Impact of electronic medical record utilization on obesity screening and intervention for obese patients with endometrial cancer

OBJECTIVE

To identify the prevalence of obesity documented within the electronic medical record problem list.

METHODS

We conducted a retrospective cohort study of adult patients with obesity and endometrial cancer receiving care from January 2018 to March 2021 at a single institution. Obesity intervention was defined as receipt of at least one of the following: referral to weight loss clinic, referral to a nutritionist, completion of obesity intervention tab, or documentation of weight loss counseling. Our secondary objectives were to (1) identify the prevalence of completed obesity interventions, (2) identify the number of patients who have achieved weight loss since their initial visit, and (3) identify covariates associated with presence of obesity on problem list, completion of obesity interventions, and weight loss.

RESULTS

We identified 372 patients who met inclusion criteria. Of eligible patients, 202 (54%) had obesity documented on their problem list and 171 (46%) completed at least one obesity intervention. Within our cohort, 195 (52%) patients achieved weight loss from diagnosis or initial clinical encounter at our institution to most recent clinical encounter with median weight loss of 3.9 kg (IQR 1.5-8.0). In the multivariable logistic regressions, patients with obesity on the problem list were approximately twice as likely to have completion of obesity intervention (OR 1.91, 95% CI 1.09, 3.35, p=0.024). Although presence of obesity on the problem list was not associated with weight loss, completion of health maintenance obesity intervention tab in the electronic medical record (Epic) was associated with weight loss (OR 2.77, 95% CI 1.11, 6.89, p=0.03).

CONCLUSIONS

Only half of obese endometrial cancer patients had documentation of obesity within the electronic medical record problem list. The electronic medical record could be leveraged to achieve compliance with weight loss interventions. Further investigation on how the electronic medical record can be optimized to help patients achieve weight loss is needed.

Development and Validation of a Model to Predict Postdischarge Opioid Use After Cesarean Birth

A model with three predictors readily found in the electronic health record—inpatient opioid use, tobacco use, and depression or anxiety—accurately estimated postdischarge opioid use.

OBJECTIVE:

To develop and validate a prediction model for postdischarge opioid use in patients undergoing cesarean birth.

METHODS:

We conducted a prospective cohort study of patients undergoing cesarean birth. Patients were enrolled postoperatively, and they completed pain and opioid use questionnaires 14 days after cesarean birth. Clinical data were abstracted from the electronic health record (EHR). Participants were prescribed 30 tablets of hydrocodone 5 mg–acetaminophen 325 mg at discharge and were queried about postdischarge opioid use. The primary outcome was total morphine milligram equivalents used. We constructed three proportional odds predictive models of postdischarge opioid use: a full model with 34 predictors available before hospital discharge, an EHR model that excluded questionnaire data, and a reduced model. The reduced model used forward selection to sequentially add predictors until 90% of the full model performance was achieved. Predictors were ranked a priori based on data from the literature and prior research. Predictive accuracy was estimated using discrimination (concordance index).

RESULTS:

Between 2019 and 2020, 459 participants were enrolled and 279 filled the standardized study prescription. Of the 398 with outcome measurements, participants used a median of eight tablets (interquartile range 1–18 tablets) after discharge, 23.5% used no opioids, and 23.0% used all opioids. Each of the models demonstrated high accuracy predicting postdischarge opioid use (concordance index range 0.74–0.76 for all models). We selected the reduced model as our final model given its similar model performance with the fewest number of predictors, all obtained from the EHR (inpatient opioid use, tobacco use, and depression or anxiety).

CONCLUSION:

A model with three predictors readily found in the EHR—inpatient opioid use, tobacco use, and depression or anxiety—accurately estimated postdischarge opioid use. This represents an opportunity for individualizing opioid prescriptions after cesarean birth.

Developmental 2,3,7,8-tetrachlorodibenzo-p-dioxin exposure of either parent enhances the risk of necrotizing enterocolitis in neonatal mice

BACKGROUND

Necrotizing enterocolitis (NEC) is a rare, but potentially fatal intestinal inflammatory condition most often arising in premature infants. Infants provided formula are also at greater risk of developing this disease. Although the majority of formula-fed, preterm infants do not develop NEC, up to 30% of infants with the disease do not survive. Thus, identifying additional, currently unrecognized factors, which may predispose a specific infant to NEC development would be a significant clinical advancement. In this regard, we have previously reported that offspring of female or male mice with a history of developmental exposure to the environmental toxicant 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) exhibit altered sensitivity to inflammatory challenges and are frequently born premature. Herein, we examined the possibility that, compared to unexposed mice (F1_NONE ), developmental TCDD exposure of either parent (maternal, F1M_TCDD , or paternal, F1P_TCDD ) would enhance the risk of NEC in offspring (F2_TCDD mice) in association with supplemental formula feeding.

METHODS

Beginning on postnatal day 7, all neonates were randomized to maternal milk only or maternal milk with up to 20 supplemental formula feedings. All pups remained with the Dams and were additionally allowed to nurse ad libitum.

RESULTS

Formula-fed F2_NONE pups rarely developed NEC while this disease was common in formula-fed F2M_TCDD and F2P_TCDD mice. Unexpectedly, 50% of F2M_TCDD pups that were not provided supplemental formula also developed NEC.

CONCLUSIONS

Our studies provide evidence that a history of parental TCDD exposure enhances the risk of NEC in offspring and suggest exposure to environmental immunotoxicants such as TCDD may also contribute to this inflammatory disease in humans.

Paternal developmental toxicant exposure is associated with epigenetic modulation of sperm and placental Pgr and Igf2 in a mouse model

Preterm birth (PTB), parturition prior to 37 weeks' gestation, is the leading cause of neonatal mortality. The causes of spontaneous PTB are poorly understood; however, recent studies suggest that this condition may arise as a consequence of the parental fetal environment. Specifically, we previously demonstrated that developmental exposure of male mice (F1 animals) to the environmental endocrine disruptor 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) was associated with reduced sperm quantity/quality in adulthood and control female partners frequently delivered preterm. Reproductive defects persisted in the F2 and F3 descendants, and spontaneous PTB was common. Reproductive changes in the F3 males, the first generation without direct TCDD exposure, suggest the occurrence of epigenetic alterations in the sperm, which have the potential to impact placental development. Herein, we conducted an epigenetic microarray analysis of control and F1 male-derived placentae, which identified 2171 differentially methylated regions, including the progesterone receptor (Pgr) and insulin-like growth factor (Igf2). To assess if Pgr and Igf2 DNA methylation changes were present in sperm and persist in future generations, we assessed methylation and expression of these genes in F1/F3 sperm and F3-derived placentae. Although alterations in methylation and gene expression were observed, in most tissues, only Pgr reached statistical significance. Despite the modest gene expression changes in Igf2, offspring of F1 and F3 males consistently exhibited IUGR. Taken together, our data indicate that paternal developmental TCDD exposure is associated with transgenerational placental dysfunction, suggesting epigenetic modifications within the sperm have occurred. An evaluation of additional genes and alternative epigenetic mechanisms is warranted.

Engaging Medical Students in Leadership Development

Leadership development plays a critical role in preparing collaborative, systems-based physicians. Medical schools across the globe have dedicated significant effort towards programming for medical student leadership development. Students report a variety of existing leadership opportunities, ranging from formal didactics to leadership positions within the community. Students identify lack of time, funding, and the hierarchy of medicine as significant barriers for engaging in leadership opportunities. Students favor a formal leadership curriculum coupled with hands-on opportunities to practice leadership skills. In order to train medical students to be engaged physician leaders, it is imperative to foster practical opportunities for leadership development.

Engaging Medical Students in Leadership Development

Leadership development plays a critical role in preparing collaborative, systems-based physicians. Medical schools across the globe have dedicated significant effort towards programming for medical student leadership development. Students report a variety of existing leadership opportunities, ranging from formal didactics to leadership positions within the community. Students identify lack of time, funding, and the hierarchy of medicine as significant barriers for engaging in leadership opportunities. Students favor a formal leadership curriculum coupled with hands-on opportunities to practice leadership skills. In order to train medical students to be engaged physician leaders, it is imperative to foster practical opportunities for leadership development.

Paternal Environmental Toxicant Exposure and Risk of Adverse Pregnancy Outcomes

Purpose of Review

Current clinical efforts to predict and prevent preterm birth are primarily focused on the mother and have made minimal progress in improving outcomes. However, recent data indicate that paternal factors can also influence timing of birth. Herein, we will review recent human and murine data examining the contribution of the father to pregnancy outcomes with an emphasis on environmental exposures that can negatively impact fertility and the timing of birth.

Recent Findings

Human epidemiology studies now clearly indicate that a variety of paternal factors (age, race, weight, smoking status) can influence sperm quality, birth timing and, in some studies, offspring health. Utilizing a mouse model, our data have 57demonstrated that developmental exposure to the environmental toxicant TCDD (2,3,7,8-tetrachlorodibenzo-p-dioxin) is associated with a transgenerational reduction in sperm number and quality and an increased risk of preterm birth in an unexposed partner.

Summary

Toxicant exposure history can clearly influence sperm quality in men and mice. Murine data further indicate that exposures which negatively affect sperm quality also impair placental function, potentially leading to preterm birth and other adverse outcomes. Of particular concern, these changes have been linked to epigenetic alterations within the male germ cell which can then be transmitted across multiple generations. Since it is not possible to prevent an ancestral toxicant exposure in a human population, identifying lifestyle modifications that can be implemented during the preconception period to improve sperm quality should be explored for the therapeutic potential to reduce the incidence of PTB and its sequelae.

A Student-Led National Conference on Leadership: Broadening the Medical Student Role

This article was migrated. The article was marked as recommended. Students have traditionally held a singular role in medical education - the learner. This narrow view neglects students unique perspective and ability to shape the future of medical education. In recognizing the need for deliberate leadership skill development and networking opportunities for medical student leaders, the American Medical Association (AMA) supported the first AMA Accelerating Change in Medical Education Student-Led Conference on Leadership in Medical Education. A planning committee of 19 students from seven medical schools collaborated to develop this conference, which took place on August 4-5, 2017 at the University of Michigan, Ann Arbor. The primary goal of the conference was for students to learn about leadership skills, connect with other student leaders, feel empowered to lead change, and continue to lead from their roles as students. Attendees participated in a variety of workshops and presentations focused on developing practical leadership skills. In addition, students formed multi-institutional teams to participate on in the MedEd Impact Challenge, attempting to address issues in medical education such as leadership curriculum development, wellness, and culture change. Post-conference surveys showed an overwhelming majority of students connected with other student leaders, shared ideas, developed collaborations, and felt empowered to enact change. Looking forward, we believe that similar student-led conferences focused on broadening the medical student role would provide avenues for positive change in medical education.

Rodent Models of Experimental Endometriosis: Identifying Mechanisms of Disease and Therapeutic Targets

BACKGROUND

Although it has been more than a century since endometriosis was initially described in the literature, understanding the etiology and natural history of the disease has been challenging. However, the broad utility of murine and rat models of experimental endometriosis has enabled the elucidation of a number of potentially targetable processes which may otherwise promote this disease.

OBJECTIVE

To review a variety of studies utilizing rodent models of endometriosis to illustrate their utility in examining mechanisms associated with development and progression of this disease.

RESULTS

Use of rodent models of endometriosis has provided a much broader understanding of the risk factors for the initial development of endometriosis, the cellular pathology of the disease and the identification of potential therapeutic targets.

CONCLUSION

Although there are limitations with any animal model, the variety of experimental endometriosis models that have been developed has enabled investigation into numerous aspects of this disease. Thanks to these models, our under-standing of the early processes of disease development, the role of steroid responsiveness, inflammatory processes and the peritoneal environment has been advanced. More recent models have begun to shed light on how epigenetic alterations con-tribute to the molecular basis of this disease as well as the multiple comorbidities which plague many patients. Continued de-velopments of animal models which aid in unraveling the mechanisms of endometriosis development provide the best oppor-tunity to identify therapeutic strategies to prevent or regress this enigmatic disease.

Postpartum Depressive Symptoms: Gestational Weight Gain as a Risk Factor for Adolescents Who Are Overweight or Obese

INTRODUCTION

Obesity is a risk factor for adverse physical health outcomes during pregnancy. Much less is known about the association between obesity and maternal mental health. Evidence suggests that prenatal depression is associated with excessive weight gain during pregnancy and that this relationship may vary according to pregravid body mass index (BMI). Young women may be particularly vulnerable to postpartum depression. The objective of this study is to examine the association between prepregnancy BMI, gestational weight gain, and postpartum depressive symptoms among adolescents.

METHODS

Participants were 505 pregnant adolescents aged 14 to 21 years followed during pregnancy and 6 months postpartum. Data were collected via interviews and medical record abstraction. Multilevel linear mixed models were used to test the association between excessive gestational weight gain as defined by National Academy of Medicine Guidelines and postpartum depressive symptoms measured via the validated Center for Epidemiologic Studies Depression (CES-D) scale. Analyses controlled for sociodemographic factors (maternal age, race, ethnicity, relationship status), health behaviors (nutrition, physical activity), prenatal depressive symptoms, and postpartum weight retention.

RESULTS

Prepregnancy BMI was classified as follows: 11% underweight, 53% healthy weight, 19% overweight, and 18% obese. One-half (50%) of participants exceeded recommended guidelines for gestational weight gain. Adolescents with excessive gestational weight gain who entered pregnancy overweight or obese had significantly higher postpartum depressive symptoms (β, 2.41; SE, 1.06 vs β, 2.58; SE, 1.08, respectively; both P < .05) compared with those with healthy prepregnancy BMI and appropriate gestational weight gain. Adolescents who gained gestational weight within clinically recommended guidelines were not at risk for increased depressive symptoms.

DISCUSSION

Adolescents who enter pregnancy overweight or obese and experience excessive weight gain may be at increased risk for postpartum depressive symptoms. Health care providers should offer preventive interventions during pregnancy and the interconceptional period to support healthy weight gain and safeguard women's mental health.

Therapeutically Targeting the Inflammasome Product in a Chimeric Model of Endometriosis-Related Surgical Adhesions

Development of adhesions commonly occurs in association with surgery for endometriosis. Even in the absence of surgery, women with endometriosis appear to be at an enhanced risk of developing adhesions. In the current study, we utilized a chimeric mouse model of experimental endometriosis in order to examine the role of inflammasome activation in the development of postsurgical adhesions. Mice were randomized to receive peritoneal injections of human endometrial tissue fragments or endometrial tissue conditioned media (CM) from women with or without endometriosis 16 hours after ovariectomy and placement of an estradiol-releasing silastic capsule. A subset of mice receiving CM was also treated with interleukin (IL) 1 receptor antagonist (IL-1ra). Our studies demonstrate that peritoneal injection of endometrial tissue fragments near the time of surgery resulted in extensive adhesive disease regardless of tissue origin. However, adhesion scores were significantly higher in mice receiving CM from tissues acquired from patients with endometriosis compared to control tissue CM ( P = .0001). Cytokine bead array analysis of endometrial CM revealed enhanced expression of IL-1β from patients with endometriosis compared to controls ( P < .01). Finally, the ability of human tissue CM to promote adhesive disease was dramatically reduced in mice cotreated with IL-1ra ( P < .0001). Our data implicate enhanced expression of IL-1β in women with endometriosis as a potential causal factor in their increased susceptibility of developing postsurgical adhesions. Thus, targeting inflammasome activation may be an effective strategy for the prevention of surgical adhesions in patients with endometriosis.

Integrin-Linked Kinase in Muscle Is Necessary for the Development of Insulin Resistance in Diet-Induced Obese Mice

Diet-induced muscle insulin resistance is associated with expansion of extracellular matrix (ECM) components, such as collagens, and the expression of collagen-binding integrin, α2β1. Integrins transduce signals from ECM via their cytoplasmic domains, which bind to intracellular integrin-binding proteins. The integrin-linked kinase (ILK)-PINCH-parvin (IPP) complex interacts with the cytoplasmic domain of β-integrin subunits and is critical for integrin signaling. In this study we defined the role of ILK, a key component of the IPP complex, in diet-induced muscle insulin resistance. Wild-type (ILK(lox/lox)) and muscle-specific ILK-deficient (ILK(lox/lox)HSAcre) mice were fed chow or a high-fat (HF) diet for 16 weeks. Body weight was not different between ILK(lox/lox) and ILK(lox/lox)HSAcre mice. However, HF-fed ILK(lox/lox)HSAcre mice had improved muscle insulin sensitivity relative to HF-fed ILK(lox/lox) mice, as shown by increased rates of glucose infusion, glucose disappearance, and muscle glucose uptake during a hyperinsulinemic-euglycemic clamp. Improved muscle insulin action in the HF-fed ILK(lox/lox)HSAcre mice was associated with increased insulin-stimulated phosphorylation of Akt and increased muscle capillarization. These results suggest that ILK expression in muscle is a critical component of diet-induced insulin resistance, which possibly acts by impairing insulin signaling and insulin perfusion through capillaries.

Heterozygous SOD2 deletion impairs glucose-stimulated insulin secretion, but not insulin action, in high-fat-fed mice

Elevated reactive oxygen species (ROS) are linked to insulin resistance and islet dysfunction. Manganese superoxide dismutase (SOD2) is a primary defense against mitochondrial oxidative stress. To test the hypothesis that heterozygous SOD2 deletion impairs glucose-stimulated insulin secretion (GSIS) and insulin action, wild-type (sod2(+/+)) and heterozygous knockout mice (sod2(+/-)) were fed a chow or high-fat (HF) diet, which accelerates ROS production. Hyperglycemic (HG) and hyperinsulinemic-euglycemic (HI) clamps were performed to assess GSIS and insulin action in vivo. GSIS during HG clamps was equal in chow-fed sod2(+/-) and sod2(+/+) but was markedly decreased in HF-fed sod2(+/-). Remarkably, this impairment was not paralleled by reduced HG glucose infusion rate (GIR). Decreased GSIS in HF-fed sod2(+/-) was associated with increased ROS, such as superoxide ion. Surprisingly, insulin action determined by HI clamps did not differ between sod2(+/-) and sod2(+/+) of either diet. Since insulin action was unaffected, we hypothesized that the unchanged HG GIR in HF-fed sod2(+/-) was due to increased glucose effectiveness. Increased GLUT-1, hexokinase II, and phospho-AMPK protein in muscle of HF-fed sod2(+/-) support this hypothesis. We conclude that heterozygous SOD2 deletion in mice, a model that mimics SOD2 changes observed in diabetic humans, impairs GSIS in HF-fed mice without affecting insulin action.

Beta-Cell sparing in transplanted islets by vascular endothelial growth factor

We have reported that vascular endothelial growth factor (VEGF) promotes the revascularization of transplanted islets, thereby reducing the initial number required to prevent diabetes. The present study was undertaken to assess other mechanisms of beta-cell sparing by VEGF. For in vitro studies, islets were cultured for 14 days with versus without 20 ng/mL VEGF. Viability, necrosis, and apoptosis were examined by specific staining (Alcein AM, propidium iodide, and annexin/phosphatidylserine). The effects of VEGF on islets were also examined in a proteomic study. In vivo streptozotocin-treated diabetic Lewis rats received 1000 Lewis or Sprague-Dawley islets beneath the renal capsule. Oxygen levels at the transplant site were monitored by a Clark-type oxygen electrode. Fasting blood glucose served as an indicator of islet survival and function. VEGF enhanced oxygen levels at the transplant site. Syngeneic recipients were euglycemic for over 6 months, whereas control islets failed within 30 to 60 days. VEGF prevented allograft rejection for over 14 days, whereas controls were rejected within 6 to 7 days. Immunostaining suggested that VEGF inhibited the presentation of MHC II antigen and promoted islet survival by the inhibition of necrosis and apoptosis. Our proteomic study suggested VEGF preserved systems required for cellular preservation (heat shock proteins) and insulin secretion. VEGF promotes the preservation of isolated and transplanted islets by a variety of mechanisms, including enhanced oxygenation and inhibition of immune rejection, necrosis, and apoptosis. The provision of exogenous VEGF may be a useful adjunct to islet transplantation.

Alterations in upper gastrointestinal motility in Helicobacter pylori-positive nonulcer dyspepsia

OBJECTIVE

To study the association between gastrointestinal motility and Helicobacter pylori (HP) among patients with nonulcer dyspepsia (NUD).

METHODS

We examined the gastric emptying and orocecal transit times (OCTT) in patients with NUD who were colonized with Helicobacter pylori (n = 27). NUD was defined as dyspeptic symptoms for at least 3 months in the absence of gastrointestinal pathology as seen on endoscopy and ultrasound. Subjects with diabetes mellitus, thyroid disorder, or abdominal surgery except appendectomy were excluded. The HP-negative patients with NUD (n = 38) served as controls. Solid phase gastric emptying was assessed by radionuclide scintigraphy. OCTT was determined by measuring exhaled breath hydrogen upon administration of lactulose.

RESULTS

The two groups were similar with respect to age, sex, race, and history of smoking. Gastric emptying (t1/2) was 64.96 +/- 3.61 min in the HP-negative and 61.0 +/- 6.59 in the HP-positive group (p = NS). The OCTT was 130.9 +/- 17.26 minutes in the HP-negative and 84.28 +/- 11.07 in the HP-positive group (p = 0.03). There was no difference in the prevalence of nonhydrogen producers between the two groups. There was no correlation between gastric emptying and OCTT (p > 0.05).

CONCLUSIONS

OCTT is faster among HP-positive patients with NUD than among HP-negative patients. However, gastric emptying is similar in the two groups.

Thyroid disease in the elderly

Thyroid disease in the aged, both hypothyroidism and hyperthyroidism, may be subtle or may be present with no clinical symptoms and signs, and is therefore difficult to diagnose on the basis of clinical evaluation. The help of the laboratory is essential in making the diagnosis of disease of the thyroid. Therapeutic strategies are different in the aged than in the younger adult with thyroid disease. It is essential for geriatricians, and all clinicians who care for the elderly, to have a solid understanding of thyroid function and dysfunctions in this group of patients so that they diagnose diseases of the thyroid correctly and treat them appropriately.

Congenital adrenal hyperplasia diagnosed in a man during workup for bilateral adrenal masses

We studied an asymptomatic 55-year-old man who was found to have markedly enlarged adrenal glands on an abdominal computed tomographic scan and was scheduled to have adrenal biopsy because of suspicious findings on an adrenal magnetic resonance image. However, hormonal studies revealed congenital adrenal hyperplasia due to 21-hydroxylase deficiency. Treatment with dexamethasone decreased the size of the adrenal glands. This is, we believe, the first report of congenital adrenal hyperplasia in an adult, diagnosed during the evaluation of an incidental adrenal lesion. Although congenital adrenal hyperplasia can present with varying severity and remain undiagnosed into adulthood, it is usually not considered in the evaluation of asymptomatic adult adrenal masses. We emphasize the need for proper hormonal studies in the evaluation of incidental adrenal lesions.

Heat stress of cultured GC cells enhances triiodothyronine-induced growth hormone production by action within the 5'-flanking region of the rat growth hormone gene

We studied the effect of incubation at 41 C on a clone of GC cells that had previously been stably transfected with a gene construct, pGHXGPT, containing -1800 to +8 of the rat growth hormone promoter fused to the structural gene for E. Coli xanthine guanine phosphoribosyl-transferase. The effect of incubation of the clone containing pGHXGPT at 41 C was to enhance triiodothyronine induction of growth hormone secretion (2-fold, p < 0.01) and of xanthine quanine phosphoribosyl-transferase activity (3-fold, p < 0.01). We conclude that the increase in triiodothyronine-induced growth hormone production during heat stress occurs by stimulation of the growth hormone promoter.