Low energy meal replacement regimens can induce short-term weight loss in patients with severe obesity, but usually require specially formulated dietary supplements. We sought to determine the effects of a milk-based meal replacement program on anthropometric and metabolic characteristics in adults with severe obesity. Methods: We conducted a retrospective cohort study of patients attending our hospital-based bariatric medicine service who completed a 24-week program consisting of eight weeks of milk-based meal replacement followed by weight stabilisation and maintenance phases. Patients were seen fortnightly by the bariatric physician, nurse and dietitian. We assessed changes in anthropometric and metabolic outcomes in completers at 0, 8, 16 and 24 weeks. Results: Of 105 program completers available for follow-up, 53.3% were female. Mean age was 51.1±11.2 years. Body weight decreased from 144.0±27.6 kg at baseline to 121.1±25.0 kg at 24 weeks (P<0.001), a mean total body weight loss of 15.9±6.0%, with a reduction in body mass index from 50.6±8.0 to 42.6±7.6 kg m −2 (P<0.001). In patients with diabetes, haemoglobin A1c decreased from 66.3±13.0 to 48.3±13.5 mmol/mol (P<0.001) and diabetes medication use decreased significantly. There were significant improvements also in lipid profiles and reductions in antihypertensive medication use. Conclusion: These preliminary findings suggest that completion of a 24-week milk-based meal replacement program has large effects on important outcomes in adults with severe obesity. However, attrition was high. Prospective assessment of the efficacy, safety, durability and cost-effectiveness of this intervention seems warranted.

DESCRIPTIONA 61-year-old man presented with right pleuritic chest pain, 15 kg weight loss, shortness of breath and two painful scalp lesions (figure 1). He had a 40-pack a year smoking history with exposure to asbestos. Thoracocentesis of a right pleural effusion demonstrated atypical cytology. Staging CT showed osseous metastases and right lung apical scarring. Bone and scalp biopsies revealed poorly differentiated squamous cell carcinoma and marrow infiltration by poorly differentiated tumour, respectively, both suggestive of lung primary. Pleural biopsy confirmed stage IV adenosquamous lung carcinoma. The patient's course post-thoracoscopy was complicated by pneumothorax, subcutaneous emphysaema and a malpositioned emergent thoracostomy tube with resultant haemoptysis. Palliative radiotherapy of cutaneous metastases was performed. Further adjuvant treatment was postponed due to iatrogenic decline in functional status, highlighting the value of less invasive procedures, such as skin biopsy, in the evaluation of metastatic processes of unknown primary.Cutaneous metastases occur in 1-12% of lung cancers. Pathogenesis is by lymphovascular invasion, with poor differentiation and upper lobe tumours increasing the risk of metastasis. Histology most commonly shows adenocarcinoma, then squamous/small-cell, followed by large-cell carcinoma. Lesions present with or before the primary in 20-60% of cases, can be single or multiple and are usually painless.1 Common sites include chest, back, head and neck. Treatment modalities include surgery, chemotherapy and radiotherapy, and treatment varies based on prognosis and symptoms. Non-resectability, small-cell histology and multiple/ distant metastases confer a poor prognosis. Learning points▸ Cutaneous metastases should be suspected in those with suspicious skin lesions and presentation suggestive of a malignancy. ▸ Diagnosis of an unknown primary malignancy can be hazardous, impacting functional status and subsequent treatment. Consideration should be given to obtaining biopsies from the safest possible site first.

A man in his 70s with a history of multiple myeloma presented with a 4-day history of right ptosis and a rapidly enlarging upper eyelid mass. On examination, a large, firm, smooth, pink lesion was found to descend from the conjunctiva of the superior fornix. The patient underwent excision biopsy. Histopathological analysis demonstrated monoclonal plasma cells expressing light-chain kappa, consistent with extramedullary plasmacytoma. Clinical ophthalmic manifestations of multiple myeloma are rare but also diverse. Ocular surface manifestations of multiple myeloma are extremely uncommon. Variable examination findings mean those involving the conjunctiva and may be particularly challenging to diagnose. Secondary ocular extramedullary plasmacytoma, despite its rarity, should be considered in patients with multiple myeloma.

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