BMI ≥ 70: A Multi-Center Institutional Experience of the Safety and Efficacy of Metabolic and Bariatric Surgery Intervention.

PURPOSE: With the escalating prevalence of obesity, healthcare providers are increasingly managing patients with a body mass index (BMI) exceeding 70. The aim of this study was to describe the perioperative experiences of this demographic group at two institutions. METHODS: An analysis encompassing 84 patients presenting with BMI ≥ 70 kg/m2 from two institutions was conducted. Data included patient demographics, 30-day postoperative outcomes, and weight-loss at different intervals (30 days, 6 months, 1 year). Additionally, rates of emergency department (ED) utilization, readmission, and reoperation in the first postoperative year were examined. RESULTS: Most patients were black (66.7%) and female (86.9%) with a mean age of 41.7 years. The majority underwent laparoscopic sleeve gastrectomy (SG, 88.1%). Patients exhibited a marked decrease in BMI (7.84% at 30 days, 20.13% at 6 months, and 26.83% at 1 year). Average length of stay was comparable across procedure (F(3,80) = 0.016, p = .997). While 30-day complications were minimal (0.7%), 14.4% of patients experienced ED visits within 30 days, escalating to 19.6% by six months and 25% at 1 year. Readmission and reoperation rates at 1 year were 6.45% and 4.83%, respectively. CONCLUSION: With global obesity rates rising, clinicians are being challenged to care for patients with BMI ≥ 70 kg/m2. Analysis of two institutions demonstrated low rates of 30-days complications but increased readmission rates and ED utilization in this patient population. Despite increased resource utilization, the study suggests that BMI ≥ 70 kg/m2 alone should not be a deterrent for surgery, emphasizing the need for nuanced care in this expanding demographic.

Early marginal ulceration prevalence following primary RYGB: a rare events model of the MBSAQIP 2015-2021.

PURPOSE: Marginal ulceration (MU) following Roux-en-Y gastric bypass (RYGB) is an established complication, with early MU (within 30-days of operation) being less understood compared to its late counterpart. This study aims to identify risk factors for early MU in patients undergoing primary RYGB. METHODS: Utilizing data from the Metabolic and Bariatric Surgery Accreditation Quality Improvement Project (MBSAQIP 2015-2021), 1,346,468 records were evaluated. After exclusions for revisions, conversions, pediatric cases, nonbinary gender, missing body mass index (BMI) data, and missing operative time; 291,625 cases of primary RYGB were included for full analysis and rare events modeling of early MU. RESULTS: The prevalence of early MU was .29% (n = 850). Higher rates of early MU were associated with BMI, race, history of diabetes mellitus (DM), prior thrombotic complications (deep vein thrombosis (DVT) and pulmonary embolism (PE)), prior percutaneous cardiac intervention (PTC), immunosuppressive therapy, and anticoagulation status. Additionally, procedural aspects like the nonspecialization of the surgeon and longer operative times also correlated with higher early MU rates. Rare-events regression modeling noted significant associations of early MU with younger age, diabetes requiring insulin, history of PTC, DVT, immunosuppressive therapy, and anticoagulation status. CONCLUSION: Early MU remains a relatively rare complication. The lower than previously reported occurrence suggests possible improvements in both patient preparation and surgical technique. The identification of relevant risk factors enables better perioperative and intraoperative management of patients at risk of developing early MU.

Impact of progressive chronic kidney disease stage on postoperative outcomes in metabolic surgery-a propensity-matched analysis using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement database.

BACKGROUND: Metabolic surgery (MS) is effective in improving renal parameters for individuals with obesity and chronic kidney disease (CKD). Despite recognized benefits, concerns linger about the perioperative safety of patients with CKD undergoing MS. This study aimed to identify the CKD stage associated with the most significant increase in postoperative complications. METHODS: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database (2017-2021) was used to identify patients undergoing laparoscopic gastric sleeve (SG) or Roux-en-Y gastric bypass (RYGB). Propensity matching was used to quantify the risk for adverse outcomes associated with progressive CKD stage. RESULTS: In total, 688,583 patients (483,898 without CKD and 204,685 with CKD stages I-V) were examined. Endpoints included length of stay (LOS) >5 days, infection, serious complications, major adverse cardiovascular events (MACE), and death. Both SG and RYGB exhibited a linear increase in risk of infection and death. For SG, patients who were stage IIIa/IIIb demonstrated the greatest risk for LOS >5 days (odds ratio [OR] 1.23; 95% confidence interval [CI] (1.05-1.45); P = .011), serious complications (OR 2.83; 95% CI 1.87-4.30; P < .001), and MACE (OR 2.82; 95% CI 1.81-4.37; P < .001). For RYGB, patients who were stage IIIa/IIIb the exhibited greatest risk of MACE (OR 1.67; 95% CI 1.06-2.62; P = .027). CONCLUSIONS: Although it is generally accepted that worsening CKD correlates with greater surgical risk, this analysis identified CKD stage III as a major inflection point for risk of LOS >5 days, serious complications, and MACE. These findings are useful for counseling and procedure selection and suggest a need for heightened attention to CKD stage III patients undergoing MS.

Clinical Outcomes of Metabolic Surgery on Diuretic Use in Patients With Heart Failure.

The beneficial impacts of metabolic surgery (MS) on patients with heart failure (HF) are incompletely characterized. We aimed to describe the cardiac and metabolic effects of MS in patients with HF and hypothesized that patients with HF would experience both improved metabolic and HF profiles using glycemic control and diuretic dependency as surrogate markers. In this single-center, university-affiliated academic study in the United States, a review of 2,342 hospital records of patients who underwent MS (2017 to 2023) identified 63 patients with a medical history of HF. Preoperative characteristics, 30-day outcomes, and up to 2-year biometric and metabolic outcomes, medication usage, and emergency department utilization were collected. At 24 months, mean body mass index change was -16 kg/m2 (p <0.001) that corresponded to a mean percentage total body weight loss of 29% (p <0.001). Weight loss was accompanied by significant reductions in hemoglobin A1c (p <0.001) and a 65% decrease in diuretic use at 24 months after surgery (p <0.001). Similarly, emergency visits for cardiac conditions (p = 0.06) and intravenous diuresis (p = 0.07) trended favorably at 1 year after surgery compared with 1 year before surgery but were not statistically significant. In conclusion, in patients with HF who were carefully selected, MS appears to provide significant reduction in oral diuretic dependency, and metabolic improvements with trends toward lower rates of emergency department utilization.

Insurance payor status and risk of major adverse cardiovascular and cerebrovascular events after metabolic and bariatric surgery.

BACKGROUND: Patients with Medicare/Medicaid insurance receive metabolic and bariatric surgery (MBS) at lower rates than privately insured (PI) patients. Although studies on some surgical procedures report that Medicare/Medicaid insurance confers increased postoperative complication rates and a longer length of stay, less is known about these outcomes after MBS. Among often-feared postoperative complications are major adverse cardiovascular and cerebrovascular events (MACEs). Although these events are rare after MBS, they have a significant impact on morbidity and mortality. OBJECTIVES: This study aimed to examine the effect of insurance payor status on MACEs after MBS. SETTING: The Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS). METHODS: HCUP-NIS was queried for cases including sleeve gastrectomy or Roux-en-Y gastric bypass between 2012 and 2019. Bivariate associations between patient-level factors and MACEs were assessed via Rao-Scott χ2 tests. Adjusted and unadjusted risks of insurance payor status for MACEs were evaluated using logistic regression. RESULTS: Incidence of MACEs was higher in both Medicare (.75% versus .11%; P < .001) and Medicaid (.15% versus .11%; P < .001) groups than in the PI group. After adjustment for high-risk demographics, high-risk co-morbidities, socioeconomic variables, and hospital factors, insurance status of Medicare (odds ratio [OR]: 1.60, 95% confidence interval [CI]: 1.23, 2.07; P = .0026) or Medicaid (OR: 1.55, 95% CI: 1.12, 2.16; P = .0026) remained an independent risk factor for MACEs. CONCLUSIONS: Our findings underscore the significance of Medicaid/Medicare payor status as an independent predictor of postoperative MACEs in MBS. The results of this study can have a significant impact on deepening our understanding of socioeconomic and health system-related issues that can be targeted to improve outcomes in both MBS and other surgical specialties.

Limitations of the 2015-2021 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database for emergency bariatric operations.

BACKGROUND: The Metabolic and Bariatric Surgery Quality Improvement Project (MBSAQIP) is the largest bariatric surgery-specific clinical data set. OBJECTIVES: In 2020, the definition of emergency cases was altered to include only revisional or conversion cases and not primary cases. The aim of this study was to examine how this change affects the utility of the data set for emergency case tracking. SETTING: MBSAQIP database. METHODS: Emergency cases were extracted from available MBSAQIP data (2015-2021). A comparison of co-morbidity profiles was done, specifically before and after the recent change to how "emergency" is defined in the data set. RESULTS: Eleven thousand and twenty-nine of the 1,048,575 total cases were coded as "emergency cases." From 2015 to 2019, 10,574 emergency cases were performed (∼2115 cases/yr), markedly decreasing in 2020 and 2021 to 455 cases (∼228 cases/yr). Before 2020, the most common procedures were the unlisted procedure of the stomach (45.14%, n = 3101), gastric band removal (25.3%, n = 2676), and reduction of internal hernia (11.8%, n = 1244). Between 2020 and 2021, this distribution changed with Roux-en-Y gastric bypass (RYGB), the most common emergency procedure (29.23%, n = 133). As expected from the change that captured only revisional cases, the average operative length was greater between 2020 and 2021 (127.6 versus 86.5 min). CONCLUSIONS: Capturable emergency cases declined in 2020, a trend related to changing the definition of emergency as part of MBSAQIP standards. This change excludes data on internal hernia reduction and does not likely reflect a real change in the prevalence of emergency bariatric cases. Because capture for emergency cases has diminished, so has any prior utility of using MBSAQIP data for studying emergency cases.

Dietary Fiber Intake and Risk of Advanced and Aggressive Forms of Prostate Cancer: A Pooled Analysis of 15 Prospective Cohort Studies.

BACKGROUND: Evidence of an association between dietary fiber intake and risk of advanced and aggressive forms of prostate cancer (PC) and PC mortality is limited. OBJECTIVE: The aim of this study was to examine associations between intakes of dietary fiber overall and by food source and risk of advanced and aggressive forms of PC. DESIGN: The study design was a pooled analysis of the primary data from 15 cohorts in 3 continents. Baseline dietary fiber intake was assessed using a validated food frequency questionnaire or diet history in each study. PARTICIPANTS/SETTING: There were 842 149 men followed for up to 9 to 22 years between 1985 and 2009 across studies. MAIN OUTCOME MEASURES: The primary outcome measures were advanced (stage T4, N1, or M1 or PC mortality), advanced restricted (excluded men with missing stage and those with localized PC who died of PC), and high-grade PC (Gleason score ≥8 or poorly differentiated/undifferentiated) and PC mortality. STATISTICAL ANALYSIS PERFORMED: Study-specific multivariable hazard ratios (MVHR) were calculated using Cox proportional hazards regression and pooled using random effects models. RESULTS: Intake of dietary fiber overall, from fruits, and from vegetables was not associated with risk of advanced (n = 4863), advanced restricted (n = 2978), or high-grade PC (n = 9673) or PC mortality (n = 3097). Dietary fiber intake from grains was inversely associated with advanced PC (comparing the highest vs lowest quintile, MVHR 0.84; 95% CI 0.76-0.93), advanced restricted PC (MVHR 0.85; 95% CI 0.74-0.97), and PC mortality (MVHR 0.78; 95% CI 0.68-0.89); statistically significant trends were noted for each of these associations (P ≤ .03), and a null association was observed for high-grade PC for the same comparison (MVHR 1.00; 95% CI 0.93-1.07). The comparable results were 1.06 (95% CI 1.01-1.10; P value, test for trend = .002) for localized PC (n = 35,199) and 1.05 (95% CI 0.99-1.11; P value, test for trend = .04) for low/intermediate grade PC (n = 34 366). CONCLUSIONS: Weak nonsignificant associations were observed between total dietary fiber intake and risk of advanced forms of PC, high-grade PC, and PC mortality. High dietary fiber intake from grains was associated with a modestly lower risk of advanced forms of PC and PC mortality.

Similar Risk of Kidney Failure among Patients with Blinding Diseases Who Receive Ranibizumab, Aflibercept, and Bevacizumab: An Observational Health Data Sciences and Informatics Network Study.

PURPOSE: To characterize the incidence of kidney failure associated with intravitreal anti-VEGF exposure; and compare the risk of kidney failure in patients treated with ranibizumab, aflibercept, or bevacizumab. DESIGN: Retrospective cohort study across 12 databases in the Observational Health Data Sciences and Informatics (OHDSI) network. SUBJECTS: Subjects aged ≥ 18 years with ≥ 3 monthly intravitreal anti-VEGF medications for a blinding disease (diabetic retinopathy, diabetic macular edema, exudative age-related macular degeneration, or retinal vein occlusion). METHODS: The standardized incidence proportions and rates of kidney failure while on treatment with anti-VEGF were calculated. For each comparison (e.g., aflibercept versus ranibizumab), patients from each group were matched 1:1 using propensity scores. Cox proportional hazards models were used to estimate the risk of kidney failure while on treatment. A random effects meta-analysis was performed to combine each database's hazard ratio (HR) estimate into a single network-wide estimate. MAIN OUTCOME MEASURES: Incidence of kidney failure while on anti-VEGF treatment, and time from cohort entry to kidney failure. RESULTS: Of the 6.1 million patients with blinding diseases, 37 189 who received ranibizumab, 39 447 aflibercept, and 163 611 bevacizumab were included; the total treatment exposure time was 161 724 person-years. The average standardized incidence proportion of kidney failure was 678 per 100 000 persons (range, 0-2389), and incidence rate 742 per 100 000 person-years (range, 0-2661). The meta-analysis HR of kidney failure comparing aflibercept with ranibizumab was 1.01 (95% confidence interval [CI], 0.70-1.47; P = 0.45), ranibizumab with bevacizumab 0.95 (95% CI, 0.68-1.32; P = 0.62), and aflibercept with bevacizumab 0.95 (95% CI, 0.65-1.39; P = 0.60). CONCLUSIONS: There was no substantially different relative risk of kidney failure between those who received ranibizumab, bevacizumab, or aflibercept. Practicing ophthalmologists and nephrologists should be aware of the risk of kidney failure among patients receiving intravitreal anti-VEGF medications and that there is little empirical evidence to preferentially choose among the specific intravitreal anti-VEGF agents. FINANCIAL DISCLOSURES: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Early Experience with the Senhance Surgical System in Bariatric Surgery.

Background and Objectives: Robotic-assisted surgery advancements have paralleled growing bariatric surgery demands. The Senhance robotic platform offers an alternative to the da Vinci surgical system but there are limited studies evaluating the Senhance system in bariatric surgery. This study aims to review a single surgeon's experience comparing outcomes between traditional laparoscopic and Senhance-assisted sleeve gastrectomy. Materials and Methods: All sleeve gastrectomies performed laparoscopically, Senhance-assisted, or da Vinci-assisted by a single surgeon at an academic center from January 2019 to July 2021 were retrospectively reviewed. Primary outcomes and quality measures were 30-day complications, operative times and length of stay. Results: A total of 268 patients, including 162 laparoscopic, 92 Senhance, and 14 da Vinci cases, were included. Operative times were significantly longer with Senhance (115.7 min) and da Vinci (122.7 min), compared to laparoscopic (94.8 min, P < .0001). Length of stay (measured in days) was significantly longer in the Senhance (1.8) and da Vinci (2.2) groups compared to laparoscopic cases (1.5, P < .0001). These differences remained significant after controlling for age, sex and body mass index. 30-day complication rates were 8.7% (n = 8) in the Senhance group, 7.1% (n = 1) in the da Vinci group and 2.5% (n = 4) in the laparoscopic group (P = .0567). Conclusion: Senhance-assisted sleeve gastrectomy is safe in bariatric surgery and comparable to laparoscopic sleeve gastrectomy with respect to 30-day complications.

Improved survival for dose-intensive chemotherapy in primary mediastinal B-cell lymphoma: a systematic review and meta-analysis of 4,068 patients.

Primary mediastinal B-cell lymphoma (PMBCL) is a distinct clinicopathologic entity. Currently, there is a paucity of randomized prospective data to inform on optimal front-line chemoimmunotherapy (CIT) and use of consolidative mediastinal radiation (RT). To assess if distinct CIT approaches are associated with disparate survival outcomes, we performed a systematic review and meta-analysis comparing dose-intensive (DI-CIT) versus standard CIT for the front-line treatment of PMBCL. Standard approach (S-CIT) was defined as R-CHOP-21/CHOP-21, with or without RT. DI-CIT were defined as regimens with increased frequency, dose, and/or number of systemic agents. We reviewed data on 4,068 patients (2,517 DI-CIT; 1,551 S-CIT) with a new diagnosis of PMBCL. Overall survival for DI-CIT patients was 88% (95% CI: 85-90) compared to 80% for the S-CIT cohort (95% CI: 74-85). Meta-regression revealed an 8% overall survival (OS) benefit for the DI-CIT group (P<0.01). Survival benefit was maintained when analyzing rituximab only regimens; OS was 91% (95% CI: 89-93) for the rituximab-DI-CIT arm compared to 86% (95% CI: 82-89) for the R-CHOP-21 arm (P=0.03). Importantly, 55% (95% CI: 43-65) of the S-CIT group received RT compared to 22% (95% CI: 15-31) of DI-CIT patients (meta-regression P<0.01). To our knowledge, this is the largest meta-analysis reporting efficacy outcomes for the front-line treatment of PMBCL. DI-CIT demonstrates a survival benefit, with significantly less radiation exposure, curtailing long-term toxicities associated with radiotherapy. As we await results of randomized prospective trials, our study supports the use of dose-intensive chemoimmunotherapy for the treatment of PMBCL.

Lessons from assembling a microbial natural product and pre-fractionated extract library in an academic laboratory.

Microbial natural products are specialized metabolites that are sources of many bioactive compounds including antibiotics, antifungals, antiparasitics, anticancer agents, and probes of biology. The assembly of libraries of producers of natural products has traditionally been the province of the pharmaceutical industry. This sector has gathered significant historical collections of bacteria and fungi to identify new drug leads with outstanding outcomes-upwards of 60% of drug scaffolds originate from such libraries. Despite this success, the repeated rediscovery of known compounds and the resultant diminishing chemical novelty contributed to a pivot from this source of bioactive compounds toward more tractable synthetic compounds in the drug industry. The advent of advanced mass spectrometry tools, along with rapid whole genome sequencing and in silico identification of biosynthetic gene clusters that encode the machinery necessary for the synthesis of specialized metabolites, offers the opportunity to revisit microbial natural product libraries with renewed vigor. Assembling a suitable library of microbes and extracts for screening requires the investment of resources and the development of methods that have customarily been the proprietary purview of large pharmaceutical companies. Here, we report a perspective on our efforts to assemble a library of natural product-producing microbes and the establishment of methods to extract and fractionate bioactive compounds using resources available to most academic labs. We validate the library and approach through a series of screens for antimicrobial and cytotoxic agents. This work serves as a blueprint for establishing libraries of microbial natural product producers and bioactive extract fractions suitable for screens of bioactive compounds. ONE-SENTENCE SUMMARY: Natural products are key to discovery of novel antimicrobial agents: Here, we describe our experience and lessons learned in constructing a microbial natural product and pre-fractionated extract library.

Hepatic Vagotomy in Patients With Obesity Leads to Improvement of the Cholesterol to High-Density Lipoprotein Ratio.

INTRODUCTION/PURPOSE: The obesity epidemic is rapidly growing, and visceral adiposity is associated with metabolic consequences secondary to peroxisome proliferator-activated receptor (PPAR)-induced inter-organ signaling pathways. PPARs are ligand-activated transcription factors that modulate vagal pathways which can improve blood pressure, arterial remodeling, cholesterol levels, and insulin sensitivity. However, an obesity-induced inflammatory milieu can interfere with the beneficial effects of PPAR activity, suggesting that a dysregulated PPAR-vagus pathway may play a role in the pathogenesis of obesity-related hypertension. Therefore, we hypothesized that hepatic vagotomy (HV) in patients with obesity would result in a significant reduction in blood pressure and/or the number of hypertension medications compared to control. METHODS: We conducted a retrospective chart review of 160 patients undergoing laparoscopic sleeve gastrectomy. Patients were divided into HV and control groups, and information was collected at each clinic visit. RESULTS: At six-months post-operation, the HV group was found to have significantly lower total cholesterol (TC)/high-density lipoprotein (HDL) ratios than the control group. The HV group also had a numerically better blood profile for TC, HDL, low-density lipoprotein (LDL), triglycerides, C-reactive protein, and LDL/HDL ratio. Hypertensive patients in the HV group showed numerically lower hypertension medication counts after six weeks when compared to control. CONCLUSION: We present the first study to report clinically significant changes related to HV in human subjects. Our results did not support our initial hypothesis but did demonstrate an improvement of the TC/HDL ratio with HV in patients with obesity. Future studies should confirm these findings in a randomized control trial.

Heterogeneous genetic architectures and evolutionary genomics of prostate cancer in Sub-Saharan Africa.

Men of African descent have the highest prostate cancer (CaP) incidence and mortality rates, yet the genetic basis of CaP in African men has been understudied. We used genomic data from 3,963 CaP cases and 3,509 controls recruited in Ghana, Nigeria, Senegal, South Africa, and Uganda, to infer ancestry-specific genetic architectures and fine-mapped disease associations. Fifteen independent associations at 8q24.21, 6q22.1, and 11q13.3 reached genome-wide significance, including four novel associations. Intriguingly, multiple lead SNPs are private alleles, a pattern arising from recent mutations and the out-of-Africa bottleneck. These African-specific alleles contribute to haplotypes with odds ratios above 2.4. We found that the genetic architecture of CaP differs across Africa, with effect size differences contributing more to this heterogeneity than allele frequency differences. Population genetic analyses reveal that African CaP associations are largely governed by neutral evolution. Collectively, our findings emphasize the utility of conducting genetic studies that use diverse populations.

Circulating trans fatty acids are associated with prostate cancer in Ghanaian and American men.

The association between fatty acids and prostate cancer remains poorly explored in African-descent populations. Here, we analyze 24 circulating fatty acids in 2934 men, including 1431 prostate cancer cases and 1503 population controls from Ghana and the United States, using CLIA-certified mass spectrometry-based assays. We investigate their associations with population groups (Ghanaian, African American, European American men), lifestyle factors, the fatty acid desaturase (FADS) genetic locus, and prostate cancer. Blood levels of circulating fatty acids vary significantly between the three population groups, particularly trans, omega-3 and omega-6 fatty acids. FADS1/2 germline genetic variants and lifestyle factors explain some of the variation in fatty acid levels, with the FADS1/2 locus showing population-specific associations, suggesting differences in their control by germline genetic factors. All trans fatty acids, namely elaidic, palmitelaidic, and linoelaidic acids, associated with an increase in the odds of developing prostate cancer, independent of ancestry, geographic location, or potential confounders.

Morbid Obesity Not a Risk for Serious Complications Following Outpatient Surgery.

Patients with class III obesity are often excluded from surgery in ambulatory surgery centers (ASCs). We hypothesize that class III obesity is not a risk factor for serious post-operative complications following outpatient operations. ACS-NSQIP database from 2012 to 2018 was queried. Patients undergoing outpatient inguinal hernia repair (IHR) and laparoscopic cholecystectomy (LC) were grouped by BMI. Baseline characteristics and 30-day outcomes were compared using univariate and multivariate analyses. Of these, 79,916 patients underwent IHR and 107,471 patients underwent LC. Multivariable analysis in IHR showed increased odds of superficial SSIs in all classes of obesity compared to normal weight (P < .0001). In the LC group, there were higher rates of SSIs with obesity (P < .0001). For both surgeries, a higher rate of readmissions to the hospital were observed in class II and IIIa obesity (both P < .0001), although rates were relatively low (<3%). Class III obesity demonstrates a statistically significant increase in SSI following IHR and LC. Severe complications requiring readmission are not mirrored, suggesting the morbidly obese patients should be considered for routine surgical procedures in outpatient settings.

Effect of high-risk factors on postoperative major adverse cardiovascular and cerebrovascular events trends following bariatric surgery in the United States from 2012 to 2019.

BACKGROUND: Recent examination of trends in postoperative major adverse cardiovascular and cerebrovascular events (MACE) following bariatric surgery, including accredited and nonaccredited centers, and the factors affecting those trends, is lacking. OBJECTIVES: The objective of this study was to evaluate current trends for postoperative MACE after bariatric surgery in both accredited and nonaccredited centers and the factors affecting these trends. SETTING: This retrospective study was conducted using National Inpatient Sample database from 2012 to 2019. METHODS: All patients who underwent inpatient laparoscopic sleeve gastrectomy (LSG), open sleeve gastrectomy (SG), laparoscopic Roux-en-Y gastric bypass (LRYGB), and open Roux-en-Y gastric bypass (RYGB) were examined. Composite MACE (acute myocardial infarction, cardiac arrest, acute stroke, and in-hospital death during bariatric surgery hospitalization) was calculated and analyzed over time along with patient demographic and co-morbid diseases using survey-weighted logistic regression. RESULTS: MACE incidence was lowest for LSG (0.07%), followed by LRYGB (0.16%), SG (3.47%), and RYBG (3.51%). Open procedure, increasing age, male sex, body mass index ≥50, coronary artery disease, congestive heart failure, and chronic kidney disease were independent predictors for increased MACE risk. MACE incidence increased over time for SG (odds ratio [OR] 1.25 [1.16, 1.34]; P < .0001) and RYGB (OR 1.14 [1.06, 1.22]; P = .0004) but decreased for LRYGB (OR 0.93 [0.87, 1] P = .06). After adjustment for high-risk covariates, increased MACE trend seen over time was attenuated in SG (OR 1.13 [1.04-1.22]; P = .005) and RYGB (OR 1.04 [0.96-1.12]; P = .36), while there was minimal effect of these high-risk covariates on MACE trend over time in LSG and LRYGB. CONCLUSIONS: MACE following LSG and LRYGB is rare, occurring in 0.1% of patients. Persistently increasing high-risk conditions and demographics has had minimal effect on MACE over time for LSG and LRYGB but has had significant effect on MACE trend over time in SG and RYGB.

Testosterone therapy and cancer risks among men in the SEER-Medicare linked database.

BACKGROUND: We examined associations between two forms of testosterone therapy (TT) and risks of seven cancers among men. METHODS: SEER-Medicare combines cancer registry data from the Surveillance, Epidemiology, and End Results programme with Medicare claims. Our population-based case-control study included incident cancer cases diagnosed between 1992-2015: prostate (n = 130,713), lung (n = 105,466), colorectal (n = 56,433), bladder (n = 38,873), non-Hodgkin lymphoma (n = 17,854), melanoma (n = 14,241), and oesophageal (n = 9116). We selected 100,000 controls from a 5% random sample of Medicare beneficiaries and used logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CI). RESULTS: TT was associated with lower risk of distant-stage prostate cancer (injection/implantation OR = 0.72, 95% CI: 0.60-0.86; topical OR = 0.50, 95% CI: 0.24-1.03). We also observed inverse associations for distant-stage colorectal cancer (injection/implantation OR = 0.75, 95% CI: 0.62-0.90; topical OR = 0.11, 95% CI: 0.05-0.24). Risks of distant-stage colorectal and prostate cancers decreased with time after initiating TT by injection/implantation. By contrast, TT was positively associated with distant-stage melanoma (injection/implantation OR = 1.70, 95% CI: 1.37-2.11). TT was not associated with bladder cancer, oesophageal cancer, lung cancer or non-Hodgkin lymphoma. CONCLUSION: TT was inversely associated with distant-stage prostate and colorectal cancers but was positively associated with distant-stage melanoma. These observations may suggest an aetiologic role for TT or the presence of residual confounding.