231 results found
Kowalka AM, Alexiadou K, Cuenco J, et al., 2022, The post-prandial secretion of Peptide YY<sub>1-36</sub> and <sub>3-36</sub> in obesity is differentially increased after gastric bypass versus sleeve gastrectomy., Clin Endocrinol (Oxf)
OBJECTIVES: Peptide tyrosine tyrosine (PYY) exists as two species, PYY<sub>1-36</sub> and PYY<sub>3-36</sub> <sup>,</sup> with distinct effects on insulin secretion and appetite regulation. The detailed effects of bariatric surgery on PYY<sub>1-36</sub> and PYY<sub>3-36</sub> secretion are not known as previous studies have used non-specific immunoassays to measure total PYY. Our objective was to characterise the effect of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) on fasting and post-prandial PYY<sub>1-36</sub> and PYY<sub>3-36</sub> secretion using a newly developed liquid chromatography-tandem mass spectrometry (LC-MS/MS) assay. DESIGN AND SUBJECTS: Observational study in 10 healthy non-obese volunteers and 30 participants with obesity who underwent RYGB (n=24) or SG (n=6) at the Imperial Weight Centre [NCT01945840]. Participants were studied using a standardised mixed meal test (MMT) before and 1 year after surgery. The outcome measure was PYY<sub>1-36</sub> and PYY<sub>3-36</sub> concentration. RESULTS: Pre-surgery, the fasting and post-prandial levels of PYY<sub>1-36</sub> and PYY<sub>3-36</sub> were low, with minimal responses to the MMT, and these did not differ from healthy non-obese volunteers. The postprandial secretion of both PYY<sub>1-36</sub> and PYY<sub>3-36</sub> at 1 year was amplified after RYGB, but not SG, with the response being significantly higher in RYGB compared to SG. CONCLUSIONS: There appears to be no difference in PYY secretion between non-obese and obese volunteers at baseline. At 1 year after surgery, RYGB, but not SG, is associated with increased post-prandial secretion of PYY<sub>1-36</sub> and PYY<sub>3-36</sub> , which may account for long-term differences in efficacy and adverse effects between the two types of surgery. This article is
Patel P, Thomas R, Hamady M, et al., 2022, O102 We know about left gastric artery embolisation and will embio provide the next solution to treat obesity?, Publisher: OXFORD UNIV PRESS, ISSN: 0007-1323
Fehervari M, Ortega P, Muir C, et al., 2022, Single Anastomosis Gastric Bypass as a revision of failed Gastric Band, Publisher: SPRINGER, Pages: 19-19, ISSN: 0960-8923
Ortega PM, Bansi D, Kaur V, et al., 2022, Utility of the Apollo OverStitch Device for the endoscopic revision of the gastro-jejunal stoma in patients with weight regain after Roux-en-Y gastric bypass (RYGB), Publisher: SPRINGER, Pages: 22-22, ISSN: 0960-8923
Patel P, Thomas R, Hamady M, et al., 2022, Simulation training to create the gold standard framework to run the EMBIO trial (left gastric artery embolisation vs placebo), a double blinded, multi-centre, randomised controlled trial., Publisher: SPRINGER, Pages: 27-27, ISSN: 0960-8923
Patel P, Thomas R, Hamady M, et al., 2022, What we know about left gastric artery embolisation and will EMBIO provide the next solution to treat obesity?, Publisher: SPRINGER, Pages: 26-27, ISSN: 0960-8923
Shibib L, Al-Qaisi M, Ahmed A, et al., 2022, Reversal and remission of T2DM - an update for practitioners, Vascular Health and Risk Management, Vol: 18, Pages: 417-443, ISSN: 1176-6344
Over the past 50 years, many countries around the world have faced an unchecked pandemic of obesity and type 2 diabetes (T2DM). As best practice treatment of T2DM has done very little to check its growth, the pandemic of diabesity now threatens to make health-care systems economically more difficult for governments and individuals to manage within their budgets. The conventional view has been that T2DM is irreversible and progressive. However, in 2016, the World Health Organization (WHO) global report on diabetes added for the first time a section on diabetes reversal and acknowledged that it could be achieved through a number of therapeutic approaches. Many studies indicate that diabetes reversal, and possibly even long-term remission, is achievable, belying the conventional view. However, T2DM reversal is not yet a standardized area of practice and some questions remain about long-term outcomes. Diabetes reversal through diet is not articulated or discussed as a first-line target (or even goal) of treatment by any internationally recognized guidelines, which are mostly silent on the topic beyond encouraging lifestyle interventions in general. This review paper examines all the sustainable, practical, and scalable approaches to T2DM reversal, highlighting the evidence base, and serves as an interim update for practitioners looking to fill the practical knowledge gap on this topic in conventional diabetes guidelines.
Lam K, Nazarian S, Gadi N, et al., 2022, Patient perspectives on surgeon-specific outcome reports in bariatric surgery, Surgery for Obesity and Related Diseases, Vol: 18, Pages: 704-713, ISSN: 1550-7289
BACKGROUND: Surgeon specific outcome reports (SSOR) in the UK can be accessed freely by the general public to promote transparency and informed decision-making. However, the views amongst bariatric patients concerning these data are unknown. OBJECTIVES: The aims of this study were to determine patient awareness, views and priorities for outcome reporting in bariatric surgery, and to provide recommendations for future surgeon-specific outcome reporting through the United Kingdom National Bariatric Surgery Registry. SETTING: Bariatric surgical unit in a UK university teaching hospital. METHODS: We adapted a previously validated questionnaire and surveyed the views of 150 patients in a single bariatric surgical unit. We collected data concerning awareness, views, and future priorities for outcome reporting. RESULTS: A full 73% of participants were unaware they could access SSOR. Of the participants that were unaware, 75% stated that they would have accessed SSOR had they been aware they could. Of the participants that had previously accessed SSOR, 86% stated they understood the data, although 61% indicated it did not influence their choice of surgeon. The majority of participants favored public release of outcome reports at the surgeon-level (75%) and hospital-level (83%). The 3 main priorities indicated by participants for future outcome reporting were complication rates (91%), patient reported outcome measures (90%), and reoperation rate (89%), all at the surgeon level. CONCLUSION: Patient awareness of outcome reporting is poor. Efforts must be made to increase awareness of SSOR. Patients should be incorporated as key stakeholders in determining future outcome reporting in bariatric surgery.
Kenkre JS, Malallah K, Davies I, et al., 2022, Patients with liver fibrosis may be less likely to remit from type 2 diabetes following bariatric surgery, Publisher: WILEY, ISSN: 0742-3071
Ruban A, Miras A, glaysher M, et al., 2022, Duodenal-jejunal bypass liner for the management of Type 2 diabetes and obesity: a multicenter randomized controlled trial, Annals of Surgery, Vol: 275, Pages: 440-447, ISSN: 0003-4932
Objective: The aim of this study was to examine the clinical efficacy and safety of the duodenal-jejunal bypass liner (DJBL) while in situ for 12 months and for 12 months after explantation.Summary Background Data: This is the largest randomized controlled trial (RCT) of the DJBL, a medical device used for the treatment of people with type 2 diabetes mellitus (T2DM) and obesity. Endoscopic interventions have been developed as potential alternatives to those not eligible or fearful of the risks of metabolic surgery.Methods: In this multicenter open-label RCT, 170 adults with inadequately controlled T2DM and obesity were randomized to intensive medical care with or without the DJBL. Primary outcome was the percentage of participants achieving a glycated hemoglobin reduction of ≥20% at 12 months. Secondary outcomes included weight loss and cardiometabolic risk factors at 12 and 24 months.Results: There were no significant differences in the percentage of patients achieving the primary outcome between both groups at 12 months [DJBL 54.6% (n = 30) vs control 55.2% (n = 32); odds ratio (OR) 0.93, 95% confidence interval (CI): 0.44–2.0; P = 0.85]. Twenty-four percent (n = 16) patients achieved ≥15% weight loss in the DJBL group compared to 4% (n = 2) in the controls at 12 months (OR 8.3, 95% CI: 1.8–39; P = .007). The DJBL group experienced superior reductions in systolic blood pressure, serum cholesterol, and alanine transaminase at 12 months. There were more adverse events in the DJBL group.Conclusions: The addition of the DJBL to intensive medical care was associated with superior weight loss, improvements in cardiometabolic risk factors, and fatty liver disease markers, but not glycemia, only while the device was in situ. The benefits of the devices need to be balanced against the higher rate of adverse events when making clinical decisions.Trial Registration: ISRCTN30845205. isrctn.org; Efficacy and Mechanism Evaluation Programme, a Medical Research
Cousin E, Duncan BB, Stein C, et al., 2022, Diabetes mortality and trends before 25 years of age: an analysis of the Global Burden of Disease Study 2019, The Lancet Diabetes & Endocrinology, Vol: 10, Pages: 177-192, ISSN: 2213-8587
BackgroundDiabetes, particularly type 1 diabetes, at younger ages can be a largely preventable cause of death with the correct health care and services. We aimed to evaluate diabetes mortality and trends at ages younger than 25 years globally using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019.MethodsWe used estimates of GBD 2019 to calculate international diabetes mortality at ages younger than 25 years in 1990 and 2019. Data sources for causes of death were obtained from vital registration systems, verbal autopsies, and other surveillance systems for 1990–2019. We estimated death rates for each location using the GBD Cause of Death Ensemble model. We analysed the association of age-standardised death rates per 100 000 population with the Socio-demographic Index (SDI) and a measure of universal health coverage (UHC) and described the variability within SDI quintiles. We present estimates with their 95% uncertainty intervals.FindingsIn 2019, 16 300 (95% uncertainty interval 14 200 to 18 900) global deaths due to diabetes (type 1 and 2 combined) occurred in people younger than 25 years and 73·7% (68·3 to 77·4) were classified as due to type 1 diabetes. The age-standardised death rate was 0·50 (0·44 to 0·58) per 100 000 population, and 15 900 (97·5%) of these deaths occurred in low to high-middle SDI countries. The rate was 0·13 (0·12 to 0·14) per 100 000 population in the high SDI quintile, 0·60 (0·51 to 0·70) per 100 000 population in the low-middle SDI quintile, and 0·71 (0·60 to 0·86) per 100 000 population in the low SDI quintile. Within SDI quintiles, we observed large variability in rates across countries, in part explained by the extent of UHC (r2=0·62). From 1990 to 2019, age-standardised death rates decreased globally by 17·0% (−
Jones B, Sands C, Alexiadou K, et al., 2022, The metabolomic effects of tripeptide gut hormone infusion compared to Roux-en-Y gastric bypass and caloric restriction, Journal of Clinical Endocrinology and Metabolism, Vol: 107, Pages: e767-e782, ISSN: 0021-972X
Context: The gut-derived peptide hormones glucagon-like peptide-1 (GLP-1), oxyntomodulin (OXM), and peptide YY (PYY) are regulators of energy intake and glucose homeostasis, and are thought to contribute to the glucose-lowering effects of bariatric surgery. Objective: To establish the metabolomic effects of a combined infusion of GLP-1, OXM and PYY (tripeptide “GOP”) in comparison to a placebo infusion, Roux-en-Y gastric bypass (RYGB) surgery, and a very low-calorie diet (VLCD). Design and setting: Sub-analysis of a single-blind, randomised, placebo-controlled study of GOP infusion (ClinicalTrials.gov NCT01945840), including VLCD and RYGB comparator groups. Patients and interventions: 25 obese patients with type 2 diabetes or prediabetes were randomly allocated to receive a 4-week subcutaneous infusion of GOP (n=14) or 0.9% saline control (SAL; n=11). An additional 22 patients followed a VLCD, and 21 underwent RYGB surgery. Main outcome measures: Plasma and urine samples collected at baseline and 4 weeks into each intervention were subjected to cross-platform metabolomic analysis, followed by unsupervised and supervised modelling approaches to identify similarities and differences between the effects of each intervention. Results: Aside from glucose, very few metabolites were affected by GOP, contrasting with major metabolomic changes seen with VLCD and RYGB. Conclusions: Treatment with GOP provides a powerful glucose-lowering effect but does not replicate the broader metabolomic changes seen with VLCD and RYGB. The contribution of these metabolomic changes to the clinical benefits of RYGB remains to be elucidated.
Schutzer-Weissmann J, Wojcikiewicz T, Karmali A, et al., 2022, Apnoeic oxygenation in morbid obesity: a randomised controlled trial comparing facemask and high-flow nasal oxygen delivery, British Journal of Anaesthesia, ISSN: 0007-0912
BackgroundObesity is a risk factor for airway-related incidents during anaesthesia. High flow nasal oxygen has been advocated to improve safety in high-risk groups but its effectiveness in the obese population is uncertain. This study compared the effect of high flow nasal oxygen and low flow facemask oxygen delivery on duration of apnoea in morbidly-obese patients.MethodsPatients undergoing bariatric surgery were randomly allocated to receive either high flow nasal (70 L min-1) or facemask (15 L min-1) oxygen. Following induction of anaesthesia, morbidly-obese patients were apnoeic for 18 minutes or until oxygen saturation dropped to 92%.ResultsEighty patients were studied (41 high flow nasal oxygen, 39 facemask). Median apnoea duration was 18 minutes in both the high flow nasal oxygen (IQR 18-18 minutes) and the facemask (IQR 4.1-18 minutes) groups. Five patients in the high flow nasal oxygen group and 14 patients in the facemask group desaturated to 92% within 18 minutes. The risk of desaturation was lower in the high flow nasal oxygen group (Hazard Ratio 0.27, 95% CI 0.11-0.65, p=0.007). ConclusionsIn experienced hands, apnoeic oxygenation is possible in the morbidly-obese and was tolerated for 18 minutes by the majority of patients, whether oxygen delivery was high flow nasal or low flow facemask. High flow nasal oxygen reduced desaturation risk compared to facemask oxygen. Desaturation risk is a more clinically relevant outcome than duration of apnoea. Individual physiological factors are likely to be the primary determinant of risk rather than method of oxygen delivery.
Wiggins T, Jamel S, Hakky S, et al., 2021, Assurance of surgical quality within multicenter randomized controlled trials for bariatric and metabolic surgery: a systematic review, 11th Annual Scientific Meeting of the British-Obesity-and-Metabolic-Surgery-Society (BOMSS), Publisher: ELSEVIER SCIENCE INC, Pages: 124-132, ISSN: 1550-7289
Tankel J, Ahmed AR, 2021, Gastrojejunostomy in Roux-En-Y Gastric Bypass for Morbid Obesity: Linear Stapler Length Does Not Affect Mid-term Outcomes, 11th Annual Scientific Meeting of the British-Obesity-and-Metabolic-Surgery-Society (BOMSS), Publisher: LIPPINCOTT WILLIAMS & WILKINS, Pages: 794-798, ISSN: 1530-4515
McLean KA, Kamarajah SK, Chaudhry D, et al., 2021, Death following pulmonary complications of surgery before and during the SARS-CoV-2 pandemic, BRITISH JOURNAL OF SURGERY, Vol: 108, Pages: 1448-1464, ISSN: 0007-1323
Ghanem A, Ahmed A, 2021, Revision of failed Vertical Banded Gastroplasty (VBG) to Roux-en-Y Gastric Bypass (RYGB), 12th Annual Scientific Meeting of the British-Obesity-and-Metabolic-Surgery-Society (BOMSS), Publisher: SPRINGER, Pages: S11-S11, ISSN: 0960-8923
Ortega PM, Ahmed A, Bansi D, et al., 2021, Duodenal switch revision: importance of intraoperative endoscopy, 12th Annual Scientific Meeting of the British-Obesity-and-Metabolic-Surgery-Society (BOMSS), Publisher: SPRINGER, Pages: S11-S12, ISSN: 0960-8923
Ortega PM, Ahmed A, Valencia JM, 2021, Managing severe abdominal pain 3 years after RYGB: resection of marginal ulcer and primary GJ reconstruction, 12th Annual Scientific Meeting of the British-Obesity-and-Metabolic-Surgery-Society (BOMSS), Publisher: SPRINGER, Pages: S12-S12, ISSN: 0960-8923
Patel K, Aggarwal R, Martin G, et al., 2021, Feasibility of a multi-parametric continuous monitoring wearable device in patients undergoing bariatric surgery, 12th Annual Scientific Meeting of the British-Obesity-and-Metabolic-Surgery-Society (BOMSS), Publisher: SPRINGER, Pages: S12-S12, ISSN: 0960-8923
Malallah K, Alexiadou K, Tabbakh Y, et al., 2021, Roux-en-Y gastric bypass and Sleeve Gastrectomy exhibit energy expenditure equally one-year post-surgery, 12th Annual Scientific Meeting of the British-Obesity-and-Metabolic-Surgery-Society (BOMSS), Publisher: SPRINGER, Pages: S8-S9, ISSN: 0960-8923
Davies I, Kenkre J, Alexiadou K, et al., 2021, Can current methods of predicting T2D remission following metabolic surgery be improved?, 12th Annual Scientific Meeting of the British-Obesity-and-Metabolic-Surgery-Society (BOMSS), Publisher: SPRINGER, Pages: S13-S13, ISSN: 0960-8923
Glasbey J, Ademuyiwa A, Adisa A, et al., 2021, Effect of COVID-19 pandemic lockdowns on planned cancer surgery for 15 tumour types in 61 countries: an international, prospective, cohort study, The Lancet Oncology, Vol: 22, Pages: 1507-1517, ISSN: 1470-2045
BackgroundSurgery is the main modality of cure for solid cancers and was prioritised to continue during COVID-19 outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of elective cancer surgery during the COVID-19 pandemic in periods of lockdown versus light restriction.MethodsThis international, prospective, cohort study enrolled 20 006 adult (≥18 years) patients from 466 hospitals in 61 countries with 15 cancer types, who had a decision for curative surgery during the COVID-19 pandemic and were followed up until the point of surgery or cessation of follow-up (Aug 31, 2020). Average national Oxford COVID-19 Stringency Index scores were calculated to define the government response to COVID-19 for each patient for the period they awaited surgery, and classified into light restrictions (index <20), moderate lockdowns (20–60), and full lockdowns (>60). The primary outcome was the non-operation rate (defined as the proportion of patients who did not undergo planned surgery). Cox proportional-hazards regression models were used to explore the associations between lockdowns and non-operation. Intervals from diagnosis to surgery were compared across COVID-19 government response index groups. This study was registered at ClinicalTrials.gov, NCT04384926.FindingsOf eligible patients awaiting surgery, 2003 (10·0%) of 20 006 did not receive surgery after a median follow-up of 23 weeks (IQR 16–30), all of whom had a COVID-19-related reason given for non-operation. Light restrictions were associated with a 0·6% non-operation rate (26 of 4521), moderate lockdowns with a 5·5% rate (201 of 3646; adjusted hazard ratio [HR] 0·81, 95% CI 0·77–0·84; p<0·0001), and full lockdowns with a 15·0% rate (1775 of 11 827; HR 0·51, 0·50–0·53; p<0·0001). In sensitivity analyses, including adjustment for SARS-CoV-2 case notif
Eslam M, Ahmed A, Despres J-P, et al., 2021, Incorporating fatty liver disease in multidisciplinary care and novel clinical trial designs for patients with metabolic diseases, LANCET GASTROENTEROLOGY & HEPATOLOGY, Vol: 6, Pages: 743-753
Moussa O, Ortega P, Mansour S, et al., 2021, Bariatric surgical services within a pandemic can continue safely: the initial experience of a UK centre of excellence., Obesity Surgery, ISSN: 0960-8923
Salem V, Demetriou L, Behary P, et al., 2021, Weight loss by low calorie diet versus gastric bypass surgery in people with diabetes results in divergent brain activation patterns: an functional MRI study, Diabetes Care, Vol: 44, Pages: 1842-1851, ISSN: 0149-5992
OBJECTIVE: Weight loss achieved with very-low-calorie diets (VLCDs) can produce remission of type 2 diabetes (T2D), but weight regain very often occurs with reintroduction of higher calorie intakes. In contrast, bariatric surgery produces clinically significant and durable weight loss, with diabetes remission that translates into reductions in mortality. We hypothesized that in patients living with obesity and prediabetes/T2D, longitudinal changes in brain activity in response to food cues as measured using functional MRI would explain this difference.RESEARCH DESIGN AND METHODS: Sixteen participants underwent gastric bypass surgery, and 19 matched participants undertook a VLCD (meal replacement) for 4 weeks. Brain responses to food cues and resting-state functional connectivity were assessed with functional MRI pre- and postintervention and compared across groups.RESULTS: We show that Roux-en-Y gastric bypass surgery (RYGB) results in three divergent brain responses compared with VLCD-induced weight loss: 1) VLCD resulted in increased brain reward center food cue responsiveness, whereas in RYGB, this was reduced; 2) VLCD resulted in higher neural activation of cognitive control regions in response to food cues associated with exercising increased cognitive restraint over eating, whereas RYGB did not; and 3) a homeostatic appetitive system (centered on the hypothalamus) is better engaged following RYGB-induced weight loss than VLCD.CONCLUSIONS: Taken together, these findings point to divergent brain responses to different methods of weight loss in patients with diabetes, which may explain weight regain after a short-term VLCD in contrast to enduring weight loss after RYGB.
Ahmed A, Morales-Conde S, Legrand M, et al., 2021, Clinical outcomes of pre-attached reinforced stapler reloads in bariatric surgery: A prospective case series, INTERNATIONAL JOURNAL OF SURGERY OPEN, Vol: 32, ISSN: 2405-8572
Samarasinghe S, Sudlow A, Dimitriadis GK, et al., 2021, Simple tool to prioritize access to bariatric surgery for people living with obesity during the COVID-19 pandemic, British Journal of Surgery, Vol: 108, Pages: e179-e180, ISSN: 0007-1323
Ghanem A, Emile S, Cousins J, et al., 2021, Bariatric surgery during COVID-19 in the UK: a British obesity and metabolic surgery society (BOMSS) survey, SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES, Vol: 36, Pages: 533-543, ISSN: 0930-2794
BackgroundAfter the declaration of COVID-19 as a pandemic last March 2020, several adjustments in surgical services were implemented. Plans are now being formulated for restarting bariatric surgery. The aim of this survey is to capture the practice during the pandemic and the readiness to restart to provide a framework to deal with the backlog of bariatric cases.MethodA survey was delivered to consultant surgeon members of the British Obesity and Metabolic Surgery Society and non-bariatric surgery consultant members of the Association of Upper GI Surgeons.ResultsThe survey elicited a response rate of 40% (n = 66) among bariatric surgeons and 15.5% (n = 34) between non-bariatric surgeons. The average question response rate was 93% (88–100%). Most of the elective bariatric surgeries and clinics were cancelled early after declaration of the pandemic. Remote technologies for patient education evolved and were used heavily during the pandemic. The average cancelled elective bariatric surgery operations per week was 9. Nearly a quarter of responders reported performing emergency bariatric surgery during the pandemic. Most of the bariatric surgeons reported being ready to restart the service within 1–2 months. Responders recommended using private sector beds to increase NHS capacity and using the link between obesity and poor COVID-19 outcomes to push for prioritisation of bariatric patients.ConclusionThis survey is an attempt to understand the impact of COVID-19 on UK bariatric service and the preparedness to restart. It expressed the bariatric surgery consultants’ view of prioritisation of bariatric patients on clinical basis rather than the first-come-first-served basis.
Kenkre J, Ahmed A, Purkayastha S, et al., 2021, Who will benefit from bariatric surgery for diabetes? A protocol for an observational cohort study, BMJ Open, Vol: 11, ISSN: 2044-6055
Introduction Type 2 diabetes mellitus (T2DM) and obesity are pandemic diseases that lead to a great deal of morbidity and mortality. The most effective treatment for obesity and T2DM is bariatric or metabolic surgery; it can lead to long-term diabetes remission with 4 in 10 of those undergoing surgery having normal blood glucose on no medication 1 year postoperatively. However, surgery carries risks and, additionally, due to resource limitations, there is a restricted number of patients who can access this treatment. Moreover, not all those who undertake surgery respond equally well metabolically. The objective of the current research is to prospectively investigate predictors of T2DM response following metabolic surgery, including those directly involved in its aetiopathogenesis such as fat distribution and genetic variants. This will inform development of a clinically applicable model to help prioritise this therapy to those predicted to have remission.Methods and analysis A prospective multicentre observational cohort study of adult patients with T2DM and obesity undergoing Roux-en-Y gastric bypass surgery. Patients will be comprehensively assessed before surgery to determine their clinical, metabolic, psychological, genetic and fat distribution profiles. A multivariate logistic regression model will be used to assess the value of the factors derived from the preoperative assessment in terms of prediction of diabetes remission.Ethics and dissemination Formal ethics review was undertaken with a favourable opinion (UK HRA RES reference number 18/LO/0931). The dissemination plan is to present the results at conferences, in peer-reviewed journals as well as to lay media and to patient organisations.Trial registration details ClinicalTrials.gov, Identifier: NCT03842475.
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