then cause mineralocorticoid receptor over-activation, cortisol is also a major player.
Reducing 11β-hydroxysteroid dehydrogenase type 2 drives excess cortisol and reduces cortisone, which then have the dual effect of increasing mineralocorticoid effects, but also increasing glucocorticoid tissue exposure, leading to some of these adverse clinical signs that we see in patients with CKD.
“We also showed reduced classic androgens in patients with CKD – most marked in men – and in both sections we found reduced 11-oxygenated androgen biosynthesis in CKD from our previous studies,” Dr Tomkins concluded.
‘It’s about learning and making connections’ – IES President
Speaking at the 49th Annual Meeting of the Irish Endocrine Society (IES), the Society’s President Prof Steven Hunter spoke with Update about the event, and his hopes for the future of the Society.
“I think it’s a great venue and we have had a great attendance,” he commented. “We start with paediatrics [on the agenda] and then we move on to adult endocrinology, so it’s a really good mix.”
This was Prof Hunter’s opening meeting as President and he also spoke about his hopes for his tenure. “I want to build on the work that has been done before – it’s about bringing people together from all parts of Ireland, learning from each other and making some connections too.”
Prof Hunter also spoke about how the specialty of endocrinology has evolved since his early days in medicine. “It has certainly grown in terms of numbers,” he told Update.
“There are a lot more endocrinologists now, and also a lot more patients with diabetes and endocrine disorders, so we are trying hard to keep pace with that.”
Prof Hunter was also asked about the main movements in the specialty at the moment around patient care. “Some of the biggest issues are the rising prevalence of diabetes, and also the new drugs to treat obesity,” he said. “These potentially look very promising and will have major implications financially for the health service. That’s something that will need to be worked out as we go forward.”
Unravelling the mysteries of Silver-Russell syndrome
The 49th Annual Meeting of the Irish Endocrine Society (IES) saw the keynote lecture delivered by Prof Justin Davies, Consultant Paediatric Endocrinologist, University Hospital Southampton, UK, and Professor of Paediatric Endocrinology, University of Southampton, UK. Prof Davies spoke on the topic of ‘Silver-Russell syndrome or Temple syndrome: Challenges in diagnosis and management’.
Prof Davies explained that Silver-Russell syndrome and Temple syndrome are imprinting disorders, “and imprinting disorders, in general, profoundly influence growth, metabolism, and neurocognition. As paediatricians and paediatric endocrinologists, these two [are recognised as] important causes of short stature, secondary to being born small for gestational age.”
Prof Davies explained that these syndromes are often missed or diagnosed late, which can lead to poor outcomes for children with these conditions, and both syndromes require bespoke management. Prof Davies explained that one of the aims of he and his colleagues is to look at outcomes from these conditions in older people and adults.
He provided an overview of Silver-Russell syndrome, explaining that Temple syndrome is the main differential diagnosis for Silver-Russell syndrome. He also presented some case studies derived from his specialist imprinting disorder service.
Prof Davies and colleagues use the Netchine-Harbison Clinical Scoring System for diagnosing Silver-Russell syndrome, which was first described in the 1950s, he explained. “We now know that Silver-Russell syndrome is a molecularly heterogenous, epigenetic disorder, and is characterised by pre- and postnatal growth failure associated with typical phenotypic features,” he told the attendees.
“It’s classified as an ultra-rare disorder – it has an incidence of between one-in-30,000 to 100,000… the molecular diagnosis is achieved in about 60 per cent of these children and the two most common molecular diagnoses are loss of methylation at the 11p15 locus and maternal uniparental disomy of chromosome 7.
“These two genetic aetiologies account for around 60 per cent of cases, and you also have much rarer monogenic causes, which account for 5 per cent of Silver-Russell syndrome cases.” This means that around 40 per cent of children do not have a molecular diagnosis of Silver-Russell syndrome and this can lead to diagnostic confusion and delay, he told the meeting.
He went on to describe the management challenges with Silver-Russell syndrome. “Management goals change radically with age and that can be very difficult for caregivers to accept, so it’s very useful when a genetic diagnosis has been made to be clear from the outset that the advice you are giving at one age may be completely reversed at another,” said Prof Davies.
The predominant issue in the first years of life is poor nutrition, he explained, and that is due to a profound loss of appetite. “Sometimes these babies will take an hour or even two hours to complete a meal,” said Prof Davies. “That can lead to a significant nutritional deficit, so the aim at this stage is to optimise the nutrition to recover calorie-related height deficits – the reduction in height due to poor nutrition.”
He continued: “We try to avoid using nasogastric tubes or gastrostomy, because we worry about how that impacts on appetite development in these children, but occasionally the situation means that you do have to use these.”
More than 60 per cent of these children will have profound eating difficulties, he added. These problems tend to reduce as the child gets older: “That’s very helpful to be able to tell parents when they are in the middle of trying to manage this very difficult situation.”
Prof Davies concluded: “These disorders have profound effects on growth, appetite, metabolism, and neurocognition. They are often masquerading in our populations of children that we are managing for short stature or short SGA [short for gestational age] and they require different management strategies,” he said.
“The health consequences of both of these conditions is becoming better understood, and there is some emerging evidence of the health consequences of MLID [multi-locus imprinting disorder].”
There is a pressing need to improve recognition and early referral in both conditions, he explained, and evidence is also accumulating on the diverse and complex medical needs of patients with Silver-Russell syndrome or Temple syndrome. “Management requires surveillance and co-ordinated multidisciplinary care, and these place a significant demand on healthcare resources,” he added.
He urged the attendees to consider a differential diagnosis of Silver-Russell syndrome, Prader-Willi syndrome, and short-stature SGA in Temple syndrome. This condition has a distinctly different management strategy to Silver-Russell syndrome, he added.
Reducing the patient’s fear of hypoglycaemia
The 49th Annual Meeting of the Irish Endocrine Society (IES) saw Prof Pratik Choudhary deliver the prestigious Hadden Lecture to attendees. Prof Choudhary is Professor of Diabetes, University of Leicester, UK, and his talk was on the topic ‘Is hypoglycaemia still a barrier to optimal glucose control?’
Prof Choudhary briefly discussed previous research and touched on a previous experiment that showed the important role of the hypothalamus in regulating hypoglycaemia. “The challenge, I think, is the difference between humans and animals [in studies],” said Prof Choudhary. “That is, what you can’t measure in animal experiments is the emotional and cognitive response to hypoglycaemia, which seems to be quite important.”
This hypothesis prompted a study involving neuroimaging in hypoglycaemia, which showed that people with normal ‘hypo-awareness’ after 20 years of diabetes do not produce the same adrenaline response as people who have never had a ‘hypo’, which is described as a low blood sugar episode, accompanied by the body’s natural warning signs. People with hypo-unawareness produce almost no adrenaline, the study also showed.
The neuroimaging research involved people without diabetes, patients with normal hypo-awareness, and those with unawareness. “When you are hypoglycaemic, there is more blood flow than when you are euglycaemic,” Prof Choudhary told the conference.
“If you are non-diabetic, brain blood flow goes into the thalamus, which is kind of our sensory awareness station and monitors what’s going on.” Certain areas of the brain that are activated inform the patient that they need to act on a particular symptom, Prof Choudhary said.
“There is also something we call ‘emotional salience’,” Prof Choudhary continued. “That is, ‘How important is that symptom for me?’ The hypo-unaware people had a very strong thalamic response and they picked up the hypoglycaemia very strongly, but the emotional frontal executive function signal was much lower.”
The research went on to probe which parts of the brain are ‘firing’ in these circumstances and in which order. “You find that this thalamic response is driven by an area that is responsible for shifting intention,” he continued. “We never truly multi-task – this part of the brain just switches attention from one stimulus to another.”
This is important in terms of whether a patient ‘listens’ to the symptoms of hypoglycaemia or not, he said. “There is no intervention yet to deal specifically with people who have a high fear of hypoglycaemia.”
Fear of hypoglycaemia is often a ‘hangover’ from the era of regular finger-pricks and the patient anxiety that was associated with that process. A continuous glucose monitor should alleviate much of that fear, he said.
“What I would like people to take away, maybe in your conversations with patients, is that hypoglycaemia has four different categories now,” Prof Choudary told the attendees. “You have preventive hypo, where there is a sense that it is going to go down and you take preventive action. It impacts negatively on quality of life, but there is no physiological impact.
“Then you have a hypo alert value of 4 – this is not hypoglycaemia, but again it’s getting close and you have to do something. A value of 3 is what you want to avoid, and also the duration of the 3, and you can have a prolonged event under 2.2, some of which will be artefacts, and some of which will be true.”
Prof Choudhary concluded: “The risk of hypoglycaemia with technological advances is dramatically reduced. We need to work to reduce the fear of hypoglycaemia, so that people can avail of the benefits of those technologies. [We need to] focus on the individual barriers to control and identifying the beliefs that drive those unhelpful behaviours.
“We need to be far clearer when someone says ‘hypoglycaemia’, that I understand what they mean, by disentangling the inconvenience and burden of living with diabetes and having hypoglycaemia, from actual risks and fears. Hypoglycaemia, of course, places a burden on people with diabetes, but technology can reduce that burden. Hypoglycaemia was a huge barrier to [glucose] control, but at the moment it’s fear and it’s our job to reduce it.”
‘Realistic medicine’ for diabetic foot patients
Each year at the 49th Annual Meeting of the Irish Endocrine Society (IES), the prestigious McKenna Lecture is delivered by a distinguished invited guest. This year’s lecture was delivered by Dr Hamish Courtney, Consultant Diabetologist, Belfast Health and Social Care Trust, Northern Ireland, who spoke on the theme ‘Making changes for diabetic feet: One step forward’.
The lecture was introduced by IES President Prof Steven Hunter, who acknowledged Dr Courtney’s significant contribution to clinical research and practice.
He discussed common complications and presented data on diabetic foot, emphasising the need for compassion in care and the importance of avoiding unnecessary procedures or aggressive management where it is not strictly necessary.
“I am very drawn by the initiative in Scotland of ‘realistic medicine’, which is supported by the Royal College,” Dr Courtney told the conference. “I think we miss out on a lot of this in our day-to-day practice and I think we really have a role as physicians in taking leadership in ‘realistic medicine’.
“So often, I think we defer to the surgeons and they make the [treatment] decision, but it is our job as physicians to understand the natural history and the burden of comorbidity, to make decisions about realistic medicine for these patients.”
He continued: “These elderly patients come in to the foot service and rather than see them, we have a ‘huddle’ and discuss them beforehand, and we are able to avoid many of these elderly people coming in an ambulance. We have been able to avoid 90 per cent of attendances at our service – a more compassionate and realistic approach is in place, rather than an aggressive medical or surgical approach.
“I am really passionate about physicians taking leadership in managing these old people who come in, for whom foot disease is perhaps part of the terminal process, rather than something active that needs to be managed in perhaps the way we manage other [conditions].”
He also touched on the cohort of patients who do not engage with diabetes services, which equates to up to 60 per cent of admissions. With these patients, there is a need to aggressively treat hyperglycaemic-driven complications; those with foot disease that is not being driven by diabetes, but by other factors such as smoking or hypertension, are less suitable candidates for secondary diabetes services.
Dr Courtney presented case studies to illustrate this point and said for a patient whose foot disease is not being driven by hyperglycaemic-driven complications, “in a resource-limited world, I’m not sure we need to see this patient,” he said. “Somebody needs to look after his lipids and blood pressure, but it may not be us…. Of course, most of the patients are in-between [these two examples], and there is a developing experience in our centre as to who we should or shouldn’t see.”
He concluded: “It’s important to have a clear course for where we’re going, but it’s also important to be flexible enough when change is needed, depending on what happens… for our journey in Northern Ireland we are making changes, one step forward and hopefully not two steps back.”
