Aim: Human dignity as an important consideration in health care has been primarily investigated from an adult perspective. This paper explores young people's perceptions of dignity and how it impacts on their health-care experience.Method: A qualitative pilot study was undertaken at the Children's Hospital, Westmead in from 2010 to 2011. Semi structured interviews were conducted with five inpatients, and data were analysed using a grounded theory approach.Results: The adolescents interviewed perceived dignity as a way of protecting their personhood. Privacy and maintaining integrity were the means by which dignity could be preserved in a health-care setting.Conclusions: The study found that young people had unique perceptions of privacy and personhood with regards to dignity. Of the concepts of dignity in the existing literature, the dignity of identity was most applicable to adolescents' conceptions. This understanding of young people's views of dignity could prevent dignity violations in health care and beneficially impact their development. Keywords: adolescent; behavioural; ethics What is already known on this topic1. Dignity is a key component in human identity, and may positively or negatively affect self-perception.2. Health-care situations can negatively impact on dignity and self-identity.3. The establishment of a stable self-identity is a key developmental task of adolescence. What this paper adds1. Adolescents viewed dignity as a way of protecting their personhood and identity.2. The concepts of privacy and maintaining integrity were uniquely described by adolescents as a way of ensuring dignity in health-care settings.3. These findings may help tailor health care to best suit young people's needs.

<u>Background</u> <p>There is substantial evidence that adults with type 1 diabetes have reduced bone mineral density (BMD), however findings in youth are inconsistent.</p> <p><u>Purpose</u></p> <p>Systematic review and meta-analysis of BMD in youth with type 1 diabetes using multiple modalities: dual energy X-ray absorptiometry (DXA), peripheral quantitative computed tomography (pQCT) and/or quantitative ultrasound (QUS).</p> <p><u>Data Sources</u></p> <p>PubMed, Embase, Scopus and Web of Science from 01/01/1990 to 31/12/2020, limited to humans, without language restriction.</p> <p><u>Study Selection</u></p> <p>Inclusion criteria: cross sectional or cohort studies that included BMD measured either by DXA, pQCT and/or QUS in youth (age <20 years) with type 1 diabetes and matched controls. </p> <p><u>Data extraction</u></p> <p>Total body (TB), lumbar spine (LS) and femoral BMD (DXA); tibia, radius and lumbar spine (pQCT); and phalanx and calcaneum (QUS). Weighted mean difference (WMD) or standardized mean difference (SMD) were estimated and meta-regression was performed using age, diabetes duration and HbA1c as covariates.</p> <p><u>Data Synthesis </u></p> <p>We identified 1300 non-duplicate studies; 46 met the inclusion criteria, including 2617 cases and 3851 controls. Mean age was 12.6 ± 2.3 years. Youth with type 1 diabetes had lower BMD: TB (WMD -0.04 g/cm², 95% CI -0.06 to -0.02, <i>P</i>=0.0006); LS (-0.02 g/cm², -0.03 to -0.0, <i>P = 0.01</i>); femur (-0.04 g/cm², -0.05 to -0.03, <i>P</i><0.00001); tibial trabecular (-11.32 g/cm³,-17.33 to -5.30, <i>P</i>=0.0002), radial trabecular (-0.91, -1.55 to -0.27, <i>P=0.005</i>); phalangeal (-0.32, -0.38 to -0.25, <i>P</i><0.00001) and calcaneal (SMD -0.69, -1.11 to -0.26, <i>P</i>=0.001). Using meta-regression TB BMD was associated with older age (coefficient -0.0063, -0.0095 to -0.0031, <i>P</i>=0.002), but not longer diabetes duration or HbA1c.</p> <p><u>Limitations</u></p> <p>Meta-analysis was limited by the small number of studies using QUS and pQCT and lack of use BMD z-scores in all studies. </p> <p><u>Conclusions</u></p> <p>Bone development is abnormal in youth with type 1 diabetes, assessed by multiple modalities. Routine assessment of BMD should be considered in all youth with type 1 diabetes.</p>

ObjectivesPrader-Willi Syndrome (PWS) is characterised by hyperphagia often leading to obesity; a known risk factor for insulin resistance and type 2 (T2) diabetes. We present a prepubertal girl with PWS who developed diabetes.Case presentationOur case was diagnosed with PWS in infancy following investigation for profound central hypotonia and feeding difficulties. She commenced growth hormone (GH) aged 8 years for short stature and treatment improved linear growth. At age 12 years, she presented with polydipsia, polyuria and vulvovaginitis. She was overweight (BMI SDS +1.43). Diabetes was diagnosed (Blood glucose = 24.2 mmol/L, HbA1c = 121 mmol/mol or 13.2%). She was not acidotic and had negative blood ketones. Autoantibodies typical of type 1 diabetes were negative. She was initially treated with basal bolus insulin regime. GH was discontinued 3 months later due to concerns regarding GH-induced insulin resistance. Off GH, insulin requirements reduced to zero, allowing Metformin monotherapy. However off GH, she reported significant lethargy with static growth and increased weight. Combinations of Metformin with differing insulin regimes did not improve glucose levels. Liraglutide (GLP-1 agonist) and Metformin did not improve glucose levels nor her weight. Liraglutide and Empaglifozin (SGLT-2 inhibitor) therapy used in combination were well tolerated and demonstrated rapid normalisation of blood glucose and improvement in her HbA1c to within target (48 mmol/mol) which was sustained after 6 months of treatment.ConclusionsNewer treatments for type 2 diabetes (e. g. GLP-1 agonists or SGLT-2 inhibitors) offer potential treatment options for those with diabetes and PWS when conventional treatments are ineffective.

BACKGROUND There is substantial evidence that adults with type 1 diabetes have reduced bone mineral density (BMD); however, findings in youth are inconsistent. PURPOSE To perform a systematic review and meta-analysis of BMD in youth with type 1 diabetes using multiple modalities: DXA, peripheral quantitative computed tomography (pQCT), and/or quantitative ultrasound (QUS). DATA SOURCES PubMed, Embase, Scopus, and Web of Science from 1 January 1990 to 31 December 2020, limited to humans, without language restriction. STUDY SELECTION Inclusion criteria were as follows: cross-sectional or cohort studies that included BMD measured by DXA, pQCT, or QUS in youth (aged &lt;20 years) with type 1 diabetes and matched control subjects. DATA EXTRACTION We collected data for total body, lumbar spine, and femoral BMD (DXA); tibia, radius, and lumbar spine (pQCT); and phalanx and calcaneum (QUS). Weighted mean difference (WMD) or standardized mean difference was estimated and meta-regression was performed with age, diabetes duration, and HbA1c as covariates. DATA SYNTHESIS We identified 1,300 nonduplicate studies; 46 met the inclusion criteria, including 2,617 case and 3,851 control subjects. Mean ± SD age was 12.6 ± 2.3 years. Youth with type 1 diabetes had lower BMD: total body (WMD −0.04 g/cm2, 95% CI −0.06 to −0.02; P = 0.0006), lumbar spine (−0.02 g/cm2, −0.03 to −0.0; P = 0.01), femur (−0.04 g/cm2, −0.05 to −0.03; P &lt; 0.00001), tibial trabecular (−11.32 g/cm3, −17.33 to −5.30; P = 0.0002), radial trabecular (−0.91 g/cm3, −1.55 to −0.27; P = 0.005); phalangeal (−0.32 g/cm3, −0.38 to −0.25; P &lt; 0.00001), and calcaneal (standardized mean difference −0.69 g/cm3, −1.11 to −0.26; P = 0.001). With use of meta-regression, total body BMD was associated with older age (coefficient −0.0063, −0.0095 to −0.0031; P = 0.002) but not with longer diabetes duration or HbA1c. LIMITATIONS Meta-analysis was limited by the small number of studies with use of QUS and pQCT and by lack of use of BMD z scores in all studies. CONCLUSIONS Bone development is abnormal in youth with type 1 diabetes, assessed by multiple modalities. Routine assessment of BMD should be considered in all youth with type 1 diabetes.

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Introduction: Craniopharyngiomas are rare brain tumours (incidence 1.1-1.7 cases/million/year). Although benign, craniopharyngioma causes major endocrine and visual morbidities including hypothalamic obesity, yet mechanisms leading to obesity are poorly understood. This study investigated the feasibility and acceptability of eating behaviour measures in patients with craniopharyngioma, to inform the design of future trials. Methods: Patients with childhood-onset craniopharyngioma and controls matched for sex, pubertal stage and age were recruited. After an overnight fast, participants received the following measures: body composition, resting metabolic rate, oral-glucose-tolerance-test including MRI (patients only), appetite ratings, eating behaviour and quality of life questionnaires, ad libitum lunch, and an acceptability questionnaire. Data are reported as median/IQR, with effect size measure (Cliffs delta) and Kendalls Tau for correlations, due to the small sample size. Results: Eleven patients (median age=14yrs; 5F/6M) and matched controls (median age=12yrs; 5F/6M) were recruited. All patients had received surgery and 9/11 also received radiotherapy. Hypothalamic damage post-surgery was graded (Paris grading): grade 2 n=6; grade 1 n=1; grade 0 n=2. The included measures were deemed highly tolerable by participants and their parent/carers. Preliminary data suggests a difference in hyperphagia between patients and controls (d=0.5), and a relationship between hyperphagia with body mass index (BMISDS) in patients (tau=0.46). Discussion: These findings demonstrate that eating behaviour research is feasible and acceptable to craniopharyngioma patients and there is an association between BMISDS and hyperphagia in patients. Thus, food approach and avoidance behaviours may be useful targets for interventions to manage obesity in this patient group.

<b><i>Introduction:</i></b> Craniopharyngiomas are rare brain tumours (incidence 1.1–1.7 cases/million/year). Although non-malignant, craniopharyngioma causes major endocrine and visual morbidities including hypothalamic obesity, yet mechanisms leading to obesity are poorly understood. This study investigated the feasibility and acceptability of eating behaviour measures in patients with craniopharyngioma to inform the design of future trials. <b><i>Methods:</i></b> Patients with childhood-onset craniopharyngioma and controls matched for sex, pubertal stage, and age were recruited. After an overnight fast, participants received the following measures: body composition, resting metabolic rate, oral glucose tolerance test including magnetic resonance imaging (patients only), appetite ratings, eating behaviour, and quality of life questionnaires, ad libitum lunch, and an acceptability questionnaire. Data are reported as median ± IQR, with effect size measure (Cliff’s delta) and Kendall’s tau for correlations, due to the small sample size. <b><i>Results:</i></b> Eleven patients (median age = 14 years; 5 F/6 M) and matched controls (median age = 12 years; 5 F/6 M) were recruited. All patients had received surgery, and 9/11 also received radiotherapy. Hypothalamic damage post-surgery was graded (Paris grading): grade 2 <i>n</i> = 6; grade 1 <i>n</i> = 1; grade 0 <i>n</i> = 2. The included measures were deemed highly tolerable by participants and their parent/carers. Preliminary data suggest a difference in hyperphagia between patients and controls (<i>d</i> = 0.5), and a relationship between hyperphagia with body mass index standard deviation score (BMISDS) in patients (<i>τ</i> = 0.46). <b><i>Discussion:</i></b> These findings demonstrate that eating behaviour research is feasible and acceptable to craniopharyngioma patients and there is an association between BMISDS and hyperphagia in patients. Thus, food approach and avoidance behaviours may be useful targets for interventions to manage obesity in this patient group.

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