patients, followed closely by privately insured patients, but long-term post-ORYGB resolution did not vary further by insurance. Obesity hypoventilation syndrome varied only to 6 months and nearly disappeared in Medicaid, private, and self-pay patients but persisted at nearly 50% of preoperative rates in Medicare. Cholelithiasis increased in Medicaid and Medicare patients but did not change postoperatively in private and self-pay patients. Abdominal hernia resulted most frequently in Medicaid patients through 24 months at rates nearly double the other 3 groups. Abdominal panniculitis increased in self-pay patients to levels more than double the other groups by 24 months. Gastroesophigal reflux disease decreased in all insurance groups but remained higher in Medicaid and Medicare patients vs privately insured patients through 24 months. The significance of increased self-pay alcohol consumption at 24 months is not clear from the data.Private and self-pay patients benefited more from ORYGB than did Medicaid or Medicare patients. Postoperatively, privately insured patients had the lowest rates of 5 weightrelated comorbidities and highest in none. Self-pay patients were highest in 3 comorbidities but resolved 24 others to the lowest levels. Medicaid and Medicare patients were highest in 16 and 11 comorbidities, respectively. Medicare patients were lowest in abdominal hernia. Medicaid patients were lowest in none.Conclusions | Our review of the literature reveals that these variations in outcomes following ORYGB have, to our knowledge, not been reported previously [4][5][6] and are important findings of this study. This advance knowledge can forewarn surgeons of possible results and post-ORYGB problems that may facilitate optimal treatment of these fragile patients.

Ultrasound guided interscalene nerve blocks for perioperative analgesia can be safely and effectively performed in the obese patient but they may be more difficult to perform and analgesia may not be as complete.

An expanding body of literature exists which describes the airway challenges and management options for lingual tonsillar hypertrophy (LTH). The use of retrograde intubation to secure a patient‘s airway in the setting of LTH has been previously unreported and should be considered early in the event of a cannot intubate, cannot ventilate scenario. A 55-year-old man, who had previously been described as an easy intubation, presented an unexpected cannot intubate, cannot ventilate scenario secondary to LTH. Various noninvasive airway maneuvers were attempted to restore ventilation without success. We describe the advantages of early use of wire-guided retrograde intubation as an alternative to a surgical airway for obtaining a secure airway in a patient with LTH, in whom noninvasive airway management maneuvers have failed. Multiple different noninvasive approaches to management of LTH have been previously described including the laryngeal tube, laryngeal mask airway, and fiberoptic bronchoscopy. Unfortunately, none of these noninvasive airway maneuvers successfully ventilated this patient and an invasive airway became necessary. Retrograde intubation is a less invasive alternative to the surgical airway with potentially less risk for complications. Retrograde intubation may be particularly effective in the setting of LTH as it may stent open an otherwise occluded airway and allow passage of an endotracheal tube. Skillful use of this technique should be considered early as a viable option in any case of unexpected difficult intubation due to LTH.

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In RA patients, MRI of the metacarpophalangeal joints can detect specific pathological changes which are observed significantly more often in either early or chronic stages and which are associated with disease activity and duration.