Publications by authors named "Paul R Burton"

110 Publications

Dietary Macronutrient Composition in Relation to Circulating HDL and Non-HDL Cholesterol: A Federated Individual-Level Analysis of Cross-Sectional Data from Adolescents and Adults in 8 European Studies.

J Nutr 2021 Apr 13. Epub 2021 Apr 13.

Molecular Epidemiology Research Group, Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany.

Background: Associations between increased dietary fat and decreased carbohydrate intake with circulating HDL and non-HDL cholesterol have not been conclusively determined.

Objective: We assessed these relations in 8 European observational human studies participating in the European Nutritional Phenotype Assessment and Data Sharing Initiative (ENPADASI) using harmonized data.

Methods: Dietary macronutrient intake was recorded using study-specific dietary assessment tools. Main outcome measures were lipoprotein cholesterol concentrations: HDL cholesterol (mg/dL) and non-HDL cholesterol (mg/dL). A cross-sectional analysis on 5919 participants (54% female) aged 13-80 y was undertaken using the statistical platform DataSHIELD that allows remote/federated nondisclosive analysis of individual-level data. Generalized linear models (GLM) were fitted to assess associations between replacing 5% of energy from carbohydrates with equivalent energy from total fats, SFAs, MUFAs, or PUFAs with circulating HDL cholesterol and non-HDL cholesterol. GLM were adjusted for study source, age, sex, smoking status, alcohol intake and BMI.

Results: The replacement of 5% of energy from carbohydrates with total fats or MUFAs was statistically significantly associated with 0.67 mg/dL (95% CI: 0.40, 0.94) or 0.99 mg/dL (95% CI: 0.37, 1.60) higher HDL cholesterol, respectively, but not with non-HDL cholesterol concentrations. The replacement of 5% of energy from carbohydrates with SFAs or PUFAs was not associated with HDL cholesterol, but SFAs were statistically significantly associated with 1.94 mg/dL (95% CI: 0.08, 3.79) higher non-HDL cholesterol, and PUFAs with -3.91 mg/dL (95% CI: -6.98, -0.84) lower non-HDL cholesterol concentrations. A statistically significant interaction by sex for the association of replacing carbohydrates with MUFAs and non-HDL cholesterol was observed, showing a statistically significant inverse association in males and no statistically significant association in females. We observed no statistically significant interaction by age.

Conclusions: The replacement of dietary carbohydrates with fats had favorable effects on lipoprotein cholesterol concentrations in European adolescents and adults when fats were consumed as MUFAs or PUFAs but not as SFAs.
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http://dx.doi.org/10.1093/jn/nxab077DOI Listing
April 2021

Proteome analysis of human adipocytes identifies depot-specific heterogeneity at metabolic control points.

Am J Physiol Endocrinol Metab 2021 Jun 12;320(6):E1068-E1084. Epub 2021 Apr 12.

Department of Anatomy and Physiology, University of Melbourne, Melbourne, Victoria, Australia.

Adipose tissue is a primary regulator of energy balance and metabolism. The distribution of adipose tissue depots is of clinical interest because the accumulation of upper-body subcutaneous (ASAT) and visceral adipose tissue (VAT) is associated with cardiometabolic diseases, whereas lower-body glutealfemoral adipose tissue (GFAT) appears to be protective. There is heterogeneity in morphology and metabolism of adipocytes obtained from different regions of the body, but detailed knowledge of the constituent proteins in each depot is lacking. Here, we determined the human adipocyte proteome from ASAT, VAT, and GFAT using high-resolution Sequential Window Acquisition of all Theoretical (SWATH) mass spectrometry proteomics. We quantified 4,220 proteins in adipocytes, and 2,329 proteins were expressed in all three adipose depots. Comparative analysis revealed significant differences between adipocytes from different regions (6% and 8% when comparing VAT vs. ASAT and GFAT, 3% when comparing the subcutaneous adipose tissue depots, ASAT and GFAT), with marked differences in proteins that regulate metabolic functions. The VAT adipocyte proteome was overrepresented with proteins of glycolysis, lipogenesis, oxidative stress, and mitochondrial dysfunction. The GFAT adipocyte proteome predicted the activation of peroxisome proliferator-activated receptor α (PPARα), fatty acid, and branched-chain amino acid (BCAA) oxidation, enhanced tricarboxylic acid (TCA) cycle flux, and oxidative phosphorylation, which was supported by metabolomic data obtained from adipocytes. Together, this proteomic analysis provides an important resource and novel insights that enhance the understanding of metabolic heterogeneity in the regional adipocytes of humans. Adipocyte metabolism varies depending on anatomical location and the adipocyte protein composition may orchestrate this heterogeneity. We used SWATH proteomics in patient-matched human upper- (visceral and subcutaneous) and lower-body (glutealfemoral) adipocytes and detected 4,220 proteins and distinguishable regional proteomes. Upper-body adipocyte proteins were associated with glycolysis, de novo lipogenesis, mitochondrial dysfunction, and oxidative stress, whereas lower-body adipocyte proteins were associated with enhanced PPARα activation, fatty acid, and BCAA oxidation, TCA cycle flux, and oxidative phosphorylation.
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http://dx.doi.org/10.1152/ajpendo.00473.2020DOI Listing
June 2021

Ectodysplasin A Is Increased in Non-Alcoholic Fatty Liver Disease, But Is Not Associated With Type 2 Diabetes.

Front Endocrinol (Lausanne) 2021 4;12:642432. Epub 2021 Mar 4.

Department of Anatomy and Physiology, The University of Melbourne, Melbourne, VIC, Australia.

Ectodysplasin A (EDA) was recently identified as a liver-secreted protein that is increased in the liver and plasma of obese mice and causes skeletal muscle insulin resistance. We assessed if liver and plasma EDA is associated with worsening non-alcoholic fatty liver disease (NAFLD) in obese patients and evaluated plasma EDA as a biomarker for NAFLD. Using a cross-sectional study in a public hospital, patients with a body mass index >30 kg/m (n=152) underwent liver biopsy for histopathology assessment and fasting liver EDA mRNA. Fasting plasma EDA levels were also assessed. Non-alcoholic fatty liver (NAFL) was defined as >5% hepatic steatosis and nonalcoholic steatohepatitis (NASH) as NAFLD activity score ≥3. Patients were divided into three groups: No NAFLD (n=45); NAFL (n=65); and NASH (n=42). Liver mRNA was increased in patients with NASH compared with No NAFLD (P=0.05), but not NAFL. Plasma EDA levels were increased in NAFL and NASH compared with No NAFLD (P=0.03). Plasma EDA was related to worsening steatosis (P=0.02) and fibrosis (P=0.04), but not inflammation or hepatocellular ballooning. ROC analysis indicates that plasma EDA is not a reliable biomarker for NAFL or NASH. Plasma EDA was not increased in patients with type 2 diabetes and did not correlate with insulin resistance. Together, we show that plasma EDA is increased in NAFL and NASH, is related to worsening steatosis and fibrosis but is not a reliable biomarker for NASH. Circulating EDA is not associated with insulin resistance in human obesity.

Clinical Trial Registration: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12615000875505, identifier ACTRN12615000875505.
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http://dx.doi.org/10.3389/fendo.2021.642432DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7970300PMC
March 2021

Myosteatosis predicts higher complications and reduced overall survival following radical oesophageal and gastric cancer surgery.

Eur J Surg Oncol 2021 Feb 19. Epub 2021 Feb 19.

Department of Surgery, Monash University, Melbourne, Australia; Oesophagogastric Bariatric Surgery Unit, Alfred Health, Melbourne, Australia.

Introduction: Low muscle attenuation, as governed by increased intramuscular fat infiltration (myosteatosis), may associate with adverse surgical outcomes. We aimed to determine whether myosteatosis is associated with an increased risk of postoperative complications and reduced long-term survival after oesophago-gastric (OG) cancer surgery.

Methods: Patients who underwent radical OG cancer surgery with preoperative abdominal computed tomography (CT) imaging were included. Myosteatosis was evaluated using previously defined cut-points for low skeletal muscle attenuation measured by CT. Oncological, surgical, complications, and outcome data were obtained from a prospective database.

Results: Of 108 patients, 56% (n = 61) had myosteatosis. Patients with myosteatosis were older (69.1 ± 9.1 vs. 62.8 ± 9.8 years, p = 0.001) and had a similar body mass index (BMI) (23.4 ± 5.3 vs. 25.9 ± 6.7 kg/m, p = 0.766) compared to patients with normal muscle attenuation. Patients with myosteatosis had a higher rate of anastomotic leaks (15% vs. 2%, p = 0.041). On multivariate analysis, myosteatosis was an independent predictor of overall (OR 3.03, 95% CI 1.31-6.99, p = 0.009) and severe complications (OR 4.33, 95% CI 1.26-14.9, p = 0.020). Patients with myosteatosis had reduced 5 year overall (54.1% vs. 83%, p = 0.004) and disease-free (55.2% vs. 87.2%, p = 0.007) survival.

Conclusion: Myosteatosis is associated with a significantly increased risk of overall and severe complications as well as substantially reduced long-term survival. Assessment of muscle attenuation provides analysis beyond standard anthropometrics and may form part of preoperative physiological staging tools used to improve surgical outcomes.
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http://dx.doi.org/10.1016/j.ejso.2021.02.008DOI Listing
February 2021

Mental Health Services in a U.S. Prison During the COVID-19 Pandemic.

Psychiatr Serv 2021 04 5;72(4):458-460. Epub 2021 Jan 5.

San Quentin State Prison, California Department of Corrections and Rehabilitation, San Quentin (Burton); Department of Psychiatry and Weill Institute for Neurosciences, University of California, San Francisco (Burton, Hirschtritt); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California (Morris); Division of Research, Kaiser Permanente Northern California, Oakland (Hirschtritt).

Pandemics pose unique risks to people in correctional facilities. Among other vulnerabilities, incarcerated populations often have high rates of mental disorders and substance use disorders, which may increase risks for morbidity and mortality during a pandemic. California's San Quentin State Prison (SQSP) experienced multiple outbreaks during the 1918 influenza pandemic, and, a century later, the prison faces a new pandemic. This Open Forum describes the modification of mental health services in SQSP during the early stages of the COVID-19 pandemic. The authors explore the challenges of reducing risks of viral contagion while maintaining high-quality mental health care in a correctional setting.
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http://dx.doi.org/10.1176/appi.ps.202000476DOI Listing
April 2021

Outcomes of single versus two stage oesophagectomy for squamous cell carcinoma.

Authors:
Paul R Burton

EClinicalMedicine 2020 Nov 24;28:100606. Epub 2020 Oct 24.

Monash University Department of Surgery, Alfred Hospital, Level 6, Alfred Centre, 99 Commercial Road, Melbourne VIC Australia 3004.

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http://dx.doi.org/10.1016/j.eclinm.2020.100606DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7588692PMC
November 2020

Recognizing, reporting and reducing the data curation debt of cohort studies.

Int J Epidemiol 2020 08;49(4):1067-1074

Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.

Good data curation is integral to cohort studies, but it is not always done to a level necessary to ensure the longevity of the data a study holds. In this opinion paper, we introduce the concept of data curation debt-the data curation equivalent to the software engineering principle of technical debt. Using the context of UK cohort studies, we define data curation debt-describing examples and their potential impact. We highlight that accruing this debt can make it more difficult to use the data in the future. Additionally, the long-running nature of cohort studies means that interest is accrued on this debt and compounded over time-increasing the impact a debt could have on a study and its stakeholders. Primary causes of data curation debt are discussed across three categories: longevity of hardware, software and data formats; funding; and skills shortages. Based on cross-domain best practice, strategies to reduce the debt and preventive measures are proposed-with importance given to the recognition and transparent reporting of data curation debt. Describing the debt in this way, we encapsulate a multi-faceted issue in simple terms understandable by all cohort study stakeholders. Data curation debt is not only confined to the UK, but is an issue the international community must be aware of and address. This paper aims to stimulate a discussion between cohort studies and their stakeholders on how to address the issue of data curation debt. If data curation debt is left unchecked it could become impossible to use highly valued cohort study data, and ultimately represents an existential risk to studies themselves.
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http://dx.doi.org/10.1093/ije/dyaa087DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7660145PMC
August 2020

Bariatric Surgery in Patients with Severe Heart Failure.

Obes Surg 2020 Aug;30(8):2863-2869

Oesophagogastric Bariatric Surgery Unit, The Alfred, Melbourne, Australia.

Purpose: Obesity and cardiac failure are globally endemic and increasingly intersecting. Bariatric surgery may improve cardiac function and act as a bridge-to-transplantation. We aim to identify effects of bariatric surgery on severe heart failure patients and ascertain its role regarding cardiac transplantation.

Materials And Methods: A retrospective study of a prospectively collected database identified heart failure patients who underwent bariatric surgery between 1 January 2008 and 31 December 2017. Patients were followed up 12 months post-operatively. Cardiac investigations, functional capacity, cardiac transplant candidacy, morbidity and length of stay were recorded.

Results: Twenty-one patients (15 males, 6 females), mean age 48.7 ± 10, BMI 46.2 kg/m (37.7-85.3) underwent surgery (gastric band (18), sleeve gastrectomy (2), biliopancreatic diversion (1)). There were no loss to follow-up. There was significant weight loss of 26.0 kg (5.0-78.5, p < 0.001), significant improvement of left ventricular ejection fraction (LVEF) (10.0 ± 11.9%, p < 0.001) and significant reduction of 0.5 New York Heart Association (NYHA) classification (0-2, p < 0.001). Multivariate models delineated the absence of atrial fibrillation and pre-operative BMI < 49 kg/m as significant predictors (adjusted R-square 69%) for improvement of LVEF. Mean length of stay was 3.6 days and in-hospital morbidity rate was 42.9%. One patient subsequently underwent a heart transplant, and two patients were removed from the waitlist due to clinical improvements.

Conclusion: Bariatric surgery is safe and highly effective in obese patients with severe heart failure with substantial improvements in cardiac function and symptoms. A threshold pre-operative BMI of 49 kg/m and absence of atrial fibrillation may be significant predictors for improvement in cardiac function. There is a role for bariatric surgery to act as a bridge-to-transplantation or even ameliorate this requirement.
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http://dx.doi.org/10.1007/s11695-020-04612-2DOI Listing
August 2020

Evaluation of the histological variability of core and wedge biopsies in nonalcoholic fatty liver disease in bariatric surgical patients.

Surg Endosc 2021 Mar 13;35(3):1210-1218. Epub 2020 Mar 13.

Department of Surgery, Central Clinical School, Monash University, Level 6, The Alfred Centre, 99 Commercial Road, Prahran, Melbourne, Australia.

Background: Liver biopsy remains the gold standard for characterizing and evaluating treatment response in nonalcoholic fatty liver disease (NAFLD). Liver heterogeneity and sampling variability can affect the reliability of results. This study aimed to compare histological variability of intraoperative wedge and core liver biopsies from different lobes in bariatric patients, to better inform surgeons on biopsy method and guide interpretation of results.

Methods: We prospectively recruited bariatric surgical patients. Intraoperative core biopsies were taken from the left and right lobe, with a wedge biopsy taken from the left. All biopsies were graded by a specialist liver pathologist, blinded to clinical details and biopsy site. Concordance of histological findings between sites was evaluated.

Results: There were 91 participants (72.2% female), mean age 46.8 ± 12.0 years, body mass index 45.9 ± 9.4 kg/m. There was no significant pattern for up- or down-grading disease dependent on biopsy technique. Moderate to strong agreement was seen in the presence of NAFLD and nonalcoholic steatohepatitis (NASH, κ = 0.609-0.865, p < 0.001) between biopsy sites. Individual components (steatosis, inflammation, ballooning) showed weaker agreement (κ = 0.386-0.656, p < 0.01). Fibrosis showed particularly poor agreement (κ = 0.223-0.496, p < 0.01). Detection of pathology improved with a combination of biopsy techniques, compared to a single biopsy method.

Conclusion: Overall diagnosis of NAFLD or NASH shows good agreement between biopsy sites, but individual components, particularly fibrosis stage, vary significantly. Clinicians should consider biopsies from varied sites, to better assess liver disease severity. These data have important implications in fibrosis assessment of NAFLD and are relevant in the interpretation of histological efficacy of investigational pharmacotherapies.

Trial Registration: ACTRN12615000875505 (Australian Clinical Trials Register).
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http://dx.doi.org/10.1007/s00464-020-07490-yDOI Listing
March 2021

The Upper Gastrointestinal Cancer Registry (UGICR): a clinical quality registry to monitor and improve care in upper gastrointestinal cancers.

BMJ Open 2019 09 30;9(9):e031434. Epub 2019 Sep 30.

Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.

Purpose: The Upper Gastrointestinal Cancer Registry (UGICR) was developed to monitor and improve the quality of care provided to patients with upper gastrointestinal cancers in Australia.

Participants: It supports four cancer modules: pancreatic, oesophagogastric, biliary and primary liver cancer. The pancreatic cancer (PC) module was the first module to be implemented, with others being established in a staged approach. Individuals are recruited to the registry if they are aged 18 years or older, have received care for their cancer at a participating public/private hospital or private clinic in Australia and do not opt out of participation.

Findings To Date: The UGICR is governed by a multidisciplinary steering committee that provides clinical governance and oversees clinical working parties. The role of the working parties is to develop quality indicators based on best practice for each registry module, develop the minimum datasets and provide guidance in analysing and reporting of results. Data are captured from existing data sources (population-based cancer incidence registries, pathology databases and hospital-coded data) and manually from clinical records. Data collectors directly enter information into a secure web-based Research Electronic Data Capture (REDCap) data collection platform. The PC module began with a pilot phase, and subsequently, we used a formal modified Delphi consensus process to establish a core set of quality indicators for PC. The second module developed was the oesophagogastric cancer (OGC) module. Results of the 1 year pilot phases for PC and OGC modules are included in this cohort profile.

Future Plans: The UGICR will provide regular reports of risk-adjusted, benchmarked performance on a range of quality indicators that will highlight variations in care and clinical outcomes at a health service level. The registry has also been developed with the view to collect patient-reported outcomes (PROs), which will further add to our understanding of the care of patients with these cancers.
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http://dx.doi.org/10.1136/bmjopen-2019-031434DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6773358PMC
September 2019

Correction to: Improving Compliance with Very Low Energy Diets (VLEDs) Prior to Bariatric Surgery-A Randomized Controlled Trial of Two Formulations.

Obes Surg 2019 Sep;29(9):2758

Monash University Department of Surgery, Central Clinical School, Monash University, Level 6, 99 Commercial Road, Melbourne, 3004, Australia.

In the original article the name of author Alexandra Klejn was misspelled.
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http://dx.doi.org/10.1007/s11695-019-04045-6DOI Listing
September 2019

Improving Compliance with Very Low Energy Diets (VLEDs) Prior to Bariatric Surgery-a Randomised Controlled Trial of Two Formulations.

Obes Surg 2019 09;29(9):2750-2757

Monash University Department of Surgery, Central Clinical School, Monash University, Level 6, 99 Commercial Road, Melbourne, 3004, Australia.

Introduction: Preoperative very low energy diets (VLEDs) improve access during bariatric surgery. Compliance with traditional VLED is variable, mainly due to gastrointestinal side effects. Formulite™ is a new formulation of VLED, with higher protein, soluble fibre and probiotics.

Aims: To compare traditional VLED (Optifast™) with the new VLED (Formulite™) and assess compliance, weight loss, satisfaction, side effects and surgical access.

Methods: This was a randomised double-blinded study involving patients scheduled for bariatric surgery. The primary outcome was compliance, assessed by urinary ketone concentration and proportion of patients in ketosis at 2 weeks. Secondary outcomes were weight loss, satisfaction and patient reported outcomes, gastrointestinal side effects and operative conditions.

Results: There were 69 participants: 35 in the Formulite™ group and 34 in the Optifast™ group. Ketosis at 2 weeks was achieved in both groups (88.5% vs 83.3%, Formulite™ vs. Optifast™, p = 0.602). Urinary ketones were higher with Formulite™ (1.5 vs 15 mmol/L, p = 0.030). Total body weight loss percentage, hunger and operative conditions were similar in both groups. Formulite™ produced less flatulence (score 3 vs 2, p = 0.010) and emotional eating (score 2 vs 1, p = 0.037); however, Optifast™ ranked higher in terms of taste (score 4 vs 3, p = 0.001) and overall satisfaction (score 5 vs 7, p = 0.011).

Conclusions: Compliance over 2 weeks was high in both VLEDs with most subjects achieving ketosis. Overall satisfaction was moderately high, although variable. Whilst Formulite™ is a viable alternative to Optifast™, better formulations of VLED that addresses key adverse effects, whilst achieving ketosis, would be of significant value.
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http://dx.doi.org/10.1007/s11695-019-03916-2DOI Listing
September 2019

Identification of Metabolically Distinct Adipocyte Progenitor Cells in Human Adipose Tissues.

Cell Rep 2019 04;27(5):1528-1540.e7

Department of Physiology, The University of Melbourne, Melbourne, VIC 3010, Australia; Department of Physiology, Monash University, Clayton, VIC 3800, Australia; Metabolism, Diabetes and Obesity Program, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC 3800, Australia. Electronic address:

Adipocyte progenitor cells (APCs) provide the reservoir of regenerative cells to produce new adipocytes, although their identity in humans remains elusive. Using FACS analysis, gene expression profiling, and metabolic and proteomic analyses, we identified three APC subtypes in human white adipose tissues. The APC subtypes are molecularly distinct but possess similar proliferative and adipogenic capacities. Adipocytes derived from APCs with high CD34 expression exhibit exceedingly high rates of lipid flux compared with APCs with low or no CD34 expression, while adipocytes produced from CD34 APCs display beige-like adipocyte properties and a unique endocrine profile. APCs were more abundant in gluteofemoral compared with abdominal subcutaneous and omental adipose tissues, and the distribution of APC subtypes varies between depots and in patients with type 2 diabetes. These findings provide a mechanistic explanation for the heterogeneity of human white adipose tissue and a potential basis for dysregulated adipocyte function in type 2 diabetes.
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http://dx.doi.org/10.1016/j.celrep.2019.04.010DOI Listing
April 2019

Reply to "Crashing NASH in Patients Listed for Bariatric Surgery".

Obes Surg 2019 02;29(2):640-641

Centre for Obesity Research and Education, Central Clinical School, Monash University, Level 6, 99 Commercial Road, Melbourne, 3181, Australia.

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http://dx.doi.org/10.1007/s11695-018-03638-xDOI Listing
February 2019

Effect of Body Mass Index, Metabolic Health and Adipose Tissue Inflammation on the Severity of Non-alcoholic Fatty Liver Disease in Bariatric Surgical Patients: a Prospective Study.

Obes Surg 2019 01;29(1):99-108

Centre for Obesity Research and Education, Central Clinical School, Monash University, Level 6, 99 Commercial Road, Melbourne, 3181, Australia.

Background: Non-alcoholic fatty liver disease (NAFLD), driven by the obesity epidemic, has become the most common form of liver disease. Despite this, there is controversy regarding the prevalence and severity of NAFLD in obesity. Obesity-related factors, such as increasing adiposity, metabolic disease and inflammation, may influence prevalence. We therefore prospectively measured NAFLD prevalence in obesity and studied factors associated with NAFLD.

Materials And Methods: We recruited consecutive bariatric patients. Intraoperative liver biopsies were taken. The liver, adipose tissue and serum were collected to measure inflammation. Adipocyte cell size was measured. NAFLD severity was correlated to body mass index (BMI), metabolic health and adipose characteristics.

Results: There were 216 participants; BMI 45.9 ± 8.9 kg/m, age 44.4 ± 12.1 years, 75.5% female. Overall NAFLD prevalence was 74.1%, with 17.1% having non-alcoholic steatohepatitis (NASH) and/or steatofibrosis. Odds of NASH/steatofibrosis increased independently with BMI category (odds ratio (OR) 2.28-3.46, all p < 0.05) and metabolic disease (OR 3.79, p = 0.003). These odds markedly increased when both super obesity (BMI > 50) and metabolic disease were present (OR 9.71, p < 0.001). NASH/steatofibrosis prevalence was significantly greater with diabetes, hypertension and dyslipidemia. Although greater visceral adipocyte hypertrophy was evident in NASH/steatofibrosis, there was no significant association between adipose inflammation and NASH/steatofibrosis.

Conclusion: NAFLD remains endemic in obesity; however, NASH/steatofibrosis are less common than previously reported. Worsening obesity and metabolic disease increase odds of NAFLD independently, with substantially compounded effect with both. These observations may help with risk stratification in obese populations. We were unable to delineate clear associations between adipose inflammation and NASH/steatofibrosis in this obese population.

Trial Registration: Australian Clinical Trials Registry ( ACTRN12615000875505 ).
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http://dx.doi.org/10.1007/s11695-018-3479-2DOI Listing
January 2019

Better governance, better access: practising responsible data sharing in the METADAC governance infrastructure.

Hum Genomics 2018 04 26;12(1):24. Epub 2018 Apr 26.

Newcastle University, Newcastle upon Tyne, UK.

Background: Genomic and biosocial research data about individuals is rapidly proliferating, bringing the potential for novel opportunities for data integration and use. The scale, pace and novelty of these applications raise a number of urgent sociotechnical, ethical and legal questions, including optimal methods of data storage, management and access. Although the open science movement advocates unfettered access to research data, many of the UK's longitudinal cohort studies operate systems of managed data access, in which access is governed by legal and ethical agreements between stewards of research datasets and researchers wishing to make use of them. Amongst other things, these agreements aim to respect the reasonable expectations of the research participants who provided data and samples, as expressed in the consent process. Arguably, responsible data management and governance of data and sample use are foundational to the consent process in longitudinal studies and are an important source of trustworthiness in the eyes of those who contribute data to genomic and biosocial research.

Methods: This paper presents an ethnographic case study exploring the foundational principles of a governance infrastructure for Managing Ethico-social, Technical and Administrative issues in Data ACcess (METADAC), which are operationalised through a committee known as the METADAC Access Committee. METADAC governs access to phenotype, genotype and 'omic' data and samples from five UK longitudinal studies.

Findings: Using the example of METADAC, we argue that three key structural features are foundational for practising responsible data sharing: independence and transparency; interdisciplinarity; and participant-centric decision-making. We observe that the international research community is proactively working towards optimising the use of research data, integrating/linking these data with routine data generated by health and social care services and other administrative data services to improve the analysis, interpretation and utility of these data. The governance of these new complex data assemblages will require a range of expertise from across a number of domains and disciplines, including that of study participants. Human-mediated decision-making bodies will be central to ensuring achievable, reasoned and responsible decisions about the use of these data; the METADAC model described in this paper provides an example of how this could be realised.
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http://dx.doi.org/10.1186/s40246-018-0154-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5918902PMC
April 2018

Evaluating feasibility and accuracy of non-invasive tests for nonalcoholic fatty liver disease in severe and morbid obesity.

Int J Obes (Lond) 2018 11 30;42(11):1900-1911. Epub 2018 Jan 30.

Centre for Obesity Research and Education, Central Clinical School, Monash University, Melbourne, Australia.

Introduction: In obese individuals, nonalcoholic fatty liver disease (NAFLD) is common but often goes undiagnosed, and therefore untreated. The presence of significant fibrosis is a key determinant of NAFLD progression, and liver steatosis has substantial cardiovascular implications. We aimed to determine the diagnostic accuracy of common noninvasive diagnostic tests for steatosis and fibrosis in the obese.

Methods: We recruited 182 severely and morbidly obese individuals undergoing bariatric surgery (age 44 ± 12 years, body mass index 45.1 ± 8.3 kg/m). Medical history, blood tests and liver biopsy were taken on the day of surgery. Serum steatosis and fibrosis scores were calculated. In a subgroup of patients, transient elastography with controlled attenuation parameter (TE/CAP) (n = 82) and proton magnetic resonance spectroscopy (H-MRS) (n = 49) were performed.

Results: H-MRS had excellent diagnostic accuracy for steatosis, with strong correlation to steatosis (r = 0.647, p < 0.001), good AUROC (0.852, p = 0.001), sensitivity (81.3%) and specificity (87.5%). However, due to low feasibility in this cohort (65.3% success), this was substantially decreased with intention-to-diagnose analysis (sensitivity 50.0%, specificity 60.9%). CAP had good feasibility (80.5%), and performed better in intention-to-diagnose analysis (AUROC 0.688, sensitivity 84.8%, specificity 47.2%). Serum steatosis scores performed poorly, with comparable accuracy to ALT. For significant fibrosis, TE had the best accuracy (AUROC 0.903, p = 0.007), which remained reasonable after intention-to-diagnose analysis (sensitivity 100%, specificity 59.0%). A combination approach using CAP with ALT for steatosis and TE with Forn index for fibrosis yielded reasonable overall accuracy.

Conclusions: H-MRS and TE/CAP had greatest accuracy for NAFLD-related steatosis and fibrosis. Failure rates in obesity significantly diminished diagnostic ability. Use of a combination of serum and imaging tests improved overall feasibility of assessment and diagnostic accuracy in obese individuals.
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http://dx.doi.org/10.1038/s41366-018-0007-3DOI Listing
November 2018

Radical gastric cancer surgery results in widespread upregulation of pro-tumourigenic intraperitoneal cytokines.

ANZ J Surg 2018 May 30;88(5):E370-E376. Epub 2017 Nov 30.

Centre for Obesity Research and Education, Monash University, Melbourne, Victoria, Australia.

Background: Radical surgical resection is the mainstay of curative treatment for oesophagogastric malignancy. However, survival and recurrence rates remain poor. Theoretical data suggests that the inflammatory response to surgery can promote tumour recurrence. The local and systemic inflammatory response to radical oesophagogastric cancer surgery has not been fully characterized. We aimed to measure this response, particularly factors associated with tumour implantation.

Methods: Consecutive patients undergoing radical junctional or gastric cancer resection over 12 months were recruited. Repeated serum and adipose tissue were collected intra-operatively. Adipose tissue was collected adjacent and remote to the tumour, and cytokine messenger RNA (mRNA) expression was measured. Post-operatively, daily serum was collected for 7 days, and analysed for inflammatory cell profile and cytokine concentration.

Results: There were nine patients recruited (67.1 ± 2.1 years). mRNA expression of interleukin-6 (IL-6), CC-chemokine ligand-2 and IL-1β increased in adipose tissue intra-operatively (P < 0.05), equally both adjacent and remote from the tumour site. Serum IL-6 concentration increased from 23.3 pg/mL to 161.8 pg/mL intra-operatively (P < 0.05) before falling steadily to 35.7 pg/mL post-operatively (P < 0.05). Serum tumour necrosis factor-α was elevated throughout, and IL-1β levels were unaffected. Leukocyte and neutrophil populations increased, while T-cell and dendritic cell populations decreased intra-operatively (P < 0.05).

Conclusion: Radical surgery dramatically upregulates the expression of pro-tumourigenic cytokines in the peritoneum. There is also a marked systemic immune and inflammatory response to surgery, including downregulation of T-cell and dendritic cell populations. This offers two potential pathways that may facilitate tumour progression - local inflammation promoting peritoneal adherence and implantation, and secondary suppression of immunosurveillance due to circulating inflammatory response.
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http://dx.doi.org/10.1111/ans.14267DOI Listing
May 2018

Detailed Description of Change in Serum Cholesterol Profile with Incremental Weight Loss After Restrictive Bariatric Surgery.

Obes Surg 2018 05;28(5):1351-1362

Centre for Obesity Research and Education, Department of Surgery, Central Clinical School, Monash University, Level 6, 99 Commercial Road, Melbourne, 3181, Australia.

Introduction: Dyslipidemia affects up to 75% of morbidly obese individuals and is a key driver of cardiovascular disease. Weight loss is an established strategy to improve metabolic risk, including dyslipidemia. We aimed to determine weight loss goals for resolution of serum lipid abnormalities, by measuring improvements during progressive weight loss in obese individuals.

Methods: We performed a prospective cohort study of obese individuals with the metabolic syndrome undergoing adjustable gastric banding. Lipid levels were monitored monthly for 9 months, then three monthly until 24 months.

Results: There were 101 participants included, age 47.4 ± 10.9 years with body mass index 42.6 ± 5.9 kg/m. At 24 months, total body weight loss (TBWL) was 18.3 ± 7.9%. This was associated with significant improvements in high-density lipoprotein (HDL) (1.18 vs 1.47, p < 0.001), triglyceride (2.0 vs 1.4, p < 0.001), and total cholesterol to HDL ratio (TC:HDL) (4.6 vs 3.6, p < 0.001). Over this time, progressive and linear improvements in HDL, triglycerides, and TC:HDL were seen with incremental weight loss (observed at 2.5% TBWL intervals). Significant improvements occurred after a threshold weight loss of 7.5-12.5% TBWL was achieved, with odds ratio (OR) 1.48-2.50 for normalization. These odds improved significantly with increasing weight loss (OR 18.2-30.4 with > 25% TBWL). Despite significant weight loss, there was no significant change in low-density lipoprotein (LDL).

Conclusion: Significant improvements in triglycerides, HDL, and TC:HDL occur after 7.5-12.5% TBWL, with ongoing benefit after greater weight loss. LDL needs to be addressed independently, as this was not observed to respond to weight loss alone.

Trial Registration Number: Australian Clinical Trials Registry (ACTRN12610000049077).
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http://dx.doi.org/10.1007/s11695-017-3015-9DOI Listing
May 2018

Diabetes Outcomes More than a Decade Following Sustained Weight Loss After Laparoscopic Adjustable Gastric Band Surgery.

Obes Surg 2018 04;28(4):982-989

Monash University Centre for Obesity Research and Education, Melbourne, VIC, Australia.

Background: Long-term outcome data are needed to define the role of bariatric surgery in type 2 diabetes (T2D). To address this, we collated diabetes outcomes more than a decade after laparoscopic adjustable gastric band (LAGB) surgery.

Method: Clinical and biochemical measures from 113 obese T2D patients who underwent LAGB surgery in 2003 and 2004 were analyzed. Diabetes remission was defined as HbA1c < 6.2% (44 mmol/mol) and fasting glucose < 7.0 mmol/L.

Results: Seventy-nine patients had weight data at 10 years and attained a median [Q1, Q3] weight loss of 16 [10, 21] percent. Sixty patients attended a follow-up assessment. Their baseline HbA1c of 7.8 [7.1, 9.3] percentage units (62 [54, 78] mmol/mol) had decreased to 6.6 [6.1, 8.4] (49 [43, 68] mmol/mol) despite no significant change in glucose-lowering therapy. Eleven patients (18%) were in diabetes remission and another 18 had HbA1c ≤ 6.5%. Significant improvements in physical measures of quality of life, blood pressure, and lipid profile were also observed but there was no change in the proportion of patients with albuminuria and a significant decline in estimated glomerular filtration rate. Twelve patients in the follow-up cohort (20%) required anti-reflux medication after surgery and 26 (43%) underwent gastric band revision surgery.

Conclusion: Weight loss for over 10 years after LAGB surgery delivers clinically meaningful improvements in HbA1c, blood pressure, lipids, and quality of life at the cost of a high rate of revision surgery and increased use of anti-reflux medication. These findings support the use of bariatric surgery as a long-term treatment for weight loss and wellbeing in patients with T2D.

Study Registration: Registered with the Australian Clinical trials registry as ACTRN12615000089538.
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http://dx.doi.org/10.1007/s11695-017-2944-7DOI Listing
April 2018

Visual Liver Score to Stratify Non-Alcoholic Steatohepatitis Risk and Determine Selective Intraoperative Liver Biopsy in Obesity.

Obes Surg 2018 02;28(2):427-436

Centre for Obesity Research and Education, Central Clinical School, Monash University, Melbourne, Australia.

Background: Non-alcoholic fatty liver disease (NAFLD) and its progressive form, non-alcoholic steatohepatitis (NASH), are endemic in obesity. We aimed to evaluate the diagnostic accuracy and reproducibility of a simple intraoperative visual liver score to stratify the risk of NASH and NAFLD in obesity and determine the need for liver biopsy.

Methods: This is a prospective cohort study of obese adults undergoing bariatric surgery. The surgical team used a visual liver score to evaluate liver colour, size and surface. This was compared to histology from an intraoperative liver biopsy.

Results: There were 152 participants, age 44.6 ± 12 years, BMI 45 ± 8.3 kg/m. Prevalence of NAFLD was 70.4%, with 12.1% NASH and 26.4% borderline NASH. Single-visual components were less accurate than total composite score. Steatosis was most accurately identified (significant steatosis: AUROC 0.746, p < 0.05; severe steatosis: AUROC 0.855, p < 0.05). NASH was identified with moderate accuracy (AUROC 0.746, p = 0.001), with sensitivity 75% for a score ≥ 2. Stratification into low (≤ 1) and high-risk (≥ 4) scores accurately identified patients who should or should not have an intraoperative biopsy. Most patients with a normal-appearing liver did not have disease (94.4%). The structured visual assessment was quick and interobserver agreement was reasonable (κ = 0.53, p < 0.05).

Conclusions: A simple, structured tool based on liver appearance can be a useful and reliable tool for NAFLD risk stratification and identification of patients who would most and least benefit from a biopsy. A normal liver appearance reliably excludes significant liver disease, avoiding the need for liver biopsy in patients otherwise at high clinical risk of NASH.
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http://dx.doi.org/10.1007/s11695-017-2859-3DOI Listing
February 2018

Long-term exposure to road traffic noise, ambient air pollution, and cardiovascular risk factors in the HUNT and lifelines cohorts.

Eur Heart J 2017 Aug;38(29):2290-2296

Department of Epidemiology and Biostatistics, MRC-PHE Centre for Environment and Health, School of Public Health, Imperial College London, St Mary's Campus, Norfolk Place, W2 1PG, London, UK.

Aims: Blood biochemistry may provide information on associations between road traffic noise, air pollution, and cardiovascular disease risk. We evaluated this in two large European cohorts (HUNT3, Lifelines).

Methods And Results: Road traffic noise exposure was modelled for 2009 using a simplified version of the Common Noise Assessment Methods in Europe (CNOSSOS-EU). Annual ambient air pollution (PM10, NO2) at residence was estimated for 2007 using a Land Use Regression model. The statistical platform DataSHIELD was used to pool data from 144 082 participants aged ≥20 years to enable individual-level analysis. Generalized linear models were fitted to assess cross-sectional associations between pollutants and high-sensitivity C-reactive protein (hsCRP), blood lipids and for (Lifelines only) fasting blood glucose, for samples taken during recruitment in 2006-2013. Pooling both cohorts, an inter-quartile range (IQR) higher day-time noise (5.1 dB(A)) was associated with 1.1% [95% confidence interval (95% CI: 0.02-2.2%)] higher hsCRP, 0.7% (95% CI: 0.3-1.1%) higher triglycerides, and 0.5% (95% CI: 0.3-0.7%) higher high-density lipoprotein (HDL); only the association with HDL was robust to adjustment for air pollution. An IQR higher PM10 (2.0 µg/m3) or NO2 (7.4 µg/m3) was associated with higher triglycerides (1.9%, 95% CI: 1.5-2.4% and 2.2%, 95% CI: 1.6-2.7%), independent of adjustment for noise. Additionally for NO2, a significant association with hsCRP (1.9%, 95% CI: 0.5-3.3%) was seen. In Lifelines, an IQR higher noise (4.2 dB(A)) and PM10 (2.4 µg/m3) was associated with 0.2% (95% CI: 0.1-0.3%) and 0.6% (95% CI: 0.4-0.7%) higher fasting glucose respectively, with both remaining robust to adjustment for air/noise pollution.

Conclusion: Long-term exposures to road traffic noise and ambient air pollution were associated with blood biochemistry, providing a possible link between road traffic noise/air pollution and cardio-metabolic disease risk.
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http://dx.doi.org/10.1093/eurheartj/ehx263DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5837618PMC
August 2017

The ECOUTER methodology for stakeholder engagement in translational research.

BMC Med Ethics 2017 04 4;18(1):24. Epub 2017 Apr 4.

Data2Knowledge (D2K) Research Group, School of Social and Community Medicine, University of Bristol, Bristol, UK.

Background: Because no single person or group holds knowledge about all aspects of research, mechanisms are needed to support knowledge exchange and engagement. Expertise in the research setting necessarily includes scientific and methodological expertise, but also expertise gained through the experience of participating in research and/or being a recipient of research outcomes (as a patient or member of the public). Engagement is, by its nature, reciprocal and relational: the process of engaging research participants, patients, citizens and others (the many 'publics' of engagement) brings them closer to the research but also brings the research closer to them. When translating research into practice, engaging the public and other stakeholders is explicitly intended to make the outcomes of translation relevant to its constituency of users.

Methods: In practice, engagement faces numerous challenges and is often time-consuming, expensive and 'thorny' work. We explore the epistemic and ontological considerations and implications of four common critiques of engagement methodologies that contest: representativeness, communication and articulation, impacts and outcome, and democracy. The ECOUTER (Employing COnceptUal schema for policy and Translation Engagement in Research) methodology addresses problems of representation and epistemic foundationalism using a methodology that asks, "How could it be otherwise?" ECOUTER affords the possibility of engagement where spatial and temporal constraints are present, relying on saturation as a method of 'keeping open' the possible considerations that might emerge and including reflexive use of qualitative analytic methods.

Results: This paper describes the ECOUTER process, focusing on one worked example and detailing lessons learned from four other pilots. ECOUTER uses mind-mapping techniques to 'open up' engagement, iteratively and organically. ECOUTER aims to balance the breadth, accessibility and user-determination of the scope of engagement. An ECOUTER exercise comprises four stages: (1) engagement and knowledge exchange; (2) analysis of mindmap contributions; (3) development of a conceptual schema (i.e. a map of concepts and their relationship); and (4) feedback, refinement and development of recommendations.

Conclusion: ECOUTER refuses fixed truths but also refuses a fixed nature. Its promise lies in its flexibility, adaptability and openness. ECOUTER will be formed and re-formed by the needs and creativity of those who use it.
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http://dx.doi.org/10.1186/s12910-017-0167-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5379503PMC
April 2017

The Physiology and Pathophysiology of Gastroesophageal Reflux in Patients with Laparoscopic Adjustable Gastric Band.

Obes Surg 2017 09;27(9):2434-2443

Centre for Obesity Research and Education, Monash University, Level 6, The Alfred Centre, 99 Commercial Rd, Melbourne, 3181, Australia.

Introduction: The effect of the laparoscopic adjustable gastric band (LAGB) on esophageal acid exposure and reflux is poorly understood. Optimal technique and normative values for acid exposure have not been established in this group.

Methods: High-resolution manometry (HRM) and 24-h ambulatory esophageal pH monitoring were performed in three groups: asymptomatic LAGB, symptomatic LAGB, and pre-operative reflux patients. This technique utilized intraluminal pressure signatures during HRM to guide accurate pH sensor placement.

Results: The LAGB groups were well matched: age 48 vs 51 years (p = 0.249), weight loss 27.3 vs 26.7 kg (p = 0.911). The symptomatic group had a larger gastric pouch (5.2 vs 3.3 cm, p = 0.012), with higher esophageal acid exposure (10.8 vs 0.9%, p < 0.001). Two acidification patterns were observed: irritant and volume acidification, associated with substantial supine acidification. Symptomatic LAGB had altered esophageal motility, with poorer lower esophageal sphincter basal tone (8.0 vs 17.7 mmHg, p = 0.022) and impaired contractility of the lower esophageal segment (90 vs 40%, p = 0.009). Compared to pre-operative reflux patients, symptomatic LAGB patients demonstrated higher total and supine esophageal acid exposure (10.8 vs 7.0%, p = 0.010; 14.9 vs 5.1%, p < 0.001), less symptoms (2 vs 6, p = 0.001) and lower symptom index (0.7 vs 0.9, p = 0.010).

Conclusions: Ambulatory pH monitoring is an effective technique if the pH sensor is positioned appropriately using HRM. The correctly positioned LAGB appears associated with low esophageal acidification. In contrast, patients with symptoms or pouch dilatation can have markedly elevated esophageal acidification, particularly when supine. This is a different pattern compared to pre-operative patients and importantly can be disproportionate to symptoms.
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http://dx.doi.org/10.1007/s11695-017-2662-1DOI Listing
September 2017

Author Reply-Bariatric Surgery and Liver Function Tests in Nonalcoholic Fatty Liver Disease.

Obes Surg 2017 04;27(4):1060

Centre for Obesity Research and Education, Monash University, 99 Commercial Road, Prahran, Melbourne, 3181, Australia.

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http://dx.doi.org/10.1007/s11695-017-2551-7DOI Listing
April 2017

Effects of Bariatric Surgery on Liver Function Tests in Patients with Nonalcoholic Fatty Liver Disease.

Obes Surg 2017 06;27(6):1533-1542

Centre for Obesity Research and Education, Monash University, 99 Commercial Road, Melbourne, Australia.

Objectives: Nonalcoholic fatty liver disease (NAFLD) affects over 80% of obese patients and is fueled by the metabolic syndrome. Weight loss is strongly advocated as a central treatment for NAFLD and has been shown to induce histological improvement. We aimed to define the patterns of improvement in NAFLD with weight loss and determine target weight goals for NAFLD resolution.

Methods: A prospective study of 84 morbidly obese patients with NAFLD undergoing bariatric surgery was conducted. Intraoperative liver biopsies were taken. Monthly follow-up, including blood tests and measurements, was performed. We monitored improvements in NAFLD by monthly alanine aminotransferase (ALT) and gamma glutamyltransferase (GGT) levels over 1 year.

Results: There was rapid improvement in ALT, particularly in the first 6 months following surgery, with statistically significant reduction in ALT at 2 months (35 vs 27 IU/L, p < 0.001). In multivariate analysis, there were significantly increased odds of ALT normalization after a %TBWL of 10-15% (odds ratio 2.49, p = 0.005). The odds of resolution increased with increasing weight loss. Triglyceride levels (odds ratio 0.59, p = 0.021) and baseline NAFLD activity score (odds ratio 0.28, p < 0.001) were also significantly related to ALT normalization. Improvements in ALT occurred prior to metabolic improvement and well before traditional ideal weight goals were reached.

Conclusion: Improvements in NAFLD occurred rapidly after bariatric surgery and were closely related to weight loss and metabolic factors. A 10-15% reduction in body weight is an appropriate target to achieve substantial improvement in ALT levels.

Trial Registration Number: Australian Clinical Trials Registry (ACTRN12610000049077).
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http://dx.doi.org/10.1007/s11695-016-2482-8DOI Listing
June 2017

Ambient air pollution, traffic noise and adult asthma prevalence: a BioSHaRE approach.

Eur Respir J 2017 01 11;49(1). Epub 2017 Jan 11.

MRC-PHE Centre for Environment and Health, Dept of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK.

We investigated the effects of both ambient air pollution and traffic noise on adult asthma prevalence, using harmonised data from three European cohort studies established in 2006-2013 (HUNT3, Lifelines and UK Biobank).Residential exposures to ambient air pollution (particulate matter with aerodynamic diameter ≤10 µm (PM) and nitrogen dioxide (NO)) were estimated by a pan-European Land Use Regression model for 2007. Traffic noise for 2009 was modelled at home addresses by adapting a standardised noise assessment framework (CNOSSOS-EU). A cross-sectional analysis of 646 731 participants aged ≥20 years was undertaken using DataSHIELD to pool data for individual-level analysis via a "compute to the data" approach. Multivariate logistic regression models were fitted to assess the effects of each exposure on lifetime and current asthma prevalence.PM or NO higher by 10 µg·m was associated with 12.8% (95% CI 9.5-16.3%) and 1.9% (95% CI 1.1-2.8%) higher lifetime asthma prevalence, respectively, independent of confounders. Effects were larger in those aged ≥50 years, ever-smokers and less educated. Noise exposure was not significantly associated with asthma prevalence.This study suggests that long-term ambient PM exposure is associated with asthma prevalence in western European adults. Traffic noise is not associated with asthma prevalence, but its potential to impact on asthma exacerbations needs further investigation.
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http://dx.doi.org/10.1183/13993003.02127-2015DOI Listing
January 2017

Changes in Outcomes, Satiety and Adverse Upper Gastrointestinal Symptoms Following Laparoscopic Adjustable Gastric Banding.

Obes Surg 2017 05;27(5):1240-1249

Centre for Obesity Research and Education (CORE), Monash University, Level 6, 99 Commercial Road, Prahran, Melbourne, VIC, 3181, Australia.

Background: Patient-reported outcomes and perceptions are critical to the overall efficacy and acceptability of a surgical procedure. Outcomes, such as patient satisfaction and perceived success of the surgery and adverse symptoms, have not been described in detail following bariatric surgery. The associations and predictors of patient satisfaction have not been defined. This study aimed to examine long-term outcomes and perceptions after laparoscopic adjustable gastric banding (LAGB).

Methods: We conducted a prospective study of outcomes, satiety and adverse upper gastrointestinal symptoms, as well as quality of life and subjective patient satisfaction in LAGB patients. Data were collected at 3 years (T1) and 8 years post-operatively (T2).

Results: One-hundred and sixty patients completed follow-up at T1 and T2. The average age was 44.0 ± 11.2 years. At T2, the total body weight loss was 17.8 ± 11.9 %. Satisfaction decreased significantly between time points (8.6 ± 1.8 vs 7.2 ± 2.9, p < 0.01), and quality of life reduced slightly across all domains. Hunger scores remained low (3.8 ± 1.8 vs 3.9 ± 1.8, p = 0.61). The dysphagia score did not change significantly (p = 0.54). There was minimal change in frequency of regurgitation, although there was significant increase in patient assessment of how bothered they were by regurgitation. Multivariate analysis identified increased awareness of regurgitation as a principal driver of reduced satisfaction.

Conclusions: Weight loss, satiety and adverse symptoms demonstrated only slight changes between 3 and 8 years post-operatively. Despite this, overall satisfaction and perception of success of the procedure reduced markedly. This appeared mediated by reduced tolerance of adverse symptoms. These data inform follow-up practises aimed at optimizing outcomes.
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http://dx.doi.org/10.1007/s11695-016-2434-3DOI Listing
May 2017

Assessing quality of care in oesophago-gastric cancer surgery in Australia.

ANZ J Surg 2018 Apr 6;88(4):290-295. Epub 2016 Sep 6.

Upper Gastro-intestinal Surgical Unit, Department of General Surgery, Alfred Hospital, Melbourne, Victoria, Australia.

Background: Outcomes of oesophago-gastric cancer are poor and highly variable between centres. It is important that complex multimodal treatments are applied optimally. Low case volumes at Australian centres mean that the analysis of crude outcomes is an inadequate assessment of overall quality of care. Detailed analysis across a range of quality domains offers the opportunity to measure performance.

Methods: We compared data from the UK National Oesophago-gastric Cancer Audit 2010 with the prospective Alfred Hospital oesophago-gastric cancer database.

Results: There were 314 Alfred and 17 279 UK patients identified. The volume of patients assessed by the Alfred was equal to the second highest quartile in the UK trust (4-5 new cases per month). Case ascertainment was better, capturing 84% of all oesophago-gastric cancer within the Alfred prospective audit (P < 0.001). The use of staging CT and PET scans was more common among Alfred patients (99% versus 89%, P < 0.01 and 83.8% versus 17%, P < 0.01, respectively). More patients embarked on a curative pathway (P < 0.01), with greater use of neo-adjuvant therapies. Acceptable lymph node yields were less in oesophagectomies (88.2% versus 96.2%, P < 0.01) and similar in gastrectomies (77.4% versus 74.6%, P = 0.61). Higher overall complications were observed in Alfred patients (P < 0.01), predominantly due to respiratory complications. Perioperative mortality after resection and 1-year survival was similar.

Conclusions: Comparing a range of quality domains as a means of identifying areas of deficiency is feasible. This allows for contemporaneous improvements in service quality and may be more appropriate in the Australian setting than focusing on volume.
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http://dx.doi.org/10.1111/ans.13752DOI Listing
April 2018