IgE to common food allergens is associated with cardiovascular mortality in the National Health and Examination Survey and the Multi-Ethnic Study of Atherosclerosis.

BACKGROUND: In individuals without symptomatic food allergy, food-specific IgE is considered clinically irrelevant. However, recent studies have suggested that galactose-α-1,3-galactose (alpha-gal) IgE is associated with cardiovascular (CV) disease. OBJECTIVE: We sought to determine whether sensitization to common food allergens is associated with CV mortality. METHODS: The association between IgE sensitization to foods and CV mortality ascertained to 2019 was examined in the National Health and Examination Survey (NHANES) 2005-2006 and the Wake Forest site of the Multi-Ethnic Study of Atherosclerosis (MESA) cohort; MESA enrolled adults without baseline clinical CV diseases between 2000 and 2002. Total and specific IgE was measured to cow's milk, egg, peanut, shrimp, and a panel of aeroallergens (NHANES), and to cow's milk, alpha-gal, peanut, dust mite, and timothy grass (MESA). Cox proportional hazard models were constructed, adjusting for sex, age, race/ethnicity, smoking, education, and asthma. RESULTS: A total of 4414 adults from NHANES (229 CV deaths) and 960 from MESA (56 CV deaths) were included. In NHANES, sensitization to at least 1 food was associated with higher CV mortality (hazard ratio [HR], 1.7 [95% confidence interval (CI), 1.2-2.4], P = .005). Milk sensitization was particularly associated (HR, 2.0 [95% CI, 1.1-3.8], P = .026), a finding replicated in MESA (HR, 3.8 [95% CI, 1.6-9.1], P = .003). Restricting analyses in NHANES to consumers of the relevant allergen strengthened food sensitization relationships, unmasking shrimp and peanut sensitization as additional risk factors for CV mortality. CONCLUSIONS: The finding that food sensitization is associated with increased risk of CV mortality challenges the current paradigm that sensitization without overt allergy is benign. Further research is needed to clarify mechanisms of this association.

The Legal Landscape for Opioid Treatment Agreements.

Policy Points Opioid treatment agreements (OTAs) are controversial because of the lack of evidence that their use reduces opioid-related harms and the potential risks they pose of stigmatizing patients and undermining the clinician-patient relationship. Even so, their use is now required in most jurisdictions, and their use is influencing the outcomes of civil and criminal lawsuits. More research is needed to evaluate how OTAs are implemented given existing requirements. If additional research does not resolve the current level of uncertainty regarding OTA benefits, then policymakers in jurisdictions where they are required should consider eliminating OTA mandates or providing flexibility in the legal requirements to make room for clinicians and health care institutions to implement best practices. CONTEXT: Opioid treatment agreements (OTAs) are documents that clinicians present to patients when prescribing opioids that describe the risks of opioids and specify requirements that patients must meet to receive their medication. Notwithstanding a lack of evidence that OTAs effectively mitigate opioids' risks, professional organizations recommend that they be implemented, and jurisdictions increasingly require them. We sought to identify the jurisdictions that require OTAs, how OTAs might affect the outcomes of lawsuits that arise when things go wrong, and instances in which the law permits flexibility for clinicians and health care institutions to adopt best practices. METHODS: We surveyed the laws and regulations of all 50 states and the District of Columbia to identify which jurisdictions require the use of OTAs, the circumstances in which OTA use is mandatory, and the terms OTAs must include (if any). We also surveyed criminal and civil judicial decisions in which OTAs were discussed as evidence on which a court relied to make its decision to determine how OTA use influences litigation outcomes. FINDINGS: Results show that a slight majority (27) of jurisdictions now require OTAs. With one exception, the jurisdictions' requirements for OTA use are triggered at least in part by long-term prescribing. There is otherwise substantial variation and flexibility within OTA requirements. Results also show that even in jurisdictions where OTA use is not required by statute or regulation, OTA use can inform courts' reasoning in lawsuits involving patients or clinicians. Sometimes, but not always, OTA use legally protects clinicians from liability. CONCLUSIONS: Our results show that OTA use is entwined with legal obligations in various ways. Clinicians and health care institutions should identify ways for OTAs to enhance clinician-patient relationships and patient care within the bounds of relevant legal requirements and risks.

Enhanced SARS-CoV-2 IgG durability following COVID-19 mRNA booster vaccination and comparison of BNT162b2 with mRNA-1273.

BACKGROUND: BNT162b2 (Pfizer/BioNTech, Comirnaty) and mRNA-1273 (Moderna, Spikevax) are messenger RNA (mRNA) vaccines that elicit antibodies against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike receptor-binding domain (S-RBD) and have been approved by the US Food and Drug Administration to combat the coronavirus disease 2019 (COVID-19) pandemic. Because vaccine efficacy and antibody levels waned over time after the 2-shot primary series, the US Food and Drug Administration authorized a booster (third) dose for both mRNA vaccines to adults in the fall of 2021. OBJECTIVE: To evaluate the magnitude and durability of S-RBD immunoglobulin (Ig)G after the booster mRNA vaccine dose in comparison to the primary series. We also compared S-RBD IgG levels after BNT162b2 and mRNA-1273 boosters and explored effects of age and prior infection. METHODS: Surrounding receipt of the second and third homologous mRNA vaccine doses, adults in an employee-based cohort provided serum and completed questionnaires, including information about previous COVID-19 infection. The IgG to S-RBD was measured using an ImmunoCAP-based system. A subset of samples were assayed for IgG to SARS-CoV-2 nucleocapsid by commercial assay. RESULTS: There were 228 subjects who had samples collected between 7 and 150 days after their primary series vaccine and 117 subjects who had samples collected in the same time frame after their boost. Antibody levels from 7 to 31 days after the primary series and booster were similar, but S-RBD IgG was more durable over time after the boost, regardless of prior infection status. In addition, mRNA-1273 post-boost antibody levels exceeded BNT162b2 out to 5 months. CONCLUSION: The COVID-19 mRNA vaccine boosters increase antibody durability, suggesting enhanced long-term clinical protection from SARS-CoV-2 infection compared with the 2-shot regimen.

Development of dementia in patients who underwent bariatric surgery.

BACKGROUND: Dementia, including Alzheimer's disease, interfere with daily function and are one of the major causes of disability, institutionalization, and death. Obesity is associated with an increased risk of dementia. However, the effect of significant and sustained weight loss following bariatric surgery on dementia is not known. The purpose of this study was to assess the long-term risk of dementia following bariatric surgery. METHODS: A surgical cohort was identified from the Utah Bariatric Surgery Registry and was linked to the Utah Population Database that includes electronic medical records, death records, and State Facility data. Adult subjects (≥ 18 years old) at time of surgery (1996-2016) were matched with non-surgical subjects. The final sample included 51,078 subjects (1:2 matching); surgery group n = 17,026; non-surgery subjects n = 34,052). Dementia were identified by ICD-9/10 diagnosis codes following surgery year or matched baseline year. Cox proportional hazard model was used to calculate the hazard ratio in the outcome between the groups. RESULTS: Average (SD) age of the subjects was 42 (12) years old at surgery or matched baseline year, 78% were female and mean follow-up time was 10.5 years. 1.4% of the surgery group and 0.5% of the control group had an incidence of dementia. Controlling the covariates in the Cox regression, the surgery group had a higher risk for dementia incidence than the matched non-surgery subjects (HR = 1.33, p = 0.02). CONCLUSIONS: The study showed an increased hazard for dementia in individuals who underwent bariatric surgery compared to matched non-surgical subjects. Additional long-term data is needed to verify this association.

Association of prenatal substance use disorders with pregnancy and birth outcomes following bariatric surgery.

BACKGROUND/OBJECTIVES: While an increased risk for substance use disorders (SUD) and also for several adverse pregnancy and birth outcomes in patients who have undergone bariatric surgery have been well documented when considered separately, an association between these important risk factors has not been investigated. This study explored the potential dependence of these two bariatric surgery-related risks. SUBJECTS/METHODS: This study was a retrospective cohort study with adult women (18-45) who underwent bariatric surgery between 1996 and 2016 and who gave birth after surgery between 1996 and 2018. The study population consisted of 1849 post-bariatric surgery women with 3010 reported post-surgical births. Subjects with post-surgical, prenatal SUD were identified based on diagnosis codes extracted within the 10 months prior to delivery. Using random-effects logistic regression with retrospective cohort data, preterm birth, low birth weight, macrosomia, Caesarian delivery, congenital anomalies, and neonatal intensive care unit admission were considered as outcomes. RESULTS: About 10% (n = 289) of women had an SUD diagnosis within 10 months prior to child delivery. Women with SUD during pregnancy had significantly more pregnancy and birth complications compared to women without SUD: preterm birth (OR = 2.08, p = 0.03, 95% CI: 1.07-4.03), low birth weight (OR = 3.41, p < 0.01, 95% CI: 1.99-5.84), Caesarian delivery (OR = 9.71, p < 0.01, 95% CI: 2.69-35.05), and neonatal intensive care unit admission (OR = 3.87, p < 0.01, 95% CI: 2.04-7.34). Women with SUD had lower risk for macrosomia than women without SUD (OR = 0.07, p = 0.02, 95% CI: 0.01-0.70). CONCLUSION: Results from this study demonstrated that post-bariatric surgery women who had SUD during pregnancy had significantly more pregnancy- and birth-related complications than post-surgery pregnant women without SUD, despite the reduction in macrosomia. Where possible, greater prenatal surveillance of post-surgery women with SUD should be considered.

Prescriptions for pain medication before and after bariatric surgery.

BACKGROUND: Significant and sustained weight loss resulting from bariatric surgery have demonstrated clinical reduction in severe obesity-related pain. Subsequentially, post-surgical pain reduction may reduce pain medication use. However, clear evidence regarding use of prescribed pain medications before and after bariatric surgery is absent. METHODS: Linking two state-wide databases, patients who underwent bariatric surgery between July 1, 2013 and December 31, 2015 were identified. Proportion tests were used to compare percent of patients with pain medication prescriptions 1 year before and 1 year after bariatric surgery. Logistic regression was used to identify baseline factors that were associated with pain medication use 1-year following surgery. RESULTS: A total of 3535 bariatric surgical patients aged 18-64 years at surgery were identified. Of these patients, 1339 patients met the following study criteria: covered by private insurance; known pre-surgical BMI; and continuous enrollment with health plan(s) from 12-month pre-surgery to 13-month post-surgery. While comparison of average number of overall pain medication prescriptions before and after surgery did not change, from 3.46 to 3.32 prescriptions (p value = 0.26), opioid prescription use increased from 1.62 vs. 2.05 (p value < 0.01). Patients prescribed more types of pain medications before surgery were more likely to have prescribed pain medications after surgery. Patients prescribed benzodiazepines at baseline had higher odds being prescribed post-surgery corticosteroids (OR = 1.89, p value < 0.01), muscle relaxants (OR = 2.18, p value < 0.01), and opioids (OR = 3.06, p value = < 0.01) compared to patients without pre-surgery--prescribed benzodiazepine. CONCLUSION: While comparison of average number of overall pain medication prescriptions before and after bariatric surgery did not decrease, opioid prescription increased post-surgery. Further studies are needed to examine whether post-surgery opioids are prescribed in lieu of or in tandem with other pain medication prescriptions.

Alpha-Gal Allergy as a Cause of Intestinal Symptoms in a Gastroenterology Community Practice.

OBJECTIVES: Immunoglobulin E (IgE) to galactose-α-1,3-galactose (alpha-gal) is a recently appreciated cause of allergic reactions to mammalian meat and dairy. In eastern North America Lone Star tick bites are the dominant mode of sensitization. Classically the alpha-gal syndrome manifests with urticaria, gastrointestinal symptoms, and/or anaphylaxis, but increasingly there are reports of isolated gastrointestinal symptoms without other common allergic manifestations. The objective of this retrospective study was to determine the frequency of IgE to alpha-gal in patients presenting with unexplained gastrointestinal symptoms to a community gastroenterology practice, and to evaluate the symptom response to the removal of mammalian products from the diet in alpha-gal-positive individuals. METHODS: An electronic medical record database was used to identify patients with alpha-gal IgE laboratory testing performed within the past 4 years. These charts were reviewed for alpha-gal test results, abdominal pain, diarrhea, nausea and vomiting, hives, bronchospasm, diagnosis of irritable bowel syndrome, postprandial exacerbation of symptoms, meat exacerbation of symptoms, patient recall of tick bite, other simultaneous gastrointestinal tract diagnoses, and clinical improvement with mammalian food product avoidance. RESULTS: A total of 1112 adult patients underwent alpha-gal IgE testing and 359 (32.3%) were positive. Gastrointestinal symptoms were similar in those positive and negative for alpha-gal seroreactivity. Of the 359 alpha-gal-positive patients, 122 had follow-up data available and 82.0% of these improved on a diet free of mammalian products. Few patients reported hives (3.9%) or bronchospasm (2.2%). Serum alpha-gal IgE titers ranged from 0.1 to >100 kU/L, with an average of 3.43 kU/L and a median of 0.94 kU/L. CONCLUSIONS: Clinicians practicing in the region of the Lone Star tick habitat need to be aware that patients with IgE to alpha-gal can manifest with isolated abdominal pain and diarrhea, and these patients respond well to dietary exclusion of mammalian products.

Physeal-sparing posteromedial portal approach reduced distance between guide pin and neurovascular structures.

PURPOSE: To compare a femoral physeal sparing anterior cruciate ligament (ACL) reconstruction technique utilizing a posteromedial portal to traditional transphyseal techniques with regards to anatomic tunnel positioning and proximity to important neurovascular structures. METHODS: Eight cadaveric knees were obtained for the study. Femoral tunnel guide pins were placed utilizing four different techniques: accessory anterior medial portal, posteromedial portal, trans-tibial, and figure-4 methods. The knees were then dissected and the following measurements taken: distance of each pin to the saphenous and peroneal nerve, popliteus tendon, neurovascular bundle, femoral ACL footprint and articular cartilage, and the angle of the guide pin entering the lateral femoral condyle. Fluoroscopic imaging was taken to determine the disruption of the physeal scar. RESULTS: Posteromedial portal guide pin was significantly closer to the neurovascular bundle, popliteal tendon and saphenous nerve when compared to the other 3 techniques, but was further from the peroneal nerve. It also had the smallest distance from the anatomic footprint of the ACL, and the largest angle to the lateral femoral condyle. The posteromedial portal guide pin had similar distance from the articular cartilage as the accessory anterior medial portal and figure-4 guide pin, with the trans-tibial guide pin being the farthest. The posteromedial portal guide pin failed to disrupt the physeal scar in all specimens, while the other three techniques consistently violated the physeal scar. CONCLUSION: The posteromedial portal technique offers an appropriate method for anatomic ACL reconstruction while protecting the distal femoral physis from injury. Care needs to be taken with this technique as it comes in closer proximity to some of the important neurovascular structures. This study indicates that posteromedial portal technique is a less technically challenging approach for physeal-sparing ACL repair with special attention required for the protection of neurovascular bundle from potential injury.

Implementation of a Quality Improvement Initiative to Decrease Opioid Prescribing in General Surgery.

BACKGROUND: There is increasing need to avoid excess opioid prescribing after surgery. We prospectively assessed overprescription in our hospital system and used these data to design a quality improvement intervention to reduce overprescription. MATERIALS AND METHODS: Beginning in January 2017, an e-mail-based survey to assess the quantity of opioids used postoperatively as well as patient-reported pain control was sent to all surgical patients in a 23-hospital system. In January 2018, as a quality improvement initiative, guidelines were given to surgeons based on patient consumption data. Prescription and consumption were then tracked prospectively. Wilcoxon signed-rank, analysis of variance, and Cuzick trend tests were used to assess for overprescription and changes over time in opioid prescribing and consumption. RESULTS: We included 2239 patients in our cohort. The amount prescribed (median [IQR]: 30 [24-45] versus 18 [12-30], P < 0.001) and consumed (median [IQR]: 12 [7-20] versus 8 [3-15], P < 0.001) each decreased between the first and last quarter studied. Academic hospitals prescribed fewer opioids than nonacademic hospitals (median [IQR]: 24[15-40] versus median [IQR]: 30 [20-45], P < 0.001). There was no difference in the quantity of opioids consumed between patients treated at academic and nonacademic facilities (median [IQR]: 10[3-19] versus 10.5 [4-20], P = 0.08). Patients consumed a median of 42% of the opioids prescribed, and there was no significant trend in the percent consumed over time (P = 0.8). CONCLUSIONS: Patients used far fewer opioids than prescribed after common adult general surgery procedures. When surgeons were provided with patient consumption data, the number of opioids prescribed decreased significantly.

Measurement of arterial occlusion pressure using straight and curved blood flow restriction cuffs.

Arterial occlusion pressure (AOP) is influenced by the characteristics of the cuff used to measure AOP. Doppler ultrasound was used to measure AOP of the brachial and superficial femoral arteries using straight and curved blood flow restriction cuffs in 21 males and 21 females. Vessel diameter and blood flow were evaluated as independent predictors of AOP. Overall, there were no significant differences in AOP when using the straight and curved cuffs in the brachial (129 mmHg vs. 128 mmHg) or superficial femoral artery (202 mmHg vs. 200 mmHg), respectively. Overall, AOP was greater (p < 0.05) in males than in females in the arm (135 mmHg, 123 mmHg) and leg (211 mmHg, 191 mmHg). Brachial (0.376 mm, 0.323 mm) and superficial femoral (0.547 mm, 0.486 mm) arteries were larger (p = 0.016) in males than in females, respectively. Systolic blood pressure (SBP) and arm circumference were predictive of brachial artery AOP, whereas SBP, diastolic blood pressure, thigh circumference, and vessel diameter were predictive of superficial femoral artery AOP. Straight and curved cuffs are efficacious in the measurement of AOP in the arm and leg. Differences in vessel size may contribute to sex differences in AOP but this requires further investigation.

Mammalian Meat Allergy and IgE to Alpha-gal in in Central Virginia: findings from a COVID-19 vaccine and patient cohort.

BACKGROUND: IgE to galactose-alpha-1,3-galactose (alpha-gal) is linked with tick bites and an important cause of anaphylaxis and urticarial reactions to mammalian meat. The "alpha-gal syndrome" (AGS) is recognized as being common in the southeastern USA, however prevalence studies are lacking and open questions remain about risk factors and clinical presentation of alpha-gal sensitization. OBJECTIVE: Here we characterized the prevalence, as well as presentation and risk factors, of AGS and alpha-gal IgE sensitization in adults in central Virginia recruited without regards to history of allergic disease. METHODS: Adults in central Virginia, primarily University of Virginia Health employees, were recruited as part of a COVID-19 vaccine study. Subjects provided at least one blood sample and answered questionnaires about medical and dietary history. ImmunoCAP was used for IgE assays and ABO blood group was assessed by reverse typing using stored serum. Biobanked serum from COVID-19 patients was also investigated. RESULTS: Of 267 enrollees, median age was 42, 76% were female and 43 (16%) were sensitized to alpha-gal (cut-off 0.1 IU/mL), of which mammalian meat allergy was reported by 7 (2.6%). Sensitized subjects were i) older, ii) had higher total IgE levels but similar frequency of IgE to common respiratory allergens, and iii) were more likely to report tick bites than non-sensitized subjects. Among those who were sensitized, alpha-gal IgE levels were higher among meat allergic than non-allergic subjects (GM 9.0 vs 0.5 IU/mL, P<0.001). Mammalian meat and dairy consumption was common in individuals with low-level sensitization. CONCLUSION: In central Virginia AGS is a dominant cause of adult food allergy with a prevalence approaching or exceeding 2%.

Pre-Operative Substance Use Disorder is Associated with Higher Risk of Long-Term Mortality Following Bariatric Surgery.

PURPOSE: Metabolic and bariatric surgery (MBS) has been associated with reduced all-cause mortality. While the number of subjects with substance use disorders (SUD) before MBS has been documented, the impact of pre-operative SUD on long-term mortality following MBS is unknown. This study assessed long-term mortality of patients with and without pre-operative SUD who underwent MBS. MATERIALS AND METHODS: Two statewide databases were used for this study: Utah Bariatric Surgery Registry (UBSR) and the Utah Population Database. Subjects who underwent MBS between 1997 and 2018 were linked to death records (1997-2021) to identify any death and cause for death following MBS. All deaths (internal, external, and unknown reasons), internal deaths, and external deaths were the primary outcomes of the study. External causes of death included death from injury, poisoning, and suicide. Internal causes of death included deaths that were associated with natural causes such as heart disease, cancer, and infections. A total of 17,215 patients were included in the analysis. Cox regression was used to estimate hazard ratios (HR) of controlled covariates, including the pre-operative SUD. RESULTS: The subjects with pre-operative SUD had a 2.47 times higher risk of death as compared to those without SUD (HR = 2.47, p < 0.01). Those with pre-operative SUD had a higher internal cause of death than those without SUD by 129% (HR = 2.29, p < 0.01) and 216% higher external mortality risk than those without pre-operative SUD (HR = 3.16, p < 0.01). CONCLUSION: Pre-operative SUD was associated with higher hazards of all-cause, internal cause, and external cause mortality in patients who undergo bariatric surgery.

Association of Pre-operative Arthritis with Long-Term Mortality Following Bariatric Surgery.

BACKGROUND: Metabolic and bariatric surgery (MBS) is an effective treatment for obesity and may reduce mortality. Several factors are associated with higher mortality following MBS. The purpose of this study was to examine whether pre-operative arthritis was associated with long-term mortality following MBS. METHODS: Using a retrospective cohort design, subjects who underwent MBS were identified from the Utah Bariatric Surgery Registry. These subjects were linked to the Utah Population Database. State death records from 1998 through 2021 were used to identify deaths following MBS. ICD-9/10 diagnosis codes were used to identify a pre-operative diagnosis of arthritis and to classify the cause of death. All causes of death, internal cause of death (e.g., diabetes, heart disease), and external cause of death (e.g., suicide) were defined as outcomes. Entropy balancing (EB) was applied to create weights to balance the baseline characteristics of the two groups. Weighted Cox proportional hazards regression was used to evaluate the association of pre-operative arthritis with long-term mortality following MBS. RESULTS: The final sample included 15,112 patients. Among them, 36% had a pre-operative arthritis diagnosis. Average (SD) age was 48(12) years old at surgery, and 75% were female. Patients with pre-operative arthritis had 25% (p < 0.01) and 26% (p < 0.01) higher risk of all cause of death and internal cause of death, respectively, compared to patients without pre-operative arthritis. CONCLUSION: Individuals with arthritis prior to MBS may have higher hazard of long-term mortality than those without pre-operative arthritis.

Clinician Perspectives on Opioid Treatment Agreements: A Qualitative Analysis of Focus Groups.

BACKGROUND: Patients with chronic pain face significant barriers in finding clinicians to manage long-term opioid therapy (LTOT). For patients on LTOT, it is increasingly common to have them sign opioid treatment agreements (OTAs). OTAs enumerate the risks of opioids, as informed consent documents would, but also the requirements that patients must meet to receive LTOT. While there has been an ongoing scholarly discussion about the practical and ethical implications of OTA use in the abstract, little is known about how clinicians use them and if OTAs themselves modify clinician prescribing practices. OBJECTIVE: To determine how clinicians use OTAs and the potential impacts of OTAs on opioid prescribing. DESIGN: We conducted qualitative analysis of four focus groups of clinicians from a large Midwestern academic medical center. Groups were organized according to self-identified prescribing patterns: two groups for clinicians who identified as prescribers of LTOT, and two who did not. PARTICIPANTS: 17 clinicians from General Internal Medicine, Family Medicine, and Palliative Care were recruited using purposive, convenience sampling. APPROACH: Discussions were recorded, transcribed, and analyzed for themes using reflexive thematic analysis by a multidisciplinary team. KEY RESULTS: Our analysis identified three main themes: (1) OTAs did not influence clinicians' decisions whether to use LTOT generally but did shape clinical decision-making for individual patients; (2) clinicians feel OTAs intensify the power they have over patients, though this was not uniformly judged as harmful; (3) there is a potential misalignment between the intended purposes of OTAs and their implementation. CONCLUSION: This study reveals a complicated relationship between OTAs and access to pain management. While OTAs seem not to impact the clinicians' decisions about whether to use LTOT generally, they do sometimes influence prescribing decisions for individual patients. Clinicians shared complex views about OTAs' purposes, which shows the need for more clarity about how OTAs could be used to promote shared decision-making, joint accountability, informed consent, and patient education.

Long-term all-cause and cause-specific mortality for four bariatric surgery procedures.

OBJECTIVE: This retrospective study incorporated long-term mortality results after different bariatric surgery procedures and for multiple age at surgery groups. METHODS: Participants with bariatric surgery (surgery) and without (non-surgery) were matched (1:1) for age, sex, BMI, and surgery date with a driver license application/renewal date. Mortality rates were compared by Cox regression, stratified by sex, surgery type, and age at surgery. RESULTS: Participants included 21,837 matched surgery and non-surgery pairs. Follow-up was up to 40 years (mean [SD], 13.2 [9.5] years). All-cause mortality was 16% lower in surgery compared with non-surgery groups (hazard ratio, 0.84; 95% CI: 0.79-0.90; p < 0.001). Significantly lower mortality after bariatric surgery was observed for both females and males. Mortality after surgery versus non-surgery decreased significantly by 29%, 43%, and 72% for cardiovascular disease, cancer, and diabetes, respectively. The hazard ratio for suicide was 2.4 times higher in surgery compared with non-surgery participants (95% CI: 1.57-3.68; p < 0.001), primarily in participants with ages at surgery between 18 and 34 years. CONCLUSIONS: Reduced all-cause mortality was durable for multiple decades, for multiple bariatric surgical procedures, for females and males, and for greater than age 34 years at surgery. Rate of death from suicide was significantly higher in surgery versus non-surgery participants only in the youngest age at surgery participants.

Long-term cancer outcomes after bariatric surgery.

OBJECTIVE: Obesity is associated with increased cancer risk. Because of the substantial and sustained weight loss following bariatric surgery, postsurgical patients are ideal to study the association of weight loss and cancer. METHODS: Retrospectively (1982-2019), 21,837 bariatric surgery patients (surgery, 1982-2018) were matched 1:1 by age, sex, and BMI with a nonsurgical comparison group. Procedures included gastric bypass, gastric banding, sleeve gastrectomy, and duodenal switch. Primary outcomes included cancer incidence and mortality, stratified by obesity- and non-obesity-related cancers, sex, cancer stage, and procedure. RESULTS: Bariatric surgery patients had a 25% lower risk of developing any cancers compared with a nonsurgical comparison group (hazard ratio [HR] 0.75; 95% CI 0.69-0.81; p < 0.001). Cancer incidence was lower among female (HR 0.67; 95% CI 0.62-0.74; p < 0.001) but not male surgery patients, with the HR lower for females than for males (p < 0.001). Female surgery patients had a 41% lower risk for obesity-related cancers (i.e., breast, ovarian, uterine, and colon) compared with nonsurgical females (HR 0.59; 95% CI 0.52-0.66; p < 0.001). Cancer mortality was significantly lower after surgery in females (HR 0.53; 95% CI 0.44-0.64; p < 0.001). CONCLUSIONS: Bariatric surgery was associated with lower all-cancer and obesity-related cancer incidence among female patients. Cancer mortality was significantly lower among females in the surgical group versus the nonsurgical group.

Central Venous Catheter Placement Gone Awry: A Case Report of Right Internal Jugular Central Line Entering Subclavian Artery.

While central venous access is necessary for a variety of situations including inadequate peripheral venous access, medication administration, hemodynamic monitoring, vasopressor administration, and hemodialysis, complications during the insertion process are not uncommon. In the United States, in both critically ill medical patients and surgical patients, millions of central venous catheters are inserted yearly. Complications occurring during or immediately following insertion include cardiac, pulmonary, and vascular injuries as well as issues with catheter placement. This case report describes a rare malposition of the central venous cannula into the subclavian artery. Few case reports of accidental subclavian artery catheterization have been published following internal jugular vein insertion. While arterial puncture is a well-recognized complication, accidental subclavian artery catheterization is even rarer than carotid artery cannulation. In the literature review, only two documented case reports for reference were found. There are severe risks associated with arterial cannulation including atherosclerotic plaque dislodgement, stroke, hemothorax, pseudoaneurysm, arteriovenous fistula formation, and death. This case follows a 78-year-old man who was brought in by emergency medical services (EMS) minimally responsive with hemodynamic instability - hypothermic, hypotensive, and tachycardic. The emergent decision was made to proceed with central venous catheter placement in the emergency department and placement was initially confirmed with radiologic evidence. Over the admission course, the patient had improvement in hemodynamic instability with minimal change in mental status, however, the need for further testing revealed the central line that was previously functioning without difficulty was arterial. Imaging demonstrated catheter traversed the internal jugular vein and inserting into the right subclavian artery requiring emergent transfer for vascular and cardiothoracic surgery intervention. While a rare complication, this case, differing from previously documented reports due to the delay in discovery, exemplifies how further investigation may be warranted to confirm catheter placement prior to removal to reduce the risk of life-threatening situations.

Depression and Anxiety Incidence During Pregnancy Between Bariatric Surgery Patients and Matched Control Subjects.

PURPOSE: Obesity is a well-known risk factor for depression and mental illnesses. Metabolic and bariatric surgery (MBS) is a common treatment for individuals with severe obesity. Studies suggest that MBS is associated with increased risk of depression. However, little is known if pregnant women following MBS have greater incidence of depression/anxiety than non-surgical pregnant women with severe obesity. MATERIALS AND METHODS: Utah Bariatric Surgery Registry (UBSR) was used to identify subjects who underwent bariatric surgery between 1996 and 2016 and were matched (1:2 matching) to subjects with severe obesity from the Utah Population Database (UPDB). Depression and anxiety diagnoses during pregnancy were identified from birth records and electronic medical records (EMRs) during 10 months before birth. A multivariate logistic regression with clustering due to same subjects with multiple births was used. RESULTS: Patients included 1427 MBS women (associated 2492 births) and 2854 non-surgical women (associated 4984 births). In the surgical group, 24.4% of the pregnancies had diagnosed depression/anxiety, while 14.3% of the pregnancies in the control group had depression/anxiety (p < 0.01). The surgery group had 1.51 times higher odds of depression and/or anxiety during pregnancy than the control group after controlling for covariates (OR = 1.51, p < 0.01). CONCLUSION: The present study provides evidence that women who previously underwent MBS have higher odds of depression/anxiety during pregnancy than women with obesity who did not undergo MBS.

Deductible Status in the Pediatric Population: A Barrier to Appropriate Care?

OBJECTIVE: The objective of this study is to evaluate the impact of high-deductible health plans on elective surgery (tonsillectomy) in the pediatric population. STUDY DESIGN: Cross-sectional study. SETTING: Health claims database from a third-party payer. METHODS: Data were reviewed for children up to 18 years of age who underwent tonsillectomy or arm fracture repair (nonelective control) from 2016 to 2019. Incidence of surgery by health plan deductible (high, low, or government insured) and met or unmet status of deductibles were compared. RESULTS: A total of 10,047 tonsillectomy claims and 9903 arm fracture repair claims met inclusion and exclusion criteria. The incidence of tonsillectomy was significantly different across deductible plan types. Patients with met deductibles were more likely to undergo tonsillectomy. In patients with deductibles ≥$4000, a 1.75-fold increase in tonsillectomy was observed in those who had met their deductible as compared with those who had not. These findings were not observed in controls (nonelective arm fracture). For those with met deductibles, those with high deductibles were much more likely to undergo tonsillectomy than those with low, moderate, and government deductibles. Unmet high deductibles were least likely to undergo tonsillectomy. CONCLUSIONS: Health insurance plan type influences the incidence of pediatric elective surgery such as tonsillectomy but not procedures such as nonelective repair of arm fracture. High deductibles may discourage elective surgery for those deductibles that are unmet, risking inappropriate care of vulnerable pediatric patients. However, meeting the deductible may increase incidence, raising the question of overutilization.

Trajectory of IgG to SARS-CoV-2 After Vaccination With BNT162b2 or mRNA-1273 in an Employee Cohort and Comparison With Natural Infection.

Three COVID-19 vaccines have received FDA-authorization and are in use in the United States, but there is limited head-to-head data on the durability of the immune response elicited by these vaccines. Using a quantitative assay we studied binding IgG antibodies elicited by BNT162b2, mRNA-1273 or Ad26.COV2.S in an employee cohort over a span out to 10 months. Age and sex were explored as response modifiers. Of 234 subjects in the vaccine cohort, 114 received BNT162b2, 114 received mRNA-1273 and six received Ad26.COV2.S. IgG levels measured between seven to 20 days after the second vaccination were similar in recipients of BNT162b2 and mRNA-127 and were ~50-fold higher than in recipients of Ad26.COV2.S. However, by day 21 and at later time points IgG levels elicited by BNT162b2 were lower than mRNA-1273. Accordingly, the IgG decay curve was steeper for BNT162b2 than mRNA-1273. Age was a significant modifier of IgG levels in recipients of BNT162b2, but not mRNA-1273. After six months, IgG levels elicited by BNT162b2, but not mRNA-1273, were lower than IgG levels in patients who had been hospitalized with COVID-19 six months earlier. Similar findings were observed when comparing vaccine-elicited antibodies with steady-state IgG targeting seasonal human coronaviruses. Differential IgG decay could contribute to differences observed in clinical protection over time between BNT162b2 and mRNA-1273.