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Ahmad Yehya Transcript

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Dr. Yehya: My name is Ahmad Yehya. I’m currently a second-year internal medicine resident at the University of Kansas, the medical center in Kansas City, Kansas state.

Steve Freed: So, you’re here with two posters. Maybe you can start with one of the posters and explain to us the background, why you even got involved in that particular poster, what you found out from that poster, what the statement is in that poster?

Dr. Yehya: So, my first poster is under the category of obesity. It’s based on the studies that have been made for the past 10 years showing that bariatric surgery does improve outcome in certain patient populations, specifically patients with BMI between 35 and 40. BMI stands for Body Mass Index, which is a ratio of your weight over the square of your height. The unit is kg per meters squared. Patients who have BMI between 35 and 40, if they have hypertension, diabetes, sleep apnea, and/or hyperlipidemia, they benefit from bariatric surgery. We talk about what are the benefits and other type of patients are those with BMI above than or equal to 40, regardless of whether they have any other comorbidity. I cited a study done by Burkwald in 2004 that showed a significant improvement in outcome, which is a resolution of these comorbidities, i.e. the diabetes, the hyperlipidemia, the hypertension, and the sleep apnea, and those undergoing bariatric surgery, we’re talking about the percentage which exceeds 70%. At least 90% if they don’t have total resolution of these comorbidities, they have improvement in outcome. That means their blood pressure improves, less blood pressure medication is needed. Their diabetes or their A1C improves and thereby some people who were on insulin, they got off insulin, whether it being off totally and medication or taking oral medications which can sometimes be into one medication. Sleep apnea was one of the entities which was mostly associated with total resolution. We know that the resolution of sleep apnea can be really helpful for a patient, his lifestyle’s going to improve. His cardiovascular mortality is going to improve, because we all know that sleep apnea is a definite risk factor for heart disease. That’s improvement in cholesterol levels and reduction in the need of statin, or even needing the statin, which is the lipid lowering medication in the first place. Then, the last thing, is improvement in the weight, obviously after this kind of surgery, which is a risk factor for heart disease. So, based on these studies and especially the Burkwald study, we decided to see if, specifically, primary care physicians are aware of these guidelines, or are they screening their patients for bariatric surgery, depending on these guidelines. We focus our study on the year of 2014 only. We asked our database called HERON database at the University of Kansas, to supply us obese patients which satisfied these guidelines. Then we applied our data through another database which has the statistics, it’s called REDCap. We came with different statistical analyses and results. It also showed that screening is not adequate to talk about percentages. So about 3% of patients with BMI above 40 are actually screened for bariatric surgery. This percentage is between 15 and 20% for patients between BMI 35 and 40 with these comorbidities. Then we looked specifically in primary care, because they are the doctors who actually see the patients in front before they refer them for specialties or refer them for surgery. Then, so we look at the internal medicine doctors and screening for internal medicine doctors is also not adequate. It’s about 15.8% and down to 3.7% by family doctors. With a total of about 18%. It’s obvious that we’re not adequately screening. If you look specifically at the comorbidities, to see if there is a comorbidity that entitles more screening, it’s still not affective. So, 3% for both hypertension, hyperlipidemia, even diabetes. Up to 10% screenings associated with sleep apnea, but still not adequate. After which we went to the demographic factors, to see if they play a role in actually making the primary care doctor decide to screen or not. Obviously, females are the ones who are most adequately screened, around 66%. Now, why, factors are probably self-image. Females are more likely to seek improvement in outcome and cosmetic improvement is also one of the reasons to seek bariatric surgery and they ask about it. Caucasians are also more likely to be screened. At least 3/4 of the patients screened were Caucasians, also being more aware, being more compliant is an issue. Then there is a very important factor, playing a role, is financial reasons, and specifically insurance. The better your insurance, the more likely you’re going to be screened, the more likely you’re going to get the surgery afterwards. Usually middle aged people are the ones that are screened, 58 years of age. That’s obvious because the older you get the more likely the surgery is going to be more detrimental than helpful. They already are more likely to benefit from lifestyle modifications. The bottom line from all of that I’m saying is we are not doing a good job. We’re not. We are probably mostly primary care physicians, because they are the ones that receive patients first. The next step is actually we are going to create a questionnaire at the University of Kansas. We’re going to ask primary care physicians, what they know about the guidelines for screening and get these answers and educate them about these studies, especially the Burkwald study and our results and then create a post-questionnaire to see if they now know who needed to be screened. The other thing that we’re pushing for is to have as part of a primary care visit, have a health maintenance tab which prompts the doctor to screen for bariatric surgery in these specific patients. Some really like screening for colon cancer or breast cancer, that’s why we’re talking with our EMR people to try to do that. That’s what’s going on from that perspective, with my first project. Do you want to know about my second project also?

Steve Freed: No, a couple questions come to mind first. What was the percentage of people that actually qualify for bariatric surgery?

Dr. Yehya: This study includes patients included in the EMR, which is a couple thousand to now. But since we limited our data to 2014, still we are talking about at least 10,000 patients being a candidate for screening for bariatric surgery.

Steve Freed: How many patients?

Dr. Yehya: Out of a total of 45 to 46 thousand patients.

Steve Freed: So, that’s about 25 to 28% of people that qualify. So, you have 28% of the people that qualify, about 10,000 people. How many people actually got bariatric surgery?

Dr. Yehya: So, 16.5% were screened, and out of these were probably 40 to 50%.

Steve Freed: So, 50% of the people who qualified did not get the surgery?

Dr. Yehya: No, so 16% out of these patients were screened. Now who qualified, I’m saying that 10,000 are in the screening guidelines. They fit in the screening guidelines. It does not mean that they need to get it.  It means they qualify. Then, this is going to be followed by having a multidisciplinary team which includes the surgeon and the phrenologist, the dietitian, the weight loss specialist, the social worker, the psychiatrist, talking about the post procedure issues which are probably more important than the pre-procedure issues. The number that is screened is very minimum. Out of this small number that is screened, around 40-50% actually underwent the surgery.

Steve Freed: Why is that? Because the physicians are not explaining it properly?

Dr. Yehya: So, you are asking why is the percentage low? Or why other people who were screened only 50% went to surgery?

Steve Freed: Why basically they were screened, they were candidates and they didn’t get it done? Obviously for many reasons.

Dr. Yehya: Yeah, as I said there is a multidisciplinary team. So, they might be a good medical candidate. It’s a surgery, it’s a risky procedure. So, you can be a good candidate for the surgery medically, but let’s say you’re not compliant with medications, you’ve never demonstrated understanding of your condition. That’s something that’s assessed by mental health and the social worker. For financial reasons also, insurance issues going on. Lack of interest from the patient is also an important issue. Probably the surgeon thought that something’s going on that we cannot do the surgery right now. He wanted to wait. Smoking, alcohol, drugs, it delays any kind of surgery, not only bariatric surgery. So, these are the factors that can and will play a role. I have to emphasize the psycho-social aspect. This patient’s after the surgery, they have a special diet, medications, vitamins, which are also very important, because otherwise they can gain back the weight, they can have complications from not taking the vitamins. So, it’s a long-term protocol that they need to follow. They need to demonstrate prior to the procedure that they’re going to be good candidates for that.

Steve Freed: I’m sure you’ve heard that many of the patients return to close to their original weight, even after surgery. What is the reason for and do we know why that is. That’s such a big expense and aim and everything that goes with it. Yet they start to gain the weight back. Obviously, we have to understand that so we can prevent it. What have you discovered in that area?

Dr. Yehya: We did not look at the post-procedure complications. But, that’s common as you said. The outcome from this procedure to gain back the weight. I’ll tell you, a lot of stuff is going on from that perspective, trying to identify the factors that can contribute. Start with, that’s why you have a multidisciplinary team. If this patient is not going to be compliant with this diet, then he’s going to gain back the weight. If he’s still going to eat the same way he did and he’s not going to exercise, he’s going to gain back a lot of that weight. So that’s the first thing. We need to make sure, like some transplant candidates, you have to make sure this patient is a good candidate medically, mentally, and psycho-socially for this kind of procedure. Ultimately not to gain back the weight, then more medical issue can play a role. Type of the procedure, that’s something surgical but let’s say there are different types of bariatric surgery, not only one type. Older ones including the banding and the sleeve gastrectomies. The newer ones, which are more likely to be done now, including the diversion procedure and the modified Roux-en-Y procedure, which is the highest number of patients get the Roux-en-Y. Which is the one associated with slowest weight gain and the least risk to gain back weight. But regardless of the type of procedure, if you go back to your original lifestyle, you’re going to gain back most of that weight. That’s what we are going to try to prevent. And then there is the issue of comorbid illnesses that have not been identified. I don’t want to just say medical jargon, but patients with Cushing’s disease, it’s a common entity causing weight gain. If they are not identified prior to the procedure, then the thing that caused them to have the weight is still there. So, you’re going to gain the weight, no matter how focused you’re going to be on your diet. So, the medical illness is still there, in addition to other illnesses that can cause you to have weight gain, uncontrolled hypothyroidism, if you’re not having adequate replacement also that can contribute. Familial problems of weight gain that have not been identified, which are rare or less likely but still can happen. Mostly I would say is the psycho-social aspect and lack of follow-up and compliance after the procedure.

Steve Freed: So, it’s really the lack of after the surgery, the lacking of some education. I can’t believe somebody would go through all that and gain the weight back, especially within the first 10 years. As time goes on, you’re not going to be able to follow all of the same guidelines for a number issues. So, I think if we know that, we can certainly work on it. Do you have any experience? Because you mentioned the sleeve and we’ve got balloons. We have all these things. Is there anything that comes to mind from your knowledge that you think might be less-invasive and more effective?

Dr. Yehya: So, all of these procedures are invasive. Now gastric banding, which is probably one of the earlier ones is associated with less post-op complications. However, the fat from this kind of surgery is less. Studies have been to show which is most effective in these medical illnesses, hypertension, hyperlipidemia, sleep apnea, and diabetes. It has been shown that the more effective ones are the modified Roux-en-y and the pancreatic, a diversion procedure which is one of the more advanced ones. The more invasive you are, the more post-op complications you’re going to have, but the more effective it will be on your weight and the less risk to gain back the weight. Even these new procedures they have been modified, what’s called modified roux-en-y, they have been studied more, better techniques, more skills by the surgeon by the high volume of patients that he’s performing these surgeries for. Nowadays, you can go for this modified roux-en-y and then just leave the next day, it’s like having an appendix or your gall bladder removed. I think these procedures come with the risks. It’s a surgery. However, they’re acceptable if the patient is a good candidate upon a decision made by this multidisciplinary team for this kind of a procedure.

Steve Freed: Something like the sleeve, that there’s no open surgery, it’s put in through the esophagus. Do you have any experience with that where you insert the sleeve into the intestines?

Dr. Yehya: No.

Steve Freed: It hasn’t been approved yet, but it’s new.

Dr. Yehya: We don’t. It’s still an open procedure, or laparoscopic procedure. The sleeve, it’s still a part of gastrectomy so we have to cut part of the stomach and thereby you think how much calories you’re going to absorb. It’s an effective procedure, however a lot of complications happen afterwards. It’s still a procedure where you have to have general anesthesia and you’re going to have a laparoscope or an open surgery depending on the surgeon’s decision.

Steve Freed: What was your other poster on. Give us a short resume on it, a brief…

Dr. Yehya: My other poster is a just a case report but it can be generalized. It’s titled PTHrP induced hyperglycemia and response to tyrosine kinase inhibitors. So basically, we have a patient, 67-year-old guy, who’s come in with abdominal pain, nausea, and vomiting. He saw his primary care physician, did some blood work, and showed that his calcium was high. So, he was referred to an endocrinologist at my institution, the University of Kansas. This endocrinologist did some more blood work, which was normal except for PTHrP or Parathyroid hormone-related peptide that was elevated. Now we know PTHrP is high as paraneoplastic feature which means there is an underlying cancer. So, this patient underwent afterwards a CAT scan of his chest, abdomen and pelvis. It came back that he had cancer in his kidneys, both of his kidneys, and his lung was involved. So, it’s stage 4 cancer. He was referred to a cancer doctor, an oncologist. He was started on a tyrosine kinase inhibitor. It’s a familiar drug, one of the new ones called Sunitinib. Now the interesting thing is after being on this drug, his PTHrP normalizes calcium, and his kidneys which were infected by the cancer, now are back to its normal function and his kidney cancer is localized. It’s not progressive anymore, which means, and I’ve included in my poster. The PTHrP is a gene. It encodes normal cellular functions, it’s not only in expressing cancer. PTHrP shows similar function as the parathyroid hormone the PTH that we know of, which includes calcium hemostasis, calcium absorption at the level of the kidneys, at the level of the intestines, calcium metabolism in the bone. Due to a mutation, involving the PTHrP, like other mutations in cancer, this protein PTHrP is over expressed. It’s over expressed in addition to its role in calcium hemostasis, it has other normal roles, including cellular growth, cellular death, invasion of the blood vessels, even cardiac regulation. So, when it’s over-expressed, as you can imagine, like in any other involving cancer, PTHrP is causing more cells to divide.  They’re not dying anymore, they’re invading, and in other words it’s causing the cancer. Thereby tyrosine kinase inhibitors, from its actions, probably targeting the PTHrP, this gene, and thereby halting the progression, or halting this gene from being overly expressed, and thereby causing the cancer to be sustained. So, our intentions for the future is developing research, conducting clinical trials, to have drugs that specifically target PTHrP and thereby targeting the effects of PTHrP, including calcium normalization, kidney function normalization. You know having good, normal calcium metabolism, but in addition, the overall picture, to stop the progression of the cancer and thereby being a good chemotherapy agent in targeting cancers that are associated with over-expression of PTHrP. Like my case of kidney cancer, but also other cancers, like squamous cell cancers, especially of the lungs that are associated definitely with the PTHrP.

Steve Freed: So, we go from your poster, what’s the next step that you’re hoping for?

Dr. Yehya: Second poster. Basically, this is going to be a contribution, not only for endocrinology, which I’m pursuing. It’s going to be a combined effort from both endocrinologists and oncologists and cancer researchers to try to come up with a selective targetive therapy of monoclonal antibody that targets PTHrP in these types of cancer that over-express PTHrP, similarly to other cancers that over-express other types of genes, whether it be the HER2 in breast cancer, or estrogen additive targetive breast cancer, other types of cancer. It’s being selective to target the PTHrP and those types of cancers.

Steve Freed: I want to thank you for your time. It was really interesting. Enjoy the rest of your stay here. I presume you’ll be at ADA?

Dr. Yehya: Hopefully yeah that’s the plan.

Steve Freed: Will you have a poster there?

Dr. Yehya: Yes, so I hope it will be ready by then. If you want to know about it, it’s just going to be trying to modify the current guidelines, the ADA guidelines, for diagnosis of diabetic ketoacidosis, and possibly involving beta hydroxybutyrate in diagnosing, because it’s been shown, so far, it’s a more sensitive and specific criteria for diagnosis as compared to the current ADA adopted criteria.

Steve Freed: Again, thank you for your time.