Working at the interface: lessons from a joined-up approach between oral medicine and paediatric dentistry.

Oral mucosal and other head and neck conditions in children have a variety of presentations. The joint oral medicine and paediatric (JOMP) dental clinic is a specialised unit within a London teaching hospital, developed to manage a wide range of oral conditions with an absolute commitment to a child-centred care approach. The authors present eight cases from the JOMP clinic experience at Guy's and St Thomas' NHS Foundation trust, over a nine-year period. Each case is unique in its presentation, diagnosis and bespoke management, tailored to the nuance of each individual patient and their unique position. The eight clinical cases demonstrate the success of the JOMP team in achieving good patient outcomes, in terms of providing accurate diagnoses for their oral conditions and for appropriately tailored management/ treatment. The cases also serve to raise awareness of some of the more unusual oral conditions affecting paediatric patients among our professional colleagues.

Bronchopulmonary Fistula Development in an Elderly Male With COVID-19 Infection.

COVID-19 pneumonia can cause a wide range of complications including pneumothorax and empyema. However, in severe cases, it can lead to bronchopulmonary fistula (BPF) formation and a persistent air leak due to a connection between the pleural space and the bronchial tree. We report the case of a 77-year-old man with a history of hypertension, who presented to the emergency department for evaluation of dyspnea. Admission labs were significant for a positive rapid antigen SARS-Cov-2 test and elevated troponin I. A chest x-ray demonstrated patchy interstitial opacification and ground glass appearance bilaterally. Within the first 24 hours of presentation, the patient developed a right-sided spontaneous pneumothorax and had a 14 French pigtail catheter placed. The patient subsequently developed a persistent air leak after chest tube placement and required video-assisted thoracoscopic surgery (VATS) with talc pleurodesis and a 32 French chest tube placement. In this unique case, we describe an elderly patient's experience of bronchopulmonary fistula formation as a complication of COVID-19 pneumonia and the successful management of this complication with VATS.

Association between neighborhood food environments and bariatric surgery outcomes.

BACKGROUND: Individual characteristics associated with weight loss after bariatric surgery are well established, but the neighborhood characteristics that influence outcomes are unknown. OBJECTIVES: The objective of this study was to determine if neighborhood characteristics, including social determinants and lifestyle characteristics, were associated with weight loss after bariatric surgery. SETTING: Single university healthcare system, United States. METHODS: In this retrospective cohort study, all patients who underwent primary bariatric surgery from 2008 to 2017 and had at least 1 year of follow-up data were included. Patient-level demographics and neighborhood-level social determinants (area deprivation index, urbanicity, and walkability) and lifestyle factors (organic food use, fresh fruit/vegetable consumption, diet to maintain weight, soda consumption, and exercise) were analyzed. Median regression with percent total body weight (%TBW) loss as the outcome was applied to examine factors associated with weight loss after surgery. RESULTS: Of the 647 patients who met inclusion criteria, the average follow-up period was 3.1 years, and the mean %TBW loss at the follow-up was 22%. In adjusted median regression analyses, Roux-en-Y gastric bypass was associated with greater %TBW loss (11.22%, 95% confidence interval [8.96, 13.48]) compared to sleeve, while longer follow-up time (-2.42% TBW loss per year, 95% confidence interval [-4.63, -0.20]) and a preoperative diagnosis of diabetes (-1.00% TBW loss, 95% confidence interval [-1.55, -0.44]) were associated with less. None of the 8 neighborhood level characteristics was associated with weight loss. CONCLUSIONS: Patient characteristics rather than neighborhood-level social determinants and lifestyle factors were associated with weight loss after bariatric surgery in our cohort of bariatric surgery patients. Patients from socioeconomically deprived neighborhoods can achieve excellent weight loss after bariatric surgery.

Obesity and "obesity-related" cancers: are there body mass index cut-points?

BACKGROUND: Despite compelling links between excess body weight and cancer, body mass index (BMI) cut-points, or thresholds above which cancer incidence increased, have not been identified. The objective of this study was to determine if BMI cut-points exist for 14 obesity-related cancers. SUBJECTS/METHODS: In this retrospective cohort study, patients 18-75 years old were included if they had ≥2 clinical encounters with BMI measurements in the electronic health record (EHR) at a single academic medical center from 2008 to 2018. Patients who were pregnant, had a history of cancer, or had undergone bariatric surgery were excluded. Adjusted logistic regression was performed to identify cancers that were associated with increasing BMI. For those cancers, BMI cut-points were calculated using adjusted quantile regression for cancer incidence at 80% sensitivity. Logistic and quantile regression models were adjusted for age, sex, race/ethnicity, and smoking status. RESULTS: A total of 7079 cancer patients (mean age 58.5 years, mean BMI 30.5 kg/m2) and 270,441 non-cancer patients (mean age 43.8 years, mean BMI 28.8 kg/m2) were included in the study. In adjusted logistic regression analyses, statistically significant associations were identified between increasing BMI and the incidence of kidney, thyroid, and uterine cancer. BMI cut-points were identified for kidney (26.3 kg/m2) and uterine (26.9 kg/m2) cancer. CONCLUSIONS: BMI cut-points that accurately predicted development kidney and uterine cancer occurred in the overweight category. Analysis of multi-institutional EHR data may help determine if these relationships are generalizable to other health care settings. If they are, incorporation of BMI into the screening algorithms for these cancers may be warranted.

Azapodophyllotoxin Causes Lymphoma and Kidney Cancer Regression by Disrupting Tubulin and Monoglycerols.

A natural compound screen identified several anticancer compounds, among which azapodophyllotoxin (AZP) was found to be the most potent. AZP caused decreased viability of both mouse and human lymphoma and renal cell cancer (RCC) tumor-derived cell lines. Novel AZP derivatives were synthesized and screened identifying compound NSC750212 to inhibit the growth of both lymphoma and RCC both in vitro and in vivo. A nanoimmunoassay was used to assess the NSC750212 mode of action in vivo. On the basis of the structure of AZP and its mode of action, AZP disrupts tubulin polymerization. Through desorption electrospray ionization mass spectrometry imaging, NSC750212 was found to inhibit lipid metabolism. NSC750212 suppresses monoglycerol metabolism depleting lipids and thereby inhibits tumor growth. The dual mode of tubulin polymerization disruption and monoglycerol metabolism inhibition makes NSC750212 a potent small molecule against lymphoma and RCC.

Obesity and BMI Cut Points for Associated Comorbidities: Electronic Health Record Study.

BACKGROUND: Studies have found associations between increasing BMIs and the development of various chronic health conditions. The BMI cut points, or thresholds beyond which comorbidity incidence can be accurately detected, are unknown. OBJECTIVE: The aim of this study is to identify whether BMI cut points exist for 11 obesity-related comorbidities. METHODS: US adults aged 18-75 years who had ≥3 health care visits at an academic medical center from 2008 to 2016 were identified from eHealth records. Pregnant patients, patients with cancer, and patients who had undergone bariatric surgery were excluded. Quantile regression, with BMI as the outcome, was used to evaluate the associations between BMI and disease incidence. A comorbidity was determined to have a cut point if the area under the receiver operating curve was >0.6. The cut point was defined as the BMI value that maximized the Youden index. RESULTS: We included 243,332 patients in the study cohort. The mean age and BMI were 46.8 (SD 15.3) years and 29.1 kg/m2, respectively. We found statistically significant associations between increasing BMIs and the incidence of all comorbidities except anxiety and cerebrovascular disease. Cut points were identified for hyperlipidemia (27.1 kg/m2), coronary artery disease (27.7 kg/m2), hypertension (28.4 kg/m2), osteoarthritis (28.7 kg/m2), obstructive sleep apnea (30.1 kg/m2), and type 2 diabetes (30.9 kg/m2). CONCLUSIONS: The BMI cut points that accurately predicted the risks of developing 6 obesity-related comorbidities occurred when patients were overweight or barely met the criteria for class 1 obesity. Further studies using national, longitudinal data are needed to determine whether screening guidelines for appropriate comorbidities may need to be revised.

Perioperative Cost Differences Between Laparoscopic Sleeve Gastrectomy and Laparoscopic Roux-en-Y Gastric Bypass: A Single Institutional Review.

Background: Minimizing bariatric surgery care costs is important since more than 250,000 patients undergo bariatric surgery annually in the United States. The study objective was to compare perioperative costs for the two most common bariatric procedures: laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). In addition, we sought to identify predictors of high-cost perioperative care. Methods: Adult patients who underwent LSG or LRYGB from 2012 to 2017 were identified using our institutional bariatric surgery database. Perioperative costs, defined as costs incurred from the time of entering the preoperative unit until exiting the postanesthesia care unit, were obtained through billing data. Median perioperative cost components of LSG and LRYGB were compared using Mann-Whitney tests. Multivariable logistic regression was performed to investigate patient-level predictors of high-cost care, defined as the top tercile of perioperative costs. Results: We included 546 bariatric surgery patients with a mean age and body mass index (BMI) of 49.7 years and 45.9 kg/m2, respectively. There were no significant differences in median perioperative costs between LSG and LRYGB ($14,942 versus $15,016; P = .80). Stapler use was the largest cost contributor for both procedures, accounting for 27.7% and 29.2% of costs for LSG and LRYGB, respectively. In multivariable analyses, preoperative patient characteristics, including BMI, were not associated with high-cost perioperative care. Conclusions: Perioperative costs for LSG and LRYGB were similar in our single institution study. Reducing costs outside of the operating room, including those related to ED visits and complications, may be more impactful than focusing on cost reduction directly related to perioperative care.

Association Between Medicaid Status, Social Determinants of Health, and Bariatric Surgery Outcomes.

OBJECTIVE: To compare outcomes after bariatric surgery between Medicaid and non-Medicaid patients and assess whether differences in social determinants of health were associated with postoperative weight loss. BACKGROUND: The literature remains mixed on weight loss outcomes and healthcare utilization for Medicaid patients after bariatric surgery. It is unclear if social determinants of health geocoded at the neighborhood level are associated with outcomes. METHODS: Patients who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) from 2008 to 2017 and had ≥1 year of follow-up within a large health system were included. Baseline characteristics, 90-day and 1-year outcomes, and weight loss were compared between Medicaid and non-Medicaid patients. Area deprivation index (ADI), urbanicity, and walkability were analyzed at the neighborhood level. Median regression with percent total body weight (TBW) loss as the outcome was used to assess predictors of weight loss after surgery. RESULTS: Six hundred forty-seven patients met study criteria (191 Medicaid and 456 non-Medicaid). Medicaid patients had a higher 90-day readmission rate compared to non-Medicaid patients (19.9% vs 12.3%, P < 0.016). Weight loss was similar between Medicaid and non-Medicaid patients (23.1% vs 21.9% TBW loss, respectively; P = 0.266) at a median follow-up of 3.1 years. In adjusted analyses, Medicaid status, ADI, urbanicity, and walkability were not associated with weight loss outcomes. CONCLUSIONS: Medicaid status and social determinants of health at the neighborhood level were not associated with weight loss outcomes after bariatric surgery. These findings suggest that if Medicaid patients are appropriately selected for bariatric surgery, they can achieve equivalent outcomes as non-Medicaid patients.

pH Impedance Parameters Associated with Improvement in GERD Health-Related Quality of Life Following Anti-reflux Surgery.

INTRODUCTION: pH impedance testing is the most sensitive diagnostic test for detecting gastroesophageal reflux disease (GERD). The literature remains inconclusive on which preoperative pH impedance testing parameters are associated with an improvement in heartburn symptoms after anti-reflux surgery. The objective of this study was to evaluate which parameters on preoperative pH impedance testing were associated with improved GERD health-related quality of life (GERD-HRQL) following surgery. METHODS: Data from a single-institution foregut database were used to identify patients with reflux symptoms who underwent anti-reflux surgery between 2014 and 2020. Acid and impedance parameters were extracted from preoperative pH impedance studies. GERD-HRQL was assessed pre- and postoperatively with a questionnaire that evaluated heartburn, dysphagia, and the impact of acid-blocking medications on daily life. Patient characteristics, fundoplication type, and four pH impedance parameters were included in a multivariable linear regression model with improvement in GERD-HRQL as the outcome. RESULTS: We included 108 patients (59 Nissen and 49 Toupet fundoplications), with a median follow-up time of 1 year. GERD-HRQL scores improved from 22.4 (SD ± 10.1) preoperatively to 4.2 (± 6.2) postoperatively. In multivariable analysis, a normal preoperative acid exposure time (p = 0.01) and Toupet fundoplication (vs. Nissen; p = 0.03) were independently associated with greater improvement in GERD-HRQL. CONCLUSIONS: Of the four pH impedance parameters that were investigated, a normal preoperative acid exposure time was associated with greater improvement in quality of life after anti-reflux surgery. Further investigation into the critical parameters on preoperative pH impedance testing using a multi-institutional cohort is warranted.

Unnecessary use of radiology studies in the diagnosis of inguinal hernias: a retrospective cohort study.

BACKGROUND: The diagnosis of inguinal hernias is predominantly based on physical exam, although imaging may be used in select cases. The objective of this study was to determine the frequency of unnecessary imaging used in the diagnosis of inguinal hernias. METHODS: Patients who underwent elective inguinal hernia repair at a large academic health system in the U.S. from 2010 to 2017 were included. Within this cohort, we identified patients who received imaging 6 months prior to surgery. Through chart review of physical exam findings and imaging indications, we categorized patients into four imaging categories: unrelated, necessary, unnecessary, and borderline. Multivariable logistic regression analysis was used to identify factors associated with receipt of unnecessary imaging. RESULTS: Of 2162 patients who underwent inguinal hernia surgery, 249 patients had related imaging studies 6 months prior to surgery. 47.0% of patients received unnecessary imaging. 66.9% and 33.1% of unnecessary studies were ultrasounds and CT scans, respectively. 24.5% of patients had necessary studies, while 28.5% had studies with borderline indications. On multivariable analysis, having a BMI between 25.0 and 29.9 kg/m2 was associated with receipt of unnecessary studies. Primary care providers and ED physicians were more likely to order unnecessary imaging. CONCLUSIONS: Nearly 50% of all patients who receive any related imaging prior to surgery had potentially unnecessary diagnostic radiology studies. This not only exposes patients to avoidable risks, but also places a significant economic burden on patients and our already-strained health system.

Phone follow-up after inguinal hernia repair.

BACKGROUND: Typically, in-person follow-up in clinic is utilized after outpatient inguinal hernia repair. Studies have shown that phone follow-up may be successfully used for the detection of postoperative hernia recurrences. However, no studies have evaluated the detection rates of other postoperative complications, such as emergency department visits and readmissions, with the utilization of phone follow-up after inguinal hernia repair. The objective of our study was to investigate the safety of a phone follow-up care pathway following elective, outpatient inguinal hernia repair. METHODS: In this retrospective cohort study, adult patients who underwent elective, outpatient inguinal hernia repair between 2013 and 2019 at a large academic health system in the Midwest United States were identified from the electronic health record. Patients were categorized by type of postoperative follow-up: in-person or phone follow-up. Baseline demographics, operative, and postoperative data were compared between follow-up groups. Multivariable logistic regression was performed to investigate predictors of having any related emergency department (ED) visit/readmission/reoperation within 90 days. RESULTS: We included 2009 patients who underwent elective inguinal hernia repair during the study period. 321 patients had in-person follow-up only, while 1,688 patients had phone follow-up. There was a higher rate of laparoscopic repair in the phone follow-up group (85.4% vs. 53.0% for in-person follow-up). There were no differences in rates of related 90-day ED visits, readmissions, and reoperations between the phone and in-person follow-up groups. On multivariable logistic regression, receipt of phone follow-up was not a predictor of having 90-day ED visits, readmissions, or reoperations (OR 1.30, 95% CI [0.83, 2.05]). CONCLUSIONS: Patients who underwent phone follow-up had similarly low rates of adverse outcomes to those with in-person follow-up. Phone follow-up protocols may be implemented as an alternative for patients and provide a means to decrease healthcare utilization following inguinal hernia repair.

National Underutilization of Neoadjuvant Chemotherapy for Gastric Cancer.

BACKGROUND: Since the publication of the landmark MAGIC trial in 2006, neoadjuvant chemotherapy has become the standard of care for stage II/III gastric cancer. Nevertheless, many patients still do not begin their treatment with neoadjuvant chemotherapy. The objective of our study was to identify factors associated with underutilization of neoadjuvant chemotherapy for stage II/III gastric cancer. METHODS: Patients with pathological stage II and III primary gastric cancer between 2004 and 2015 were identified from the American College of Surgeons National Cancer Database. Patients who received neoadjuvant chemotherapy were compared with those who underwent surgery only or surgery followed by chemotherapy. Predictors of receipt of neoadjuvant chemotherapy were identified using multivariable logistic regression model. Median survival was calculated for each treatment strategy. RESULTS: We included 15,947 patients with pathological stage II/III gastric cancer. The proportion of patients receiving neoadjuvant chemotherapy increased from less than 5% before 2006 to 27.5% in 2015. On multivariable analysis, factors associated with no receipt of neoadjuvant therapy included treatment year before 2006 and age greater than 80. Treatment at high-volume centers, academic research programs, or integrated network cancer programs and undergoing total/subtotal or en bloc gastrectomy predicted receipt of neoadjuvant chemotherapy. CONCLUSIONS: Ten years after the publication of the MAGIC trial, fewer than 1/3 of patients with stage II/III gastric cancer are receiving neoadjuvant chemotherapy, which has been shown to improve disease-specific survival. Further studies are needed to understand these disparities and ensure both patients and providers are having evidence-based discussions about multimodal therapy for gastric cancer.

Weight Loss for Patients With Obesity: An Analysis of Long-Term Electronic Health Record Data.

BACKGROUND: Numerous studies have reported that losing as little as 5% of one's total body weight (TBW) can improve health, but no studies have used electronic health record data to examine long-term changes in weight, particularly for adults with severe obesity [body mass index (BMI) ≥35 kg/m]. OBJECTIVE: To measure long-term weight changes and examine their predictors for adults in a large academic health care system. RESEARCH DESIGN: Observational study. SUBJECTS: We included 59,816 patients aged 18-70 years who had at least 2 BMI measurements 5 years apart. Patients who were underweight, pregnant, diagnosed with cancer, or had undergone bariatric surgery were excluded. MEASURES: Over a 5-year period: (1) ≥5% TBW loss; (2) weight loss into a nonobese BMI category (BMI <30 kg/m); and (3) predictors of %TBW change via quantile regression. RESULTS: Of those with class 2 or 3 obesity, 24.2% and 27.8%, respectively, lost at least 5% TBW. Only 3.2% and 0.2% of patients with class 2 and 3 obesity, respectively, lost enough weight to attain a BMI <30 kg/m. In quantile regression, the median weight change for the population was a net gain of 2.5% TBW. CONCLUSIONS: Although adults with severe obesity were more likely to lose at least 5% TBW compared with overweight patients and patients with class 1 obesity, sufficient weight loss to attain a nonobese weight class was very uncommon. The pattern of ongoing weight gain found in our study population requires solutions at societal and health systems levels.

The MYC Oncogene Cooperates with Sterol-Regulated Element-Binding Protein to Regulate Lipogenesis Essential for Neoplastic Growth.

Lipid metabolism is frequently perturbed in cancers, but the underlying mechanism is unclear. We present comprehensive evidence that oncogene MYC, in collaboration with transcription factor sterol-regulated element-binding protein (SREBP1), regulates lipogenesis to promote tumorigenesis. We used human and mouse tumor-derived cell lines, tumor xenografts, and four conditional transgenic mouse models of MYC-induced tumors to show that MYC regulates lipogenesis genes, enzymes, and metabolites. We found that MYC induces SREBP1, and they collaborate to activate fatty acid (FA) synthesis and drive FA chain elongation from glucose and glutamine. Further, by employing desorption electrospray ionization mass spectrometry imaging (DESI-MSI), we observed in vivo lipidomic changes upon MYC induction across different cancers, for example, a global increase in glycerophosphoglycerols. After inhibition of FA synthesis, tumorigenesis was blocked, and tumors regressed in both xenograft and primary transgenic mouse models, revealing the vulnerability of MYC-induced tumors to the inhibition of lipogenesis.

30-Day Outcomes After Intraoperative Leak Testing for Bariatric Surgery Patients.

BACKGROUND: Intraoperative testing of anastomoses and staples lines is commonly performed to minimize the risk of postoperative leaks in bariatric surgery, but its impact is unclear. The aim of this study was to determine the association between leak testing and 30-d postoperative leak, bleed, reoperation, and readmission rates for patients undergoing laparoscopic sleeve gastrectomy (LSG) or Roux-en-Y gastric bypass (RYGB). METHODS: This is a retrospective observational study utilizing 2015-2016 data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. Postoperative outcomes were compared using χ2 test. Multivariable logistic regression was used to identify factors associated with 30-d outcomes. RESULTS: We included 237,081 patients. Leak testing was performed on 73.0% and 92.1% of LSG and RYGB patients, respectively. LSG was associated with lower rates of leak, bleed, reoperation, and readmission than RYGB. On multivariable analysis, intraoperative leak testing was associated with increased rates of postoperative leak for LSG and RYGB (OR 1.48 and 1.90, respectively) and lower rates of bleed for LSG (OR 0.76). There were no significant associations between leak testing and rates of reoperation or readmission. CONCLUSIONS: Use of intraoperative leak testing was not associated with improved outcomes for either LSG or RYGB. A prospective trial investigating leak testing is warranted to better elucidate its impact.