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Background Most studies on obesity surgery have measured renal function using the estimated GFR. However, due to the reduction of muscle mass, and therefore creatinine that accompanies weight loss, such measures can falsely suggest an improvement in renal function. To balance the risks of surgery versus any potential benefits on renal function, we need to be able to determine renal function using valid and reliable methodologies. In this pilot study we aimed to measure renal function in patients with CKD undergoing obesity surgery using the gold standard 51 Cr-EDTA GFR clearance methodology which is independent of measures of muscle mass. Methods Nine consecutive obese patients with CKD underwent obesity surgery. Their renal function was assessed using 51 Cr-EDTA GFR, cystatin C and serum creatinine as well as using eGFR equations including MDRD CKD Epi, Cockcroft Gault and CKD Epi cystatin before and 12 months after surgery. Results Renal function using the 51 Cr-EDTA measured GFR did not change significantly after surgery. Similar results were obtained when Cystatin C, CKD Epi cystatin, CKD Epi cystatin creatinine and adjusted Cockcroft Gault Creatinine clearance methods were used. In contrast there were either trends or significant improvements in renal function measured using the MDRD and CKD Epi equations. Conclusions In this pilot study using the gold standard 51 Cr-EDTA method we found stabilisation in renal function after obesity surgery. Until further definitive data emerge it is critical to balance the risk and benefits of surgery, especially if renal function may not improve as often as previously suggested. Trial registration ClinicalTrials.gov NCT01507350 . Registered June 2011.

Aims/hypothesis We aimed to examine the effects of bariatric surgery on microvascular complications in patients with type 2 diabetes using objective measures. Methods Prospective case–control study of 70 obese surgical patients with type 2 diabetes undergoing gastric bypass surgery matched for age, sex and duration of diabetes to 25 medical patients treated using international guidelines. Microvascular complications were assessed before and 12–18 months after intervention using urine albumin creatinine ratio (ACR) measurements, two-field digital retinal images and peripheral nerve conduction studies (in the surgical group only). Results Urine ACR decreased significantly in the surgical group but increased in the medical group. There were no significant differences between the surgical and medical groups in the changes in retinopathy. There were no changes in the nerve conduction variables in the surgical group. Conclusions/interpretation In the short term, bariatric surgery may be superior to medical care in the treatment of diabetic nephropathy, but not retinopathy or neuropathy.

Background Despite the evidence for benefits beyond weight loss following bariatric surgery, assessments of surgical outcomes are often limited to changes in weight and remission of type 2 diabetes mellitus. To address this shortfall in assessment, the King’s Obesity Staging System was developed. This system evaluates the individual in severity stages of physical, psychological, socio-economic and functional disease. These are categorised into disease domains arranged so as to allow an alphabetic mnemonic as Airways, Body Mass Index (BMI), Cardiovascular, Diabetes, Economic, Functional, Gonadal, Health Status (perceived) and (body) Image. Methods In this cohort study, patients were assessed before and 12 months after surgery using the modified King’s Obesity Staging Score. We studied 217 consecutive patients undergoing Roux-en-Y gastric bypass (RYGB; N  = 148) and laparoscopic adjustable gastric band (LAGB; N  = 69) using the modified King’s Obesity Staging System to determine health benefits after bariatric surgery. Results Preoperatively, the groups had similar BMI, but the RYGB group had worse Airways, Cardiovascular, and Diabetes scores ( p  < 0.05). After surgery, RYGB and LAGB produced improvements in all scores. In a subgroup paired analysis matched for preoperative Airways, BMI, Cardiovascular, and Diabetes scores, both procedures showed similar improvements in all scores, except for BMI where RYGB had a greater reduction than LAGB ( p  < 0.05). Conclusions Both RYGB and LAGB deliver multiple benefits to patients as evaluated by the modified King’s Obesity Staging System beyond BMI and glycaemic markers. A validated staging score such as the modified King’s Obesity Staging System can be used to quantify these benefits.

Bariatric surgery such as Roux-en-Y gastric bypass (RYGB) is increasingly performed in obese patients with type 2 diabetes (T2DM) due to its beneficial metabolic effect. RYGB is distinct from non-bariatric surgery as it improves glycaemic control immediately post-surgery. Most bariatric centres also use a low calorie diet preoperatively which also impacts on glycaemic control before surgery. Glycaemic management of these patients therefore needs to be reviewed perioperatively to avoid hypoglycaemia. To date, no study has assessed how best to manage this group of patients preoperatively and postoperatively. GLUCOSURG-pre and GLUCOSURG-post studies were designed to assess the effect of intensive glucose management before and after RYGB on glycaemic outcome. Moreover, patients with difficult controlled diabetes are more at risk of complications of diabetes. Given the rapid improvement in glucose control following RYGB, its effect on microvascular complications needs to be assessed. In this thesis, I measured the changes in diabetic nephropathy, retinopathy and neuropathy; and compared the changes in nephropathy and retinopathy to a control group. My study showed that 3 months of intensive management of glycaemia before surgery, or the first 2 weeks after surgery had not resulted in better glycaemic control at 1 year. RYGB has substantial effects on glucose control, and additional intensive glucose-lowering interventions do not confer clinical benefits compared to conservative approaches. In the case-control study, RYGB patients showed substantial reductions in albuminuria, while the rates of retinopathy progression were similar to those observed in a medically treated group. There was no change in peripheral nerve function 1 year after RYGB surgery. My study was limited by small sample size and short duration of follow up. Nonetheless, the result would reaffirm the importance of annual surveillance for diabetic retinopathy and neuropathy after RYGB.

To evaluate the rate and predictors of non-adherence to imatinib in gastrointestinal stromal tumor (GIST) patients, as well as to compare the difference in health-related quality of life (HRQOL) between adherent and non-adherent patients. A cross-sectional study at the Oncology Clinic, Hospital Kuala Lumpur was conducted from March to August 2018. All patients with metastatic and/or unresectable GIST aged ≥18 years old and on at least 3 months of imatinib were included. Adherence to imatinib was assessed using the 10-item validated Medication Compliance Questionnaire, with a score of <100% indicating non-adherence. Non-adherence predictors were determined by multiple logistic regressions. HRQOL was evaluated by the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30). The difference in the mean HRQOL scores between adherent and non-adherent groups was determined by multivariate analysis of variance. A total of 89 patients were enrolled, of which 49 (55.1%) were considered non-adherent. The significant predictors of non-adherence were age (adjusted odds ratio [OR] 0.93; CI 0.89-0.98; P = 0.007), presence of nausea and vomiting (OR 5.63; CI 1.25-25.27; P = 0.024), and presence of comorbidities (OR 4.56; CI 1.44-14.40; P = 0.010). Patients who were in the adherent group showed significantly better score in overall HRQOL, F (15, 73) = 2.09, P < 0.02; Pillai's trace = 0.3, partial eta squared = 0.30. Non-adherence to long-term treatment with imatinib among patients with GIST should not be underestimated. Significant predictors of non-adherence among this population are younger age, presence of nausea and vomiting, as well as comorbidities. Patients with good adherence portrayed better HRQOL.

This study was conducted to evaluate the extracts of Houttuynia cordata (Saururaceae), Lobelia chinensis (Campanulaceae) and Selaginella uncinata (Selaginellaceae) for their antimicrobial activities against Chikungunya virus, selected yeasts, filamentous fungi, and gram-positive and gram-negative bacteria of medical importance. Fresh preparations of the studied plants were sequentially extracted to obtain six different extracts. The extracts were examined for cytopathic inhibition effect on African monkey kidney epithelial (Vero) cells co-infected with Chikungunya virus. The chloroform extract of L. chinensis had the highest cytopathic inhibition effect with mean (±SD) cell viability of 66.5% (± 2.1)% at 40 µg/ml. The mean (± SD) 50% effective concentration and selectivity index for this extract were 28.4 (± 0.8) µ/ml and 7.5, respectively. A colorimetric broth microdilution assay revealed the hexane extract of H. cordata was the only extract with broad spectrum fungistatic activity against all six species of fungi evaluated, with mean minimum inhibitory concentration (MIC) values ranging from 0.08 to 1.25 mg/ml. As for antibacterial activity, the chloroform and ethyl acetate extracts of S. uncinata exhibited broad spectrum bacteriostatic activity against all six species of bacteria, with mean MIC ranges of 0.63-1.25 and 0.63-2.50 mg/ml, respectively. The antimicrobial activities of the extracts were found to be dependent on the species of microorganisms, testing concentration, and extractant used. The leaf extracts of H. cordata and S. uncinata are potential sources of new antifungal or antibacterial agents with broad spectrum activity. The chloroform extract of L. chinensis warrants isolation of the compounds active against Chikungunya virus due to its potency.