Imperial College London

Dr Alex Miras

Faculty of MedicineDepartment of Metabolism, Digestion and Reproduction

Clinical Senior Lecturer
 
 
 
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Contact

 

+44 (0)7958 377 674a.miras

 
 
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Location

 

Commonwealth BuildingHammersmith Campus

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Summary

 

Publications

Publication Type
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119 results found

Ruban A, Miras A, glaysher M, Goldstone A, Teare Jet al., 2021, Duodenal-jejunal Bypass Liner for the management of Type 2 Diabetes and Obesity: A Multicenter Randomized Controlled Trial, Annals of Surgery, ISSN: 0003-4932

Journal article

Sheridan W, Da Silva AS, Leca BM, Ostarijas E, Patel AG, Aylwin SJB, Vincent RP, Panagiotopoulos S, El-Hasani S, le Roux CW, Miras AD, Cardozo L, Dimitriadis GKet al., 2021, Weight loss with bariatric surgery or behaviour modification and the impact on female obesity-related urine incontinence: A comprehensive systematic review and meta-analysis, Clinical Obesity, Pages: 1-19, ISSN: 1758-8103

Women with obesity are at risk of pelvic floor dysfunction with a 3-fold increased incidence of urge urinary incontinence (UUI) and double the risk of stress urinary incontinence (SUI). The National Institute for Health and Care Excellence (NICE) and European Association of Urology (EAU) recommend that women with a body mass index ≥30 kg/m2 should consider weight loss prior to consideration for incontinence surgery. This systematic review and meta-analysis will assess this recommendation to aid in the counselling of women with obesity-related urinary incontinence (UI). Medical Literature Analysis and Retrieval System online (MEDLINE), EMBASE, Cochrane, ClinicalTrials.gov, and SCOPUS were systematically and critically appraised for all peer reviewed manuscripts that suitably fulfilled the inclusion criteria established a priori and presented original, empirical data relevant to weight loss intervention in the management of urinary incontinence. Thirty-three studies and their outcomes were meta-analysed. Weight loss interventions were associated in a decreased prevalence in UI (OR 0.222, 95% CI [0.147, 0.336]), SUI (OR 0.354, 95% CI [0.256, 0.489]), UUI (OR 0.437, 95% CI [0.295, 0.649]) and improved quality of life (PFDI-20, SMD -0.774 (95% CI [−1.236, −0.312]). This systematic review and meta-analysis provide evidence that weight loss interventions are effective in reducing the prevalence of obesity-related UI symptoms in women. Bariatric surgery in particular shows greater sustained weight loss and improvements in UI prevalence. Further large scale, randomized control trials assessing the effect of bariatric surgery on women with obesity-related UI are needed to confirm this study's findings.

Journal article

Salem V, Demetriou L, Behary P, Alexiadou K, Miras A, Scoltz S, Purkayastha S, Ahmed S, Dhillo W, Tan Tet al., 2021, Weight loss by low-calorie diet versus gastric bypass surgery in people with diabetes results in divergent brain activation patterns which may explain differences in long-term outcomes: an FMRI study, The Diabetes UK Professional Conference 2021, Publisher: Wiley, Pages: 1-1, ISSN: 0742-3071

Objective: Clinically significant weight loss can produce remission of type 2 diabetes. Bariatric surgery (specifically, Roux-en-Y gastric bypass, RYGB) produces durable weight loss that translates into reductions in mortality. In contrast, weight regain is very common after very low-calorie diets (VLCD). No study has investigated longitudinal changes in brain activity using functional MRI in patients living with obesity and prediabetes/type 2 diabetes to explain this difference.Methods: Visual food cue responses and resting state connectivity was assessed with functional MRI pre- and post-intervention and compared between 16 participants who underwent gastric bypass surgery and 19 age, gender, and disease stage matched participants who undertook a VLCD for 4 weeks.Results: Brain responses to RYGB-induced weight loss diverge from those induced by VLCD in three domains: (i) dieting resulted in increased responsiveness to visual food cues in reward areas whereas after RYGB this was reduced; (ii) dieting therefore engaged greater activation of brain regions involved in cognitive control, associated with the need to exercise increased restraint over eating; and (iii) a homeostatic appetitive system (centred on the hypothalamus) was better engaged following RYGB-induced weight loss than dieting.Conclusion: This study provides a holistic view of multiple 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 with the enduring weight loss after RYGB.

Conference paper

Samarasinghe S, Sudlow A, Dimitriadis GK, Ahmed AR, Purkayastha S, Tsironis C, Hakky S, Moorthy K, Aylwin SJB, Panagiotopoulos S, El-Hassani S, Patel AG, Chahal H, Hameed S, le Roux CW, Pournaras DJ, Miras ADet 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

Journal article

Glaysher M, Ward J, Aldhwayan M, Ruban A, Prechtl CG, Fisk HL, Chhina N, Al-Najim W, Smith C, Klimowska-Nassar N, Johnson N, Falaschetti E, Goldstone AP, Miras AD, Byrne JP, Calder PC, Teare Jet al., 2021, The effect of a duodenal-jejunal bypass liner on lipid profile and blood concentrations of long chain polyunsaturated fatty acids, Clinical Nutrition, Vol: 40, Pages: 2343-2354, ISSN: 0261-5614

Background & aimsDuodenal-jejunal bypass liners (DJBLs) prevent absorption in the proximal small intestine, the site of fatty acid absorption. We sought to investigate the effects of a DJBL on blood concentrations of essential fatty acids (EFAs) and bioactive polyunsaturated fatty acids (PUFAs).MethodsSub-study of a multicentre, randomised, controlled trial with two treatment groups. Patients aged 18–65 years with type-2 diabetes mellitus and body mass index 30–50 kg/m2 were randomised to receive a DJBL for 12 months or best medical therapy, diet and exercise. Whole plasma PUFA concentrations were determined at baseline, 10 days, 6 and 11.5 months; data were available for n = 70 patients per group.ResultsWeight loss was significantly greater in the DJBL group compared to controls after 11.5 months: total body weight loss 11.3 ± 5.3% versus 6.0 ± 5.7% (mean difference [95% CI] = 5.27% [3.75, 6.80], p < 0.001). Absolute concentrations of both EFAs, linoleic acid and α-linolenic acid, and their bioactive derivatives, arachidonic acid, eicosapentaenoic acid, docosapentaenoic acid and docosahexaenoic acid, were significantly lower in the DJBL group than in the control group at 6 and 11.5 months follow-up. Total serum cholesterol, LDL-cholesterol and HDL-cholesterol were also significantly lower in the DJBL group.ConclusionOne year of DJBL therapy is associated with superior weight loss and greater reductions in total serum cholesterol and LDL-cholesterol, but also depletion of EFAs and their longer chain derivatives. DJBL therapy may need to be offset by maintaining an adequate dietary intake of PUFAs or by supplementation.

Journal article

Miras AD, Kamocka A, Tan T, Pérez-Pevida B, Chahal H, Moorthy K, Purkayastha S, Patel A, Umpleby AM, Frost G, Bloom SR, Ahmed AR, Rubino Fet al., 2021, Long limb compared with standard limb Roux-en-Y gastric bypass for type 2 diabetes and obesity: the LONG LIMB RCT, Efficacy and Mechanism Evaluation, Vol: 8, ISSN: 2050-4365

BackgroundRoux-en-Y gastric bypass is recognised as a standard of care in the treatment of diabetes mellitus and obesity. However, the optimal length of the Roux-en-Y gastric bypass limbs remains controversial, with substantial variation in practice. Specifically, a longer biliopancreatic limb length of 150 cm (‘long limb’) has been hypothesised to be better for the treatment of diabetes mellitus because it increases the postprandial secretion of gut hormones, such as glucagon-like peptide 1, and increases insulin sensitivity, compared with the Roux-en-Y gastric bypass utilising a standard biliopancreatic limb length of 50 cm (‘standard limb’).ObjectiveTo evaluate the mechanisms, clinical efficacy and safety of long limb versus the standard limb Roux-en-Y gastric bypass in patients undergoing metabolic surgery for obesity and diabetes mellitus.DesignA double-blind, mechanistic randomised controlled trial was conducted to evaluate the mechanisms, clinical efficacy and safety of the two interventions.SettingImperial College London, King’s College London and their associated NHS trusts.ParticipantsPatients with obesity and type 2 diabetes mellitus who were eligible for metabolic surgery.InterventionsParticipants were randomly assigned (1 : 1) to 150-cm (long limb) or 50-cm (standard limb) biliopancreatic limb Roux-en-Y gastric bypass with a fixed alimentary limb of 100 cm. The participants underwent meal tolerance tests to measure glucose excursions, glucagon-like peptide 1 and insulin secretion, and hyperinsulinaemic–euglycaemic clamps with stable isotopes to measure insulin sensitivity preoperatively, at 2 weeks after the surgery and at matched 20% total body weight loss. Clinical follow-up continued up to 1 year.Main outcome measuresPrimary – postprandial peak of active glucagon-like peptide 1 concentration at 2 weeks after intervention. Secondary – fasting and postprandial glucose an

Journal article

Ilesanmi I, Tharakan G, Alexiadou K, Behary P, Alessimii H, Bovill-Taylor C, Kenkre J, Choudhury S, Doyle C, Purkayastha S, Miras A, Tsironis C, Chahal H, Bloom SR, Oliver NS, Ahmed AR, Khoo B, Tan TM-Met al., 2021, Roux-en-Y Gastric Bypass Increases Glycemic Variability and Time in Hypoglycemia in Patients With Obesity and Prediabetes or Type 2 Diabetes: A Prospective Cohort Study, DIABETES CARE, Vol: 44, Pages: 614-617, ISSN: 0149-5992

Journal article

Miras A, Kamocka A, Pérez-Pevida B, Purkayastha S, Moorthy K, Patel A, Chahal H, Frost G, Bassett P, Castagnetto-Gissey L, Coppin L, Jackson N, Umpleby M, Bloom S, Tan T, Ahmed A, Rubino Fet al., 2021, The effect of standard versus longer intestinal bypass on GLP-1 regulation and glucose metabolism in patients with type 2 diabetes undergoing roux-en-Y gastric bypass. The long-limb study, Diabetes Care, Vol: 44, Pages: 1-9, ISSN: 0149-5992

ObjectiveRoux-en-Y gastric bypass (RYGB) characteristically enhances post-prandial levels of Glucagon-like peptide 1 (GLP-1), a mechanism that contributes to its profound glucose-lowering effects. This enhancement is thought to be triggered by bypass of food to the distal small intestine with higher densities of neuroendocrine L-cells. We hypothesised that if this is the predominant mechanism behind the enhanced secretion of GLP-1, a longer intestinal bypass would potentiate the post-prandial peak in GLP-1, translating into higher insulin secretion and thus additional improvements in glucose tolerance. To investigate this, we conducted a mechanistic study comparing two variants of RYGB that differ in the length of intestinal bypass.Research Design and MethodsFifty-three patients with type 2 diabetes and obesity were randomised to either ‘standard limb’ RYGB (50cm biliopancreatic limb) or ‘long limb’ RYGB (150cm biliopancreatic limb). They underwent measurements of GLP-1 and insulin secretion following a mixed meal and insulin sensitivity using euglycaemic hyperinsulinaemic clamps at baseline, 2 weeks and at 20% weight loss after surgery.ResultsBoth groups exhibited enhancement in post-prandial GLP-1 secretion and improvements in glycaemia compared to baseline. There were no significant differences in post-prandial peak concentrations of GLP-1, time to peak, insulin secretion, and insulin sensitivity. ConclusionThe findings of this study demonstrate that lengthening of the intestinal bypass in RYGB does not affect GLP-1 secretion. Thus, the characteristic enhancement of GLP-1 response after RYGB might not depend on delivery of nutrients to more distal intestinal segments.

Journal article

Miras AD, le Roux CW, 2021, Metabolic surgery versus conventional therapy in type 2 diabetes, The Lancet, Vol: 397, Pages: 256-257, ISSN: 0140-6736

Journal article

Ruban A, Glaysher MA, Miras AD, Goldstone AP, Prechtl CG, Johnson N, Li J, Aldhwayan M, Aldubaikhi G, Glover B, Lord J, Onyimadu O, Falaschetti E, Klimowska-Nassar N, Ashrafian H, Byrne J, Teare JPet al., 2020, A duodenal sleeve bypass device added to intensive medical therapy for obesity with type 2 diabetes: a RCT, Efficacy and Mechanism Evaluation, Vol: 7, Pages: 1-130, ISSN: 2050-4365

BackgroundThe EndoBarrier® (GI Dynamics Inc., Boston, MA, USA) is an endoluminal duodenal–jejunal bypass liner developed for the treatment of patients with obesity and type 2 diabetes mellitus. Meta-analyses of its effects on glycaemia and weight have called for larger randomised controlled trials with longer follow-up.ObjectivesThe primary objective was to compare intensive medical therapy with a duodenal–jejunal bypass liner with intensive medical therapy without a duodenal–jejunal bypass liner, comparing effectiveness on the metabolic state as defined by the International Diabetes Federation as a glycated haemoglobin level reduction of ≥ 20%. The secondary objectives were to compare intensive medical therapy with a duodenal–jejunal bypass liner with intensive medical therapy without a duodenal–jejunal bypass liner, comparing effectiveness on the metabolic state as defined by the International Diabetes Federation as a glycated haemoglobin level of < 42 mmol/mol, blood pressure of < 135/85 mmHg, and the effectiveness on total body weight loss. Additional secondary outcomes were to investigate the cost-effectiveness and mechanism of action of the effect of a duodenal–jejunal bypass liner on brain reward system responses, insulin sensitivity, eating behaviour and metabonomics.DesignA multicentre, open-label, randomised controlled trial.SettingImperial College Healthcare NHS Trust and University Hospital Southampton NHS Foundation Trust.ParticipantsPatients aged 18–65 years with a body mass index of 30–50 kg/m2 and with inadequately controlled type 2 diabetes mellitus who were on oral glucose-lowering medications.InterventionsParticipants were randomised equally to receive intensive medical therapy alongside a duodenal–jejunal bypass liner device (n = 85) or intensive medical therapy alone for 12 months (n = 85), and were followed up

Journal article

Hameed S, Salem V, Alessimii H, Scholtz S, Dar O, Miras AD, Meeran K, Bloom SR, Ahmed AR, Purkayastha S, Chahal H, Tan Tet al., 2020, Imperial Satiety Protocol: A new non-surgical weight-loss programme, delivered in a health care setting, produces improved clinical outcomes for people with obesity, Diabetes, Obesity and Metabolism: a journal of pharmacology and therapeutics, Vol: 23, Pages: 270-275, ISSN: 1462-8902

‘Imperial Satiety Protocol’ (I-SatPro) is a new multifaceted approach to weight loss for people with obesity (PwO), encompassing dietary advice, time-restricted eating, physical activity and coaching to support behaviour change. Participants (n = 84) attended fortnightly I-SatPro group sessions for 30 weeks, with 70% of participants completing. On completion at 30 weeks, the mean weight loss was 15.2 ± 1.1 kg (13.2 ± 0.8% from baseline, P < .0001), which was maintained to 52 weeks (16.6 ± 1.5 kg, 14.1 ± 1.2%, P < .0001). Weight loss was not associated with reduced energy expenditure. In participants with type 2 diabetes and pre-diabetes (n = 16), glycated haemoglobin fell from 50 to 43 mmol/mol (P < .01). Systolic blood pressure fell by 12 mmHg (P < .0001). Triglycerides fell by 0.37 mmol/L (P < .01) and high-density lipoprotein rose by 0.08 mmol/L (P < .01). Short Form-36 (SF-36) functioning and wellbeing scores increased in all domains post I-SatPro intervention. For selected PwO, I-SatPro delivers clinically meaningful weight loss, and the potential for long-term health and wellbeing improvements.

Journal article

Ruban A, Glaysher M, Miras A, Prechtl CG, Goldstone AP, Johnson NA, Aldhwayan M, Chhina N, Al-Najim W, Ashrafian H, Patel M, Byrne J, Teare JPet al., 2020, ONE YEAR OF DUODENAL-JEJUNAL BYPASS LINER THERAPY (ENDOBARRIER (R)) LEADS TO SIGNIFICANT CHANGES IN LIVER BIOCHEMISTRY ASSOCIATED WITH NON-ALCOHOLIC FATTY LIVER DISEASE, GI Fellows Sessions at Digestive Disease Week / 61st Annual Meeting of the Society-for-Surgery-of-the-Alimentary-Tract, Publisher: MOSBY-ELSEVIER, Pages: AB225-AB226, ISSN: 0016-5107

Conference paper

Kamocka A, McGlone ER, Pérez-Pevida B, Moorthy K, Hakky S, Tsironis C, Chahal H, Miras AD, Tan T, Purkayastha S, Ahmed ARet al., 2020, Candy cane revision after Roux-en-Y gastric bypass, Surgical Endoscopy, Vol: 34, Pages: 2076-2081, ISSN: 0930-2794

BACKGROUND: An excessively long-blind end of the alimentary limb following a Roux-en-Y gastric bypass (RYGB), known as a 'candy cane' (CC), may cause symptoms including abdominal pain, regurgitation and vomiting. Very few studies have examined the efficacy of surgical resection of the CC. OBJECTIVES: The aim of this study was to assess sensitivity of preoperative diagnostic tools for CC, as well as perioperative outcomes and symptom resolution after CC revision surgery. SETTING: High volume bariatric centre of excellence, United Kingdom. METHODS: Observational study of CC revisions from 2010 to 2017. RESULTS: Twenty-eight CC revision cases were identified (mean age 45 ± 9 years, female preponderance 9:1). Presenting symptoms were abdominal pain (86%), regurgitation/vomiting (43%), suboptimal weight loss (36%) and acid reflux (21%). Preoperative tests provided correct diagnosis in 63% of barium contrast swallows, 50% of upper gastrointestinal endoscopies and 29% computed tomographies. Patients presenting with pain had significantly higher CC size as compared with pain-free group (4.2 vs. 2 cm, p = 0.001). Perioperative complications occurred in 25% of cases. Complete or partial symptom resolution was documented in 73% of patients undergoing CC revision. Highest success rates were recorded in the regurgitation/vomiting group (67%). CONCLUSION: Surgical revision of CC is associated with good symptom resolution in the majority of patients, especially those presenting with regurgitation/vomiting. However, it carries certain risk of complications. CC diagnosis may frequently be missed; hence more than one diagnostic tool should be considered when investigating symptomatic patients after RYGB.

Journal article

Glaysher M, Miras A, Ruban A, Prechtl C, Shojaee-Moradie F, Jackson N, Coppin L, Aldhwayan M, Johnson N, Chhina N, Al-Najim W, Smith C, Klimowska-Nassar N, Goldstone A, Patel M, Le Roux C, Umpleby M, Byrne J, Teare Jet al., 2020, The effect of a duodenal-jejunal bypass liner device (Endobarrier (R)) on insulin sensitivity, 11th Annual Scientific Meeting of the British-Obesity-and-Metabolic-Surgery-Society (BOMSS), Publisher: SPRINGER, Pages: S25-S26, ISSN: 0960-8923

Conference paper

Kamocka A, Miras AD, Perez-Pevida B, Umpleby AM, Chahal H, Moorthy K, Purkayastha S, Patel A, Bloom S, Tan T, Ahmed AR, Rubino Fet al., 2020, Long versus standard biliopancreatic limb in the Roux-en-Y gastric bypass. The LONG LIMB Trial., 11th Annual Scientific Meeting of the British-Obesity-and-Metabolic-Surgery-Society (BOMSS), Publisher: SPRINGER, Pages: S4-S4, ISSN: 0960-8923

Conference paper

Ruban A, Liu Z, Glaysher M, Ashrafian H, Miras A, Prechtl C, Goldstone A, Aldhwayan M, Chhina N, Al-Najim W, Johnson N, Patel M, Li J, Byrne J, Teare Jet al., 2020, One year of duodenal-jejunal bypass liner therapy (Endobarrier (R)) leads to perturbations in the metabolic profile of urine, plasma and stool of obese diabetic patients., 11th Annual Scientific Meeting of the British-Obesity-and-Metabolic-Surgery-Society (BOMSS), Publisher: SPRINGER, Pages: S10-S10, ISSN: 0960-8923

Conference paper

Glaysher M, Ward J, Aldhwayan M, Ruban A, Prechtl C, Fisk H, Gelauf C, Chhina N, Al-Najim W, Smith C, Klimowska-Nassar N, Johnson N, Goldstone A, Miras A, Patel M, Byrne J, Calder P, Teare Jet al., 2020, The effect of a duodenal-jejunal bypass liner device (Endobarrier (R)) on lipid profile and blood concentrations of long chain polyunsaturated fatty acids, 11th Annual Scientific Meeting of the British-Obesity-and-Metabolic-Surgery-Society (BOMSS), Publisher: SPRINGER, Pages: S16-S17, ISSN: 0960-8923

Conference paper

Miras AD, Ravindra S, Humphreys A, Lascaratos G, Quartey KNK, Ahmed AR, Cousins J, Moorthy K, Purkayastha S, Hakky S, Tan T, Chahal HSet al., 2019, Metabolic changes and diabetes microvascular complications 5 years after obesity surgery., Obesity Surgery, Vol: 29, Pages: 3907-3911, ISSN: 0960-8923

BACKGROUND: Obesity surgery has pronounced effects on metabolic profile of patients with type 2 diabetes mellitus (T2DM); however, reports on long-term remission rates based on the standardised and holistic criteria by the International Diabetes Federation (IDF) and effects on T2DM microvascular complications are scarce in the literature. In this retrospective clinical trial, our objectives were to assess these variables 5 years after surgery. METHODS: Clinical data and direct measurements of renal and retinal damage were collected prospectively and analysed retrospectively for 82 patients with T2DM who underwent obesity surgery and were followed up for 5 years. RESULTS: The cohort of 82 patients with T2DM that were followed up 5 years after obesity surgery was predominantly female (71%) with a median age of 51 years, weight of 133.5 kg, BMI of 46.8 kg/m2 and pre-operative duration of T2DM of 8 years; 6% of patients had diet-controlled T2DM, 57% were on non-insulin treatment and 37% were on insulin treatment pre-operatively. Of the total 82 patients, 59 patients underwent Roux-en-Y gastric bypass, 15 sleeve gastrectomy and 8 patients underwent gastric band operations. At 5 years, 5% and 15% patients achieved optimisation and improvement of the metabolic state based on the IDF criteria respectively. Surgery was associated with almost halving of the albumin-creatinine ratio in 22 patients with pre-existing albuminuria (follow-up data available for 64 patients) and an overall stabilisation of retinopathy in 24 patients with retinal images available at 5 years. CONCLUSION: Whilst the findings on microvascular complications are encouraging, the rates of metabolic remission were lower than expected and raise the need for validated protocols to assist clinicians in managing these patients more aggressively post-operatively to achieve optimum cardio-metabolic risk factor control and hopefully further reduction in microvascular an

Journal article

Ruban A, Prechtl C, Glaysher M, Chhina N, Al-Najim W, Miras A, smith C, Goldstone A, Patel M, Moore M, Ashrafian H, Byrne J, Teare Jet al., 2019, Effectiveness of different recruitment strategies in an RCT of a surgical device:;Experience from the Endobarrier trial, BMJ Open, Vol: 9, ISSN: 2044-6055

Recruiting participants into clinical trials is notoriously difficult and poses the greatest challenge when planning any investigative study. Poor recruitment may not only have financial ramifications owing to increased time and resources being spent but could adversely influence the clinical impact of a study if it becomes underpowered. Herein we present our own experience of recruiting into a nationally funded, multi-centre, randomised controlled trial (RCT) of the Endobarrier vs. standard medical therapy in obese patients with type 2 diabetes. Despite these both being highly prevalent conditions, there were considerable barriers to the effectiveness of different recruitment strategies across each study site. Although recruitment from primary care proved extremely successful at one study site, this largely failed at another site prompting the implementation of multimodal recruitment strategies including a successful media campaign to ensure sufficient participants were enrolled and the study was adequately powered. From this experience we propose where appropriate the early engagement and investment in media campaigns to enhance recruitment into clinical trials.

Journal article

Perez-Pevida B, Escalada J, Miras AD, Fruhbeck Get al., 2019, Mechanisms underlying Type 2 diabetes remission after metabolic surgery, Frontiers in Endocrinology, Vol: 10, Pages: 1-9, ISSN: 1664-2392

Type 2 diabetes prevalence is increasing dramatically worldwide. Metabolic surgery is the most effective treatment for selected patients with diabetes and/or obesity. When compared to intensive medical therapy and lifestyle intervention, metabolic surgery has shown superiority in achieving glycemic improvement, reducing number of medications and cardiovascular risk factors, which translates in long-term benefits on cardiovascular morbidity and mortality. The mechanisms underlying diabetes improvement after metabolic surgery have not yet been clearly understood but englobe a complex interaction among improvements in beta cell function and insulin secretion, insulin sensitivity, intestinal gluconeogenesis, changes in glucose utilization, and absorption by the gut and changes in the secretory pattern and morphology of adipose tissue. These are achieved through different mediators which include an enhancement in gut hormones release, especially, glucagon-like peptide 1, changes in bile acids circulation, gut microbiome, and glucose transporters expression. Therefore, this review aims to provide a comprehensive appraisal of what is known so far to better understand the mechanisms through which metabolic surgery improves glycemic control facilitating future research in the field.

Journal article

Charani E, Cunnington AJ, Yousif AHA, Ahmed MS, Ahmed AEM, Babiker S, Bedri S, Buytaert W, Crawford MA, Elbashir MI, Elhag K, Elsiddig KE, Hakim N, Johnson MR, Miras AD, Swar MO, Templeton MR, Taylor-Robinson SDet al., 2019, In transition: current health challenges and priorities in Sudan, BMJ Global Health, Vol: 4:e001723, ISSN: 2059-7908

A recent symposium and workshop in Khartoum, the capital of the Republic of Sudan, brought together broad expertise from three universities to address the current burden of communicable and non-communicable diseases facing the Sudanese healthcare system. These meetings identified common challenges that impact the burden of diseases in the country, most notably gaps in data and infrastructure which are essential to inform and deliver effective interventions. Non-communicable diseases, including obesity, type 2 diabetes, renal disease and cancer are increasing dramatically, contributing to multimorbidity. At the same time, progress against communicable diseases has been slow, and the burden of chronic and endemic infections remains considerable, with parasitic diseases (such as malaria, leishmaniasis and schistosomiasis) causing substantial morbidity and mortality. Antimicrobial resistance has become a major threat throughout the healthcare system, with an emerging impact on maternal, neonatal, and paediatric populations. Meanwhile, malnutrition, micronutrient deficiency, and poor perinatal outcomes remain common and contribute to a lifelong burden of disease. These challenges echo the UN sustainable development goals and concentrating on them in a unified strategy will be necessary to address the national burden of disease. At a time when the country is going through societal and political transition, we draw focus on the country and the need for resolution of its healthcare needs.

Journal article

Kamocka A, Miras AD, Perez-Pevida B, Umpleby AM, Chahal H, Moorthy K, Purkayastha S, Patel A, Tan T, Bloom S, Ahmed AR, Rubino Fet al., 2019, LONG VS STANDARD BILIOPANCREATIC LIMB ROUX-EN-Y GASTRIC BYPASS FOR TYPE 2 DIABETES. THE LONG LIMB TRIAL Type 2 diabetes and metabolic surgery, 24th World Congress of the International-Federation-for-the-Surgery-of-Obesity-and-Metabolic-Disorders (IFSO) / 21st SECO Congress, Publisher: SPRINGER, Pages: 234-234, ISSN: 0960-8923

Conference paper

Diamanti-Kandarakis E, Duntas L, Kanakis GA, Kandaraki E, Karavitaki N, Kassi E, Livadas S, Mastorakos G, Migdalis I, Miras AD, Nader S, Papalou O, Poladian R, Popovic V, Rachon D, Tigas S, Tsigos C, Tsilchorozidou T, Tzotzas T, Bargiota A, Pfeifer Met al., 2019, Drug-induced endocrinopathies and diabetes: a combo-endocrinology overview, European Journal of Endocrinology, Vol: 181, Pages: R73-R105, ISSN: 0804-4643

In the currently overwhelming era of polypharmacy, the balance of the dynamic and delicate endocrine system can easily be disturbed by interfering pharmaceutical agents like medications. Drugs can cause endocrine abnormalities via different mechanisms, including direct alteration of hormone production, changes in the regulation of the feedback axis, on hormonal transport, binding and signaling, as well as similar changes to counter-regulatory hormone systems. Furthermore, drugs can interfere with the hormonal assays, leading to erroneous laboratory results that disorientate clinicians from the right diagnosis. The purpose of this review is to cover a contemporary topic, the drug-induced endocrinopathies, which was presented in the monothematic annual Combo Endo Course 2018. This challenging part of endocrinology is constantly expanding particularly during the last decade, with the new oncological therapeutic agents, targeting novel molecular pathways in the process of malignancies. In this new context of drug-induced endocrine disease, clinicians should be aware that drugs can cause endocrine abnormalities via different mechanisms and mimic a variety of clinical scenarios. Therefore, it is extremely important for clinicians not only to promptly recognize drug-induced hormonal and metabolic abnormalities, but also to address the therapeutic issues for timely intervention.

Journal article

Kamocka A, Miras AD, 2019, Comment on: Changes in total sperm count after gastric bypass and sleeve gastrectomy: the BARIASPERM prospective study, SURGERY FOR OBESITY AND RELATED DISEASES, Vol: 15, Pages: 1279-1280, ISSN: 1550-7289

Journal article

Perez-Pevida B, Kamocka A, Aldhwayan M, Kopanou A, Miras AD, Tan T, Scholtz Set al., 2019, IMPACT OF EATING BEHAVIOURS ON POSTOPERATIVE OUTCOMES IN SUBOPTIMAL RESPONDERS AFTER OBESITY SURGERY Psychology and bariatric surgery - pre and post-op challenges, 24th World Congress of the International-Federation-for-the-Surgery-of-Obesity-and-Metabolic-Disorders (IFSO) / 21st SECO Congress, Publisher: SPRINGER, Pages: 247-247, ISSN: 0960-8923

Conference paper

Miras AD, Pérez-Pevida B, Aldhwayan M, Kamocka A, McGlone ER, Al-Najim W, Chahal H, Batterham RL, McGowan B, Khan O, Greener V, Ahmed AR, Petrie A, Scholtz S, Bloom SR, Tan TMet al., 2019, Adjunctive liraglutide treatment in patients with persistent or recurrent type 2 diabetes after metabolic surgery (GRAVITAS): a randomised, double-blind, placebo-controlled trial, The Lancet Diabetes & Endocrinology, Vol: 7, Pages: 549-559, ISSN: 2213-8587

BackgroundMany patients with type 2 diabetes do not achieve sustained diabetes remission after metabolic (bariatric) surgery for the treatment of obesity. Liraglutide, a glucagon-like peptide-1 analogue, improves glycaemic control and reduces bodyweight in patients with type 2 diabetes. Our aim was to assess the safety and efficacy of liraglutide 1·8 mg in patients with persistent or recurrent type 2 diabetes after metabolic surgery.MethodsIn the GRAVITAS randomised double-blind, placebo-controlled trial, we enrolled adults who had undergone Roux-en-Y gastric bypass or vertical sleeve gastrectomy and had persistent or recurrent type 2 diabetes with HbA1c levels higher than 48 mmol/mol (6·5%) at least 1 year after surgery from five hospitals in London, UK. Participants were randomly assigned (2:1) via a computer-generated sequence to either subcutaneous liraglutide 1·8 mg once daily or placebo, both given together with a reduced-calorie diet, aiming for a 500 kcal per day deficit from baseline energy intake, and increased physical activity. The primary outcome was the change in HbA1c from baseline to the end of the study period at 26 weeks, assessed in patients who completed the trial. Safety was assessed in the safety analysis population, consisting of all participants who received either liraglutide or placebo. This trial is registered with EudraCT, number 2014-003923-23, and the ISRCTN registry, number ISRCTN13643081.FindingsBetween Jan 29, 2016, and May 2, 2018, we assigned 80 patients to receive either liraglutide (n=53) or placebo (n=27). 71 (89%) participants completed the study and were included in the principal complete-cases analysis. In a multivariable linear regression analysis, with baseline HbA1c levels and surgery type as covariates, liraglutide treatment was associated with a difference of −13·3 mmol/mol (−1·22%, 95% CI −19·7 to −7·0; p=0·0001) in HbA1c change from baselin

Journal article

Tharakan G, Ilesanmi II, Behary P, Alexiadou K, Doyle CS, Chahal H, Purkayastha S, Miras A, Oliver N, Ahmed A, Bloom S, Tan TMet al., 2019, Changes in Glycaemic Variability after RYGB: A One-Year Prospective Study with Comparison to Patients with Post-bariatric Hypoglycaemia, 79th Scientific Sessions of the American-Diabetes-Association (ADA), Publisher: AMER DIABETES ASSOC, ISSN: 0012-1797

Conference paper

Kamocka A, Perez-Pevida B, Miras AD, Markakis H, Castagneto-Gissey L, Casella J, Villa F, Panagiotopoulos S, Reyhani A, Petronio B, Patel A, Tan T, Moorthy K, Purkayastha S, Ahmed AR, Bloom S, Rubino Fet al., 2019, Total small bowel length varies considerably among patients with obesity and diabetes: Is there a role for individualisation of limb lengths in Roux-en-Y gastric bypass?, 10th Annual Scientific Meeting of the British-Obesity-and-Metabolic-Surgery-Society (BOMSS), Publisher: SPRINGER, Pages: S11-S11, ISSN: 0960-8923

Conference paper

Pérez-Pevida B, Núñez-Córdoba JM, Romero S, Miras A, Ibañez P, Vila N, Margall MÁ, Silva C, Salvador J, Frühbeck G, Escalada Jet al., 2019, Discriminatory ability of anthropometric measurements of central fat distribution for prediction of post-prandial hyperglycaemia in patients with normal fasting glucose: the DICAMANO Study, Journal of Translational Medicine, Vol: 17, ISSN: 1479-5876

Background and aimsObesity is associated with impaired glucose tolerance which is a risk factor for cardiovascular risk. However, the oral glucose tolerance test (OGTT) is not usually performed in patients with normal fasting glycaemia, thus offering false reassurance to patients with overweight or obesity who may have post-prandial hyperglycaemia. As an alternative to resource demanding OGTTs, we aimed to examine the predictive value of anthropometric measures of total and central fat distribution for post-prandial hyperglycaemia in patients with overweight and obesity with normal fasting glycaemia enrolled in the DICAMANO study.MethodsWe studied 447 subjects with overweight/obesity with a fasting glucose value ≤ 5.5 mmol l−1 (99 mg dl−1) and BMI ≥ 25 kg/m2 who underwent a 75-g OGTT. Post-prandial hyperglycaemia was defined as a glucose level ≥ 7.8 mmol l−1 (140 mg dl−1) 2-h after the OGTT. The anthropometric measurements included body mass index, body adiposity index, waist circumference, neck circumference, waist-to-hip ratio and waist-to-height ratio.ResultsThe prevalence of post-prandial hyperglycaemia was 26%. Mean 1-h OGTT glucose levels, insulin resistance and beta cell dysfunction was higher in those subjects in the highest tertile for each anthropometric measurement, irrespective of fasting glucose level. Central fat depot anthropometric measurements were strongly and independently associated with an increased risk of post-prandial hyperglycaemia. After multivariable-adjustment for fasting plasma glucose level, smoking, and physical activity level, the odds ratio (95% confidence intervals) for the presence of post-prandial hyperglycaemia for neck circumference, waist circumference and waist-to-height ratio were 3.3 (1.4, 7.7), 2.4 (1.4, 4.4) and 2.5 (1.4, 4.5), respectively.ConclusionsIn this large and comprehensively phenotyped cohort, one in four subjects had post-prandial hyperglycaemia

Journal article

Abdeen GN, Miras AD, Alqahtani AR, le Roux CWet al., 2019, Vertical sleeve gastrectomy in adolescents reduces the appetitive reward value of a sweet and fatty reinforcer in a progressive ratio task, Surgery for Obesity and Related Diseases, Vol: 15, Pages: 194-199, ISSN: 1550-7289

© 2018 Background: Adolescent obesity is challenging to treat even if good multidisciplinary approaches are started early. Vertical sleeve gastrectomy (VSG) is an effective intervention for long-term weight loss, but the underlying mechanisms that result in reduced calorie intake are controversial. Anecdotal evidence from the clinic and evidence in rodents after VSG suggest a decrease in the reward value of high-calorie dense foods. Objectives: To determine changes in appetitive behavior of candies (high in sugar and fat) after VSG in adolescents with obesity. Setting: University hospital. Methods: Sixteen adolescents with obesity (age 15.3 ±.5 yr) who had VSG and 10 control patients (age 13.8 ±.6 yr) who had not undergone surgery were studied. Both groups completed a progressive ratio task by clicking a computer mouse on a progressive ratio schedule to receive a candy high in sugar and fat. In the task, patients were required to expend an increasing amount of effort to obtain the reinforcer until they reach a breakpoint (measure of the reward value of the reinforcer). The task was performed before VSG and 12 and 52 weeks after VSG. Results: The VSG group's bodyweight decreased from the baseline 136.6 ± 5.1 to 110.9 ± 5.2 to 87.4 ± 3.7 kg after 12 and 52 weeks, respectively (P <.001). The median breakpoint for candies decreased after VSG from the baseline 320 (160–640) to 80 (50–320) to 160 (80–560) after 12 and 52 weeks, respectively (P =.01). Breakpoints for the control patients did not change (480 [160–640] versus 640 [280–640], P =.17). Conclusion: VSG resulted in a reduction in the reward value of a candy, as suggested by the reduced amount of effort adolescents were prepared to expend to obtain the high-sugar and high-fat candy. The effect was most pronounced 12 weeks after surgery but was largely maintained at 1 year. Long-term attenuation of appetitive behavior may be the key to weight

Journal article

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