Good morning. Be sure to check out some prehistoric surgery in our closer look.

How far does the Juul settlement go?

What should we make of Tuesday’s $438.5 million settlement between 30 states and the e-cigarette maker Juul over its alleged marketing toward children? STAT’s Nicholas Florko takes us back to a multibillion-dollar settlement reached two decades ago between states and cigarette companies that changed the way tobacco companies marketed their products. Tobacco control advocates had hoped for something as sweeping and historic this time around, but the Juul agreement (still not public) doesn’t have the same scope for at least two reasons:

The cigarette settlement required tobacco companies to release internal documents on marketing strategies, including how they knew their products caused cancer, but the new Juul settlement doesn’t appear to do so.
Funds from the cigarette settlement were used to set up a foundation dedicated to tackling youth smoking, but the Juul settlement appears to include less specific promises.

Judge invalidates parts of ACA covering some preventive services and drugs

If you thought battles over the Affordable Care Act were in the past, think again. Yesterday a federal judge in Texas ruled that parts of the law mandating that health insurance companies cover many preventive services and drugs for free are unconstitutional. Judge Reed O’Connor also said requiring health plans to cover HIV pre-exposure prophylaxis, or PrEP, at no cost violates religious freedom law. The decision is a temporary win for the plaintiffs, which include Steven Hotze, a physician and conservative activist who has campaigned against the ACA and previously called same-sex marriage a “wicked, evil movement.”

HHS did not immediately say if it would appeal the decision, although it’s considered likely. The requirements that insurers cover some kids’ services, reproductive services, and vaccines still stand for now. In 2018, O’Connor ruled the ACA was unconstitutional but the Supreme Court overturned O’Connor’s ruling in 2021. Read more.

Fentanyl threatens lives. A tool to detect it remains illegal in many states

Fentanyl has made the nation’s opioid epidemic even more deadly. Even so, a tool to detect it is illegal in more than a dozen states. That’s because the $1 test strips are classified as drug paraphernalia, limiting their use to check for unknown toxins in illegal drugs, which increasingly means fentanyl. Some states are widening access to drug-checking tools, but others like Texas and Florida are keeping a hardline stance, arguing that they only serve to facilitate drug use.

It’s an argument familiar to people who advocate harm reduction as a way to save lives. “With limitations on drug-checking mechanisms, really what we’re saying is: People who use drugs don’t deserve to live, and we don’t believe that they care about their health,” Hill Brown, the southern director for Faith in Harm Reduction, told STAT’s Lev Facher. Read more.

Closer look: Prehistoric skeleton reveals oldest surgical amputation

(COURTESY TIM MALONEY)

I don’t know about you, but when imagining amputation before the modern era of surgical sophistication, anesthesia, and infection control, my mind goes to the Civil War. That’s off by many millennia. A new report in Nature documents the successful amputation of a 12-year-old’s lower leg some 31,000 years ago, one that was so skillfully done that the child lived for another six to nine years, according to analyses of the skeleton.

The skeleton’s discovery in a cave on Borneo, in what is now Indonesia, places the oldest known surgical amputation 24,000 years earlier than that of a farmer in France, who had his left arm cut off an estimated 7,000 years ago. As STAT’s Andrew Joseph notes, the Borneo child’s bones showed signs of healing, no lasting indication of infection, and signals that the prehistoric surgeon or surgeons knew how to stanch blood loss. Read more.

Prior stress and depression have stronger link to long Covid than physical conditions

This observational study can’t draw a straight line between cause and effect, but it does spot an intriguing signal between psychological stressors before Covid-19 infection and long Covid after. What’s more, the large study in JAMA Psychiatry found that among the more than 54,000 participants (most of whom were or had been health workers), depression and loneliness were stronger predictors of persistent symptoms than physical conditions like immunosuppression or hypertension.

Depression, anxiety, perceived stress, loneliness, and worry about Covid were associated with a 1.3- to 1.5-fold increase in risk for reporting long Covid symptoms. People who reported two or more types of distress had nearly a 50% increased risk for long Covid. “It’s just the beginning of uncovering this story to really get to, more precisely, the factors that are at play,” Aric Prather of UCSF, who was not involved in the study, told STAT’s Brittany Trang. Read more.

No, the sunshine vitamin doesn't protect you from Covid, two studies say

Here’s another negative finding on taking a substance to reduce the risk of catching Covid or other serious respiratory infections. This wasn’t the thoroughly debunked ivermectin or hydroxychloroquine, but hopes were high for vitamin D and its potential to help our innate immune response to respiratory viruses and bacteria. Most studies to date have been observational and their results have been mixed. Two new, more rigorous studies just out in BMJ report on randomized clinical trials to answer the question.

One tested vitamin D supplements in 6,200 U.K. adults for six months — half took the pills, half didn’t — finding no difference in infections from Covid or other illnesses. The other study asked half of more than 34,000 adults to take cod liver oil, which is rich in vitamin D, vitamin A, and omega-3 fatty acids, for six months. Again, there was no difference in Covid or other infections.

On this week's episode of the "First Opinion Podcast," First Opinion editor Patrick Skerrett talks with pediatric oncologist and cancer researcher, William Woods, who now has ALS, about what Woods sees as the glacial pace of approving an experimental ALS drug. Listen here.

What to read around the web today

In reversal, FDA advisors vote a second time to support approval of Amylyx’s drug for ALS, STAT
Pregnant women held for months in one Alabama jail to protect fetuses from drugs, AL.com
What scientists have learnt from Covid lockdowns, Nature
Clinicians dismiss Black women’s pain. The consequences are dire, Capital B
Gilead drug prolongs survival of women with common form of breast cancer, STAT