Effects of different metabolic states and surgical models on glucose metabolism and secretion of ileal L-cell peptides: results from the HIPER-1 study.

AIM: To compare the impact of four surgical procedures (mini-gastric bypass, sleeve gastrectomy, ileal transposition and transit bipartition) vs medical management on gut peptide secretion, ß-cell function and resolution of hyperglycaemia in people with type 2 diabetes. RESEARCH DESIGN AND METHODS: A mixed-meal tolerance test was administered 6-24 months after each surgical procedure (mini-gastric bypass, sleeve gastrectomy, ileal transposition and transit bipartition; n=30 in each group) and the results were compared with those obtained in matched lean (n=30) and obese (n=30) people with type 2 diabetes undergoing medical management. RESULTS: Participants in the mini-gastric bypass and ileal transposition groups had a greater increase in plasma glucose concentration after the mixed-meal tolerance test than those in the sleeve gastrectomy and transit bipartition groups. Participants in the mini-gastric bypass group exhibited the greatest increase in the incremental area under the curve of plasma glucose concentration above baseline (P<0.0001). Insulin sensitivity was similar across surgical groups, and statistically greater in participants in the surgical groups than in obese participants in the non-surgical group (P<0.0001). ß-cell responsiveness to glucose was greater in participants in the sleeve gastrectomy and transit bipartition groups than in the mini-gastric bypass and ileal transposition groups (P<0.001) despite a smaller incremental increase above baseline in the area under the plasma glucagon-like peptide-1 concentration curve relative to ileal transposition. Postoperative ß-cell function was the strongest predictor of hyperglycaemia resolution. CONCLUSIONS: The present study showed that the level of ß-cell function after bariatric surgery is the strongest predictor of hyperglycaemia resolution. The study also demonstrates a disconnect between postprandial GLP-1 levels and ß-cell function among the studied surgical procedures.

LAP-BAND for BMI 30-40: 5-year health outcomes from the multicenter pivotal study.

BACKGROUND: We performed a 5-year multicenter study to evaluate the safety and effectiveness of the LAP-BAND System surgery (LBS) in patients with obesity with a body mass index (BMI) of 30-39.9 kg m(-)(2). This pivotal study was designed to support LBS application to the US Food and Drug Administration for broadening the indications for surgery and the lower BMI indication was approved with 1-year data in 2011, with the intention to complete the 5-year evaluation. OBJECTIVES: To present broad health outcome data including weight change, patient reported outcomes, comorbidity change and complications during the 5-year study. SETTING: The study was conducted at seven US private practice clinical trial sites. METHODS: We enrolled 149 BMI 30-39.9 subjects into a 5-year, multicenter, longitudinal, prospective post-approval study. Data for those completing each time point are presented. RESULTS: The predefined target of at least 30% excess weight loss was achieved by more than 76% of subjects by 1-year and at every year thereafter during the 5-year study. Mean percentage weight loss at 5 years was 15.9±12.4%. Sustained weight loss was accompanied by sustained improvement in generic and weight-specific quality of life, symptoms of depression and the prevalence of binge-eating disorder. The number of subjects with normal fasting triglyceride, high-density lipoprotein cholesterol, plasma glucose and HbA1c increased significantly between baseline and 5 years. Fifty-four months after LBS implantation, the rate of device explants without replacement was 5.4%; however, the rate of explants increased to 12.1% by month 60 owing to no cost-elective band removals offered to subjects at study exit. No deaths or unanticipated adverse device effects were reported. CONCLUSIONS: The LBS is safe and effective for people with BMI 30-39.9 with demonstrated improvements in weight loss, comorbidities and quality of life, and with a low explant rate through 5 years following treatment.

'Obesity paradox' misunderstands the biology of optimal weight throughout the life cycle.

The 'obesity paradox' refers to observations that run counter to the thesis that normal weight (BMI 18.5-24.9 g/m(2)) provides the lowest mortality and higher weight is associated with greater mortality. We argue that the weight of lowest mortality is influenced by aging and chronic disease, with mortality advantage extending into the overweight and even class I obese ranges under some circumstances. A focus on quality nutrition, physical activity, fitness, and maintaining function in these weight ranges may be preferable to a focus on intentional weight loss, which has uncertain effects. The 'obesity paradox' is no 'paradox' if one defines and interprets 'ideal' weight appropriately.

Vastus medialis fat infiltration - a modifiable determinant of knee cartilage loss.

BACKGROUND: There is growing interest in the role of intramuscular fat and how it may influence clinical outcomes. Vastus medialis (VM) is a functionally important quadriceps muscle that helps to stabilise the knee joint. This longitudinal study examined the determinants of VM fat infiltration and whether VM fat infiltration influenced knee cartilage volume. METHODS: 250 participants without any diagnosed arthropathy were assessed at baseline between 2005 and 2008, and 197 participants at follow-up between 2008 and 2010. Ambulatory and sporting activity were assessed and magnetic resonance imaging (MRI) was used to determine knee cartilage volume and VM fat infiltration. RESULTS: Age, female gender, BMI and weight were positively associated with baseline VM fat infiltration (P ≤ 0.03), while ambulatory and sporting activity were negatively associated with VM fat infiltration (P ≤ 0.05). After adjusting for confounders, a reduction in VM fat infiltration was associated with a reduced annual loss of medial tibial (ß = -10 mm(3); 95% CI -19 to 0 mm(3); P = 0.04) and patella (ß = -18 mm(3); 95% CI -36 to 0 mm(3); P = 0.04) cartilage volume. CONCLUSION: This community-based study of healthy adults has shown that VM fat infiltration can be modified by lifestyle factors including weight loss and exercise, and reducing fat infiltration in VM has beneficial effect on knee cartilage preservation. The findings suggest that modifying VM fat infiltration via lifestyle interventions may have the potential to reduce the risk of knee OA.

Fat-free mass loss generated with weight loss in overweight and obese adults: What may we expect?

There is concern that intentional weight loss may generate excessive loss of fat-free mass (FFM). Idealists target minimal loss of FFM, while others consider that FFM loss of up to 25% of weight loss is acceptable. In a cross-sectional study of 275 weight-stable, overweight or obese adults, we used whole-body dual-energy X-ray absorptiometry to measure FFM. A range of models was used to estimate the expected ΔFFM/Δweight ratio required to attain the body composition of a weight-stable individual at a lower body mass index (BMI). Higher BMI was associated linearly with higher FFM in men and women. Proportional ΔFFM/Δweight was influenced by sex, BMI and age. Direct scatter plot analysis, quadratic curve fit modelling and linear FFM-BMI modelling provided similar estimates for each model of ΔFFM/Δweight ratio, with 40% for men and 33% for women. These results show that the 25% rule is inappropriate and our estimates are higher than those generally reported after intentional weight loss indicating favourable preservation of FFM.

Severe obesity and diabetes self-care attitudes, behaviours and burden: implications for weight management from a matched case-controlled study. Results from Diabetes MILES--Australia.

AIMS: To investigate whether diabetes self-care attitudes, behaviours and perceived burden, particularly related to weight management, diet and physical activity, differ between adults with Type 2 diabetes who are severely obese and matched non-severely obese control subjects. METHODS: The 1795 respondents to the Diabetes MILES--Australia national survey had Type 2 diabetes and reported height and weight data, enabling BMI calculation: 530 (30%) were severely obese (BMI ≥ 35 kg/m(2); median BMI = 41.6 kg/m(2)) and these were matched with 530 control subjects (BMI < 35 kg/m(2); median BMI = 28.2 kg/m(2)). Diabetes self-care behaviours, attitudes and burden were measured with the Diabetes Self-Care Inventory-Revised. Within-group and between-group trends were examined. RESULTS: The group with BMI ≥ 35 kg/m(2) was less likely to achieve healthy diet and exercise targets, placed less importance on diet and exercise recommendations, and found the burden of diet and exercise recommendations to be greater than the group with BMI < 35 kg/m(2). The group with BMI ≥ 35 kg/m(2) was more likely to be actively trying to lose weight, but found weight control a greater burden. These issues accentuated with increasing obesity and were greatest in those with BMI > 45 kg/m(2). There were no between-group differences in other aspects of diabetes self-care: self-monitoring of blood glucose, use of medications and smoking. Moderate-to-severe symptoms of depression were independently associated with reduced likelihood of healthy diet and physical activity, and with greater burden associated with diet, physical activity and weight management. CONCLUSIONS: Severely obese people with diabetes demonstrated self-care attitudes, behaviours and burdens that infer barriers to weight loss. However, other important diabetes self-care behaviours are supported equally by severely obese and non-severely obese individuals.

Control of type 2 diabetes after 1 year of laparoscopic adjustable gastric banding in the helping evaluate reduction in obesity (HERO) study.

AIMS: The 5-year, open-label, prospective, observational helping evaluate reduction in obesity (HERO) study (N = 1106) examines efficacy and safety of the LAP-BAND AP(®) laparoscopic adjustable gastric band (LAGB) in obese patients. This interim analysis assessed the control of type 2 diabetes (T2D), 1 year after the implantation of the LAGB. METHODS: Baseline T2D was defined by chart review or use of antidiabetic medications or haemoglobin A1c (HbA1c) ≥ 7.0%. Control of T2D at 1 year was defined as A1c <7.0% (with or without antidiabetic medications). RESULTS: After 1 year, 187 of 273 patients with T2D at baseline had adequate data available to assess T2D status, of which 135 patients (72.2%) achieved target control of T2D compared with 42.8% control rate at baseline. Independent predictors of achieving target control at 1 year included the following: (i) shorter diabetes duration odds ratio (OR) 0.914 [95% confidence interval (CI), 0.839, 0.995, p = 0.038], (ii) not using insulin therapy OR 0.16 (95% CI, 0.06, 0.47, p < 0.001) and (iii) greater mean % weight loss OR 1.176 (95% CI, 1.093, 1.266, p < 0.001). Patients using insulin at baseline were 84% less likely to achieve control of T2D after 1 year; each additional year of diabetes at baseline reduced the likelihood of good control by 9%; and each 1% of weight loss increases the likelihood of good control by 18%. Rates of device-related adverse events and reoperations were low and were not significantly different between patients with and without baseline T2D at 1 year. CONCLUSIONS: Greater % weight loss, not using insulin therapy, and shorter disease duration predicted increased likelihood of target control of T2D, 1 year after implantation of the LAGB.

Gastric bypass in Type 2 diabetes with BMI < 30: weight and weight loss have a major influence on outcomes.

AIM: To assess factors influencing glycaemic control following gastric bypass surgery in patients with Type 2 diabetes and BMI< 30 kg/m(2) . METHODS: Prospective longitudinal study of 103 patients with inadequate glycaemic control who underwent gastric bypass surgery at Soonchunhyang University, Seoul, Korea (n = 66) and Min-Sheng General Hospital, Taipei, Taiwan (n = 37). Procedures were performed August 2009 to January 2011. Key outcome measures were excellent glycaemic control of Type 2 diabetes defined as HbA1c < 42 mmol/mol (≤6%); inadequate response defined as HbA1c > 53 mmol/mol (> 7%). Analysis was conducted using binary logistic regression, and cut-points obtained from receiver operator characteristics. RESULTS: Excellent glycaemic control was achieved in 31 (30%) at 1 year. Diabetes duration of < 7 years and BMI > 27 kg/m(2) provided independent predictors and useful cut-points. Likelihood of excellent glycaemic control for an individual could be estimated using loge (Odds) = -6.7 + (0.26 × BMI) + (-1.2 × diabetes duration). Baseline BMI of < 27 kg/m(2) and baseline C-peptide of < 2.0ng/ml, best predicted a poor glycaemic response. In those with favourable baseline characteristics percentage weight loss (%WL) had a dominant influence on glycaemic outcomes. Baseline C-peptide (> 2.4 ng/ml) and subsequent percentage weight loss (> 16%) were associated with excellent glycaemic control. Higher BMI was associated with greater percentage weight loss. CONCLUSION: In patients with Type 2 diabetes and BMI < 30 kg/m(2) , glycaemic response to gastric bypass is predicted by higher baseline BMI, shorter disease duration and higher fasting C-peptide. Post-surgery weight loss has a dominant effect. Baseline BMI and weight loss have a major influence on outcomes.

Neural and humoral changes associated with the adjustable gastric band: insights from a rodent model.

BACKGROUND: Bariatric surgical procedures, including the laparoscopic adjustable gastric band (LAGB), are currently the only effective treatments for morbid obesity, however, there is no clear understanding of the mechanisms underpinning the efficacy of LAGB. The aim of this study is to examine changes in activation of the sensory neuronal pathways and levels of circulating gut hormones associated with inflation of an AGB. DESIGN AND RESULTS: The trajectory within the central nervous system of polysynaptic projections of sensory neurons innervating the stomach was determined using the transsynaptically transported herpes simplex virus (HSV). Populations of HSV-infected neurons were present in the brainstem, hypothalamus and cortical regions associated with energy balance. An elevation of Fos protein was present within the nucleus of the solitary tract, a region of the brainstem involved in the control of food intake, following acute and chronic band inflation. Two approaches were used to test (1) the impact of inflation of the band alone (on a standard caloric background) or (2) the impact of a standard caloric meal (on the background of the inflated band) on circulating gut hormones. Importantly, there was a significant elevation of glucagon-like peptide-1 (GLP-1) and peptide YY (PYY) following oral gavage of a liquid meal in animals with pre-inflated bands. There was no impact of inflation of the band alone on circulating GLP-1, PYY or ghrelin in animals on a standard caloric background. CONCLUSION: These data are consistent with the notion that the LAGB exerts its effects on satiety, reduced food intake and reduced body weight by the modulation of both neural and hormonal responses with the latter involving an elevation of meal-related levels of GLP-1 and PYY. These data are contrary to the view that the surgery is purely 'restrictive'.

The effects of dietary weight loss with or without exercise training on liver enzymes in obese metabolic syndrome subjects.

AIM: Insulin resistance and visceral adiposity are predisposing factors for fatty liver disease. The main objectives of this study were (i) to compare the effects of caloric restriction (CR) alone or together with moderate-intensity aerobic exercise training (CR+EX) on liver enzymes, a surrogate marker of liver injury, in obese metabolic syndrome (MetS) subjects and (ii) to identify anthropometric, metabolic, cardiovascular and dietary predictors of changes in liver enzymes. METHODS: Sedentary men and women (n = 63), aged 55 ± 6 (s.d.) years with body mass index 32.7 ± 4.1 kg/m(2) and confirmed MetS, were randomized to 12-week CR, CR+EX or no treatment (Control). RESULTS: Weight loss averaged 7.6% in the CR and 9.1% in the CR+EX group (time effect, p < 0.001; group effect, p = 0.11); insulin sensitivity improved by 49 and 45%, respectively (both p < 0.001). Fitness (maximal oxygen consumption) increased by 19% in the CR+EX group only (p < 0.001). Alanine aminotransferase (ALT) levels decreased by 20% in the CR and 24% in the CR+EX group (time effect, both p < 0.001; group effect, p = 0.68); corresponding values for γ-glutamyltransferase (GGT) were -28 and -33%, respectively (time effect, both p < 0.001; group effect, p = 0.28). Reduction in abdominal fat mass (measured by DXA from L1 to L4) independently predicted ΔALT (r = 0.42, p = 0.005) and ΔGGT (r = 0.55, p < 0.001), whereas change in dietary saturated fat intake was independently associated with ΔALT (r = 0.35, p = 0.03). CONCLUSIONS: Reductions in central adiposity and saturated fat intake are key drivers of improvement in liver enzymes during lifestyle interventions. Exercise training did not confer significant incremental benefits in this study.

Bariatric surgery: an IDF statement for obese Type 2 diabetes.

The International Diabetes Federation Taskforce on Epidemiology and Prevention of Diabetes convened a consensus working group of diabetologists, endocrinologists, surgeons and public health experts to review the appropriate role of surgery and other gastrointestinal interventions in the treatment and prevention of Type 2 diabetes. The specific goals were: to develop practical recommendations for clinicians on patient selection; to identify barriers to surgical access and suggest interventions for health policy changes that ensure equitable access to surgery when indicated; and to identify priorities for research. Bariatric surgery can significantly improve glycaemic control in severely obese patients with Type 2 diabetes. It is an effective, safe and cost-effective therapy for obese Type 2 diabetes. Surgery can be considered an appropriate treatment for people with Type 2 diabetes and obesity not achieving recommended treatment targets with medical therapies, especially in the presence of other major co-morbidities. The procedures must be performed within accepted guidelines and require appropriate multidisciplinary assessment for the procedure, comprehensive patient education and ongoing care, as well as safe and standardized surgical procedures. National guidelines for bariatric surgery need to be developed for people with Type 2 diabetes and a BMI of 35 kg/m(2) or more.

Delayed introduction of solid feeding reduces child overweight and obesity at 10 years.

BACKGROUND: The function that the timing of introduction of solid foods may have in the development of child obesity has not been adequately explored, either as a potential confounder of the relationship between breastfeeding and child obesity, or as an independent modifiable risk factor. OBJECTIVE: To determine the association between infant feeding practices and child overweight/obesity. PATIENTS AND METHODS: Six hundred and twenty subjects were recruited antenatally from 1990 to 1994. A total of 18 telephone interviews over the first 2 years of life recorded infant feeding practices. At mean age of 10 years, height and weight were measured for 307 subjects. Multiple logistic regression was used to determine whether infant feeding practices (duration of exclusive and any breastfeeding, and age at introduction of solid foods) were associated with odds of being overweight/obese (internationally age- and sex-standardized body mass index category) at age 10 years, after adjustment for confounders. RESULTS: Delayed introduction of solid foods was associated with reduced odds of being overweight/obese at age 10 years, after controlling for socioeconomic status, parental smoking and childcare attendance (adjusted odds ratio (aOR)=0.903 per week, 95% CI=0.841-0.970, P=0.005). Antenatal parental smoking was associated with overweight/obesity at age 10 years (aOR=3.178, 95% CI=1.643-6.147, P=0.001). Duration of exclusive or any breastfeeding was not associated with the outcome. CONCLUSIONS: Delayed introduction of solids is associated with reduced odds of child overweight/obesity. Wider promotion of current infant feeding guidelines could have a significant impact on the rates of child overweight and obesity.

A rodent model of adjustable gastric band surgery-implications for the understanding of underlying mechanisms.

BACKGROUND: Bariatric surgery is currently the only anti-obesity therapy that can deliver weight loss of up to 20-30% of body weight. Laparoscopic adjustable gastric banding (LAGB) and Roux-en-y gastric bypass are the most commonly performed of these surgeries. The mechanisms by which LAGB initiates an increase in satiety remain completely unknown. The aim of this study is to establish a rodent model of adjustable gastric banding (AGB) that will enable investigation of these mechanisms. METHODS: Sprague-Dawley rats were implanted with adjustable gastric bands immediately below the gastro-esophageal junction around the glandular stomach. This band, as in humans, can be inflated via an exteriorized port resulting in an incremental impact on the stomach. RESULTS: Rats with an incremental inflation of the AGB showed a clear stepwise reduction in food intake and body weight. Normal food intake and body weight gain were restored with band deflation. Barium-assisted X-ray of the stomach showed the formation of a small gastric pouch proximal to the inflated band in a manner analogous to the human LAGB. CONCLUSIONS: This is the first animal model of the AGB that allows incremental inflation for optimal tightening of the band in the conscious animal with corresponding effects on food intake and body weight. This model will allow measurement of acute and chronic neural and hormonal changes following activation of the band in the conscious animal and will provide the potential to inform and improve surgical approaches that are at the forefront of obesity treatments.

Prospective study of skin surgery in smokers vs. nonsmokers.

BACKGROUND: Smoking may increase complications following minor surgery leading many clinicians to urge patients to refrain from smoking before and after surgery. OBJECTIVE: To study the association between smoking and complications following skin surgery. METHODS: In a 5-year prospective observational study 7224 lesions were excised on 4197 patients. Patients were not instructed regarding smoking. All complications were recorded. RESULTS: A total of 439 smokers (10.5%) underwent 646 procedures (9%), 3758 nonsmokers (89.5%) underwent 6578 procedures (91%). Smokers were younger (55 +/- 16 years) than nonsmokers (66 +/- 17 years) (P < 0.001). Infection incidence was not significantly different, 1.9% (12/646) in smokers compared with 2.2% (146/6578) in nonsmokers (P = 0.55). There were two bleeds with smokers (0.3%) vs. 50 in nonsmokers (0.8%) (P = 0.2). The incidence of wound dehiscence in nonsmokers (three) was not different from nonsmokers (21) (P = 0.54). However, the incidence of scar contour distortion in smokers (three) was greater than in nonsmokers (two) (odds ratio 15.3; 95% confidence interval 2.5-92). Total complication incidence was similar, 3.6% in smokers vs. 4.0% in nonsmokers (P = 0.58). Out of 2371 flaps there were 14 (0.6%) cases of end-flap necrosis but smokers were not at increased risk. The case-control analysis compared each smoker with two nonsmokers matched for age, sex, postal code and outdoor occupational exposure. This again demonstrated no difference in infection, scar complication, bleed, dehiscence, end-flap necrosis or total complication incidence. CONCLUSIONS: Smokers and nonsmokers suffer skin surgery complications similarly. The increased risk of contour distortion identified was difficult to interpret. Advice to cease smoking in the short term to improve outcomes with skin cancer surgery is not supported by these data.

Synthesis of todorokite.

Todorokite of chemical composition (Mg(0.77)Na(0.03))(Mg(0.18)Mn(2+)(0.60)Mn(4+)(5.22)22) O(12).3.07 H(2)O was synthesized by a two-step procedure. First, sodium birnessite was synthesized and magnesium was exchanged for sodium to form magnesium birnessite, which was autoclaved under a saturated steam pressure at 155 degrees C for 8 hours to form well-crystallized todorokite. Synthesized todorokite particles consisted of fibers extending from a central plate. The plate itself was made of twinned fibers forming a trilling pattern. The infrared spectra and x-ray diffraction patterns were similar to those of natural todorokite samples. Calcium birnessite and nickel birnessite, when autoclaved under conditions similar to those for magnesium birnessite, yielded a todorokite structure. However, the formation of todorokite from calcium and nickel birnessite was less extensive.

Factors associated with percent change in visceral versus subcutaneous abdominal fat during weight loss: findings from a systematic review.

BACKGROUND: Visceral adipose tissue (VAT) is associated with greater obesity-related metabolic disturbance. Many studies have reported preferential loss of VAT with weight loss. OBJECTIVE: This systematic review looks for factors associated with preferential loss of VAT relative to subcutaneous abdominal fat (SAT) during weight loss. DESIGN: Medline and Embase were searched for imaging-based measurements of VAT and subcutaneous abdominal adipose tissue (SAT) before and after weight loss interventions. We examine for factors that influences the percentage change in VAT versus SAT (%deltaV/%deltaS) with weight loss. Linear regression analyses were performed on the complete data set and on subgroups of studies. Factors examined included percentage weight loss, degree of caloric restriction, exercise, initial body mass index (BMI), gender, time of follow-up and baseline VAT/SAT. RESULTS: There were 61 studies with a total of 98 cohort time points extracted. Percentage weight loss was the only variable that influenced %deltaV/%deltaS (r=-0.29, P=0.005). Modest weight loss generated preferential loss of VAT, but with greater weight loss this effect was attenuated. The method of weight loss was not an influence with one exception. Very-low-calorie diets (VLCDs) provided exceptional short-term (<4 weeks) preferential VAT loss. But this effect was lost by 12-14 weeks. CONCLUSIONS: Visceral adipose tissue is lost preferentially with modest weight loss, but the effect is attenuated with greater weight loss. Acute caloric restriction, using VLCD, produces early preferential loss of VAT. These observations may help to explain the metabolic benefits of modest weight loss.

Commissioning guidance for weight assessment and management in adults and children with severe complex obesity.

The challenge of managing the epidemic of patients with severe and complex obesity disease in secondary care is largely unmet. In England, the National Institute of Health and Care Excellence and the National Health Service England have published guidance on the provision of specialist (non-surgical) weight management services. We have undertaken a systematic review of 'what evidence exists for what should happen in/commissioning of: primary or secondary care weight assessment and management clinics in patients needing specialist care for severe and complex obesity?' using an accredited methodology to produce a model for organization of multidisciplinary team clinics that could be developed in every healthcare system, as an update to a previous review. Additions to the previous guidance were multidisciplinary team pathways for children/adolescent patients and their transition to adult care, anaesthetic assessment and recommendations for ongoing shared care with general practitioners, as a chronic disease management pathway.

Bleeding complications in skin cancer surgery are associated with warfarin but not aspirin therapy.

BACKGROUND: The aim was to identify risk factors for postoperative bleeding following skin cancer surgery. METHODS: This was a prospective study of 5950 skin lesions excised in 2394 patients. No patient stopped taking aspirin or warfarin unless the international normalized ratio (INR) exceeded 3.0. RESULTS: The rate of postoperative bleeding was 0.7 per cent overall and 2.5 per cent in the 320 patients taking warfarin. The rate of bleeding was 1.0 per cent for skin flap repairs, 0.4 per cent for simple excision and closure, and 5.0 per cent for skin grafts. Diabetic patients and smokers were not at increased risk of bleeding. There were four independent factors for bleeding: age 67 years or older (odds ratio (OR) 4.7 (95 per cent confidence interval 1.8 to 12.2); P = 0.002), warfarin therapy (OR 2.9 (1.4 to 6.3); P = 0.006), surgery on or around the ear (OR 2.6 (1.2 to 5.7); P = 0.012) and closure with a skin flap or graft (OR 2.7 (1.4 to 5.3); P = 0.004). Aspirin therapy was not an independent risk factor for bleeding. CONCLUSION: Most postoperative bleeds were inconvenient but not life threatening, unlike the potential risk of thromboembolism after stopping warfarin or aspirin. There was no case for discontinuing aspirin before skin surgery, but the INR should be monitored in patients taking warfarin.

Weigh Forward: a clinical audit of weight management in Australian general practice.

Weigh Forward was a prospective clinical audit, aimed to assess the use and efficacy of 12-week weight management program in general practice. Twenty-eight practitioners participated in the audit, with a total of 258 patients observed. Of these, 147 (57%) were retained to 24 weeks. Practices were asked to implement a structured 12-week weight loss program, and encouraged to utilize relevant weight management guidelines as necessary. Patients were followed up regularly, and comprehensively assessed at baseline, 12 and 24 weeks. Evaluations were made of patient weight loss, practitioner willingness to utilize available weight loss interventions, practitioner set weight loss goals and the appropriateness of such goals. Overall, the 57% of completing patients lost an average of 6.1% ± 0.5% body weight, with 27.2% losing ≥10% body weight. Practitioners were hesitant to intensify treatment, and those with comorbidities were less likely (odds ratio 1.8; 95% CI 1.4-2.4) to receive intensified treatment than those without. Practitioners also tended to set high weight loss goals, with a mean goal of 17.3% body-weight loss. The clinically significant mean weight loss demonstrates that practitioners are able to generate meaningful weight loss in primary care settings, however, could benefit from increased use of available interventions.