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The Scottish Intercollegiate Guidelines Network (2010) evidence-based guidelines state that bariatric surgery should be considered on an individual case basis following assessment of risk/benefit in obese patients with "evidence of completion of a structured weight management program involving diet, physical activity, psychological and drug interventions, not resulting in significant and sustained improvement in the comorbidities. This information is useful in substantiating that the patient has made reasonable attempts to control weight before considering obesity surgery. The guidelines state that preoperative weight loss should be considered for patients in whom reduced liver volume can improve the technical aspects of surgery (Mechanick, et al. Despite limited evidence-based support, it is optimal for patients to demonstrate good eating and exercise habits prior to undergoing bariatric surgery in preparation for the post-surgical regimen. Types of Bariatric Surgery Bariatric surgery for morbid obesity involves reducing the size of the gastric reservoir, contributing to the establishment of an energy deficit by restricting caloric intake. The goal of bariatric surgery is to induce and maintain permanent loss of at least half of the preoperative, excess body weight. This amount of weight loss Page 8 of 49 Coverage Policy Number: 0051 should bring the patient to a weight at which many or most weight-related comorbidities are reverted or markedly ameliorated. Gastroplasty: Gastroplasty, also referred to as stomach stapling, is the prototypical restrictive procedure. A simple gastroplasty involves the stapling of the upper portion of the stomach horizontally. The outlet of the pouch is restricted by a band, which slows emptying, allowing the person to feel full after only a few bites of food. It has been reported in the literature that those who have undergone this procedure seldom experience any satisfaction from eating, and tend to eat more, causing vomiting and tearing of the staple line. The available literature also reports that horizontal stapling alone has led to poor long-term weight loss. Because many simple gastroplasty patients have eventually required some type of revision operation in order to achieve successful weight loss, this procedure has largely been abandoned. The pouch limits the amount of food that can be eaten at one time and slows passage of the food into the remainder of the stomach and gastrointestinal tract. Gastric Banding: In this restrictive procedure, a band made of special material. Adjustable gastric banding refers to bands in which the pressure can be changed without an invasive procedure. The open approach to gastric banding is considered obsolete in practice and has largely been replaced by laparoscopic techniques. The adjustable band can be inflated or deflated percutaneously via an access port (reservoir) attached to the band by connection tubing, based on weight changes. The access port is placed in or on the rectus muscle, allowing for noninvasive band adjustment. Appropriate adjustments, made up to six times annually, are critical for successful outcomes (Buchwald, 2005). Currently, adjustable gastric banding devices approved for marketing in the U. Results showed that 80% of patients demonstrated a 30% loss of excess weight which was maintained at one year. Some patients in Page 9 of 49 Coverage Policy Number: 0051 the study lost no weight, while others lost more than 80% of their excess weight. Approximately 70% of patients experienced an adverse event, most often vomiting and difficulty swallowing. The first band adjustment is typically done approximately four to six weeks after the initial placement. There is no set schedule for adjustments, as the surgeon decides when it is appropriate to adjust the band based on weight loss, amount of food the individual can eat, exercise and amount of fluid currently in the band. Fluoroscopy may be used to assist in locating the access port, or to guide the needle into the port. It is also used after the band has been adjusted to evaluate the pouch size and stoma size. During each adjustment, a very small amount of saline will be added to or removed from the band. The exact amount of fluid required to make the stoma the right size is unique for each person. More than one adjustment may be needed to achieve an ideal fill that will result in gradual weight loss.

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National health registers combined with National quality registers, which contain detailed data of gynaecologic surgery, give an opportunity to investigate the association between obstetric risk factors and adhesions as well as complications in gynaecologic surgery on large scale. The regis ter is validated and covers more than 98 % of all deliveries in Sweden [123, 124]. Information is prospectively collected from standardised prenatal, ob stetrical and neonatal medical records. Data are collected by patient questionnaires (pre operatively, at eight weeks and one year after the surgery) [128]. Information of the surgical pro cedure and per and post-operative complications is retrieved from standard ised tick boxes filled in by the surgeon and the attending physician. Centres of recruitment were all units that were users of the data record system Obstetrix during the time period (23 out of 46). In the second pregnancy, 7,683 women attempted a trial of labour at 42 different maternity units in Sweden and defined the study population. The Obstetrix database provided information about uterine closure dichotomized into single or double layers. The hospitals support a pro active management of extremely preterm births in Sweden, including obstet ric and neonatal interventions from 22 weeks of gestation. If coexisting maternal and fetal conditions prevailed, indication was regarded maternal. The study population consisted of 15,479 women undergoing hysterectomy and/or adnexal surgery. Data from Gynop included demo graphic variables at surgery and details of the surgical procedure. Route of hysterectomy was divided into abdominal or minimally inva sive which included laparoscopic and vaginal approaches. For identified cases with uterine rupture, full surgical reports were ob tained from the maternity departments. Uterine rupture during labour was defined as a full thickness separation of the uterine wall or when a separation covered by the visceral or bladder peritoneum presented with clinical symp toms such as excessive vaginal bleeding, fetal heart rate abnormalities, ab dominal pain or palpable fetal part through the abdominal wall. The diagno sis was confirmed during caesarean section or during laparotomy performed immediately after delivery and, in one case, by abdominal ultrasound that revealed an abdominal haemorrhage and a scar defect of the uterus. Type of uterine incision was divided into low transverse and other types (classic-, T or J shaped or low vertical incision). Presence of adhesions was assessed and filled in by the surgeon as yes, no, mild, moderate or ex tensive by standardised check boxes at time of the gynaecologic procedure. Organ injuries includ ed mild and severe bladder-; vascular-, bowel and ureter injuries identified per-operatively or during the hospital stay and detected ureter injuries within eight weeks post-operatively. Information was retrieved from Gynop, by standardised check boxes, which information of blood loss, duration of sur gery and post-operative infection and hematoma reported by the caregiver either at discharge or at eight weeks follow-up. Statistical methods Measures of disease occurrence the average risk for a group of people of a diseases or health event to occur could be referred to as an incidence proportion. Logistic regression and point estimates In the following papers, the term risk and risk factor refers to an increased incidence of the outcome after exposure. In Paper I, factors from the first and second deliveries and uterine rupture were analysed, and significant factors retrieved from bivari ate analysis and logistic regression were included in the models. In the multiple logistic regres sion model, factors with plausible biologic associations with the outcome were included. The independence assump tion of observations in regression analysis is then violated, hence necessitat ing multilevel regression to be conducted. Factors, selected with the means of logistic regression and with plausible biologic associations with adhesions, were used in the model. Ethical considerations Risk and benefit of the importance of the research question and the integrity of individuals in the research databases were assessed and regarded as being balanced. The Swedish National Board of Health and Welfare keep the key of personal identification number for three years.

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But in reality, any solution that requires a big change in routine or effort is diffcult to implement or continue over time. Therefore, come up with a fall-back plan?something convenient that is close to what you were already doing. Jim was reluctant to consider a less-than-ideal alternative, but he came up with the following plan: Jim decided his fall-back plan would be one he had originally rejected. He decided that, should he and his wife falter in their commitment to prepare frozen meals, he would plan to choose healthier options at a fast-food restaurant. To minimize his risk of choosing old unhealthy favorites, he decided to choose a fast-food restaurant 106 Dealing with Bumps in the Road that mostly offered healthy choices (for example, a sub or pita restaurant). Although he felt it wasn?t the ideal solution, he was confdent he could rely on it; it was similar to his previous behavior and was certainly convenient. To increase his motivation, Jim decided to ask one of the other dads, one who always brought his dog, to join him in walking the feld. Depending on how things go, consider whether you need to modify the plan for future use. Jim found that he actually enjoyed cooking with his wife and feeling more in control of what he would be eating. He struggled the frst few days to get up at the earlier time to exercise, but he adjusted by going to bed a bit earlier the night before. Jim did acknowledge that there might be times in their lives when it would be hard to keep up this level of preparation. He felt good about his efforts to follow his ideal plan, but he was reassured to know that he had a fall-back plan for more challenging times. You may need to fll out the following worksheet many times over the frst few weeks as you identify different situations that have interfered with your eating and activity plan. You can photocopy the blank worksheet and fll out the photocopies or record the answers in a notebook. Situational trigger contributing to the problem: What are some possible solutions to this problem? Solution 1: Solution 2: Solution 3: Solution 4: What are the pros and cons of each possible solution? Solution 1: Solution 2: Solution 3: Solution 4: Which solution is the best ft for you? Be as detailed as possible (what, how, when, where, and who): Once you implement your plan, think about how it went. When you are solving problems around these situational triggers, feel free to take advantage of some of the suggestions we provide. Your friend shows up to watch a movie and brings a bag of chips; he opens the bag and offers you some. These are examples of foods where one bite just seems to lead to the next, until all the food disappears. Give some thought to the foods that seem to trigger your overeating, and make a list below: Your list may include both treat foods and foods that would be considered part of a healthy meal (for example, pasta, bread, or cheese). In resolving how to handle trigger foods, consider the following suggestions: Limit your access to these foods. When you do choose to eat these foods, try to plan things so that you only have access to the serving size you wish to eat. You may wish to stop at a convenience store to pick up one chocolate bar or one small bag of chips. If you have to buy treat foods for others in your home, try to choose foods that aren?t your preference so you won?t be as tempted. Only cook what you think will be eaten at that meal when preparing a trigger food. With treat foods, try to eat them when you have already eaten a meal or snack and aren?t hungry. These foods are meant to bring pleasure into your life; they should not be relied on to alleviate hunger, if possible. Give some thought to the circumstances in which you tend to eat your meals and describe each below: Breakfast: Lunch: 109 the Cognitive Behavioral Workbook for Weight Management Dinner: Snacks: Now evaluate where you eat against the following recommendations: When possible, eat your meals at the table. Spend some time on the presentation of the meal: prepare a plate of food that looks attrac tive and balanced. When you are fnished with your meal, leave the table and make yourself comfortable.

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In addition to the major etiologies of liver cirrhosis (alcohol or hepatitis viruses), 5-10% of cases have rare causes, being secondary to: autoimmune cirrhosis, Wilson cirrhosis (ceruloplasmin deficiency), hemochromatosis, alpha-1-antitrypsin deficiency cirrhosis, primary biliary cirrhosis, drug-induced cirrhosis, and cryptogenic cirrhosis (a rare condition). Thus, in a group of 1200 liver transplants performed in Dallas, almost 10% were performed for cryptogenic cirrhosis. In our group (in an endemic hepatitis virus area), the frequency of cryptogenic cirrhosis is much lower, but this might be due to the fact that cirrhosis is too easily labeled as alcoholic when no other etiological factor can be determined (without taking into account the need for alcohol consumption in a toxic dose for a long enough time). The inspection of the abdomen and chest can reveal collateral abdominal circulation (not a very specific sign) or the presence of spider angiomas (spider naevi) on the chest. Applying pressure makes them disappear, while if the pressure stops they will subsequently reappear, this being a criterion for differentiation of various vascular angiectasis. The patient in dorsal decubitus, with the knees slightly bent for the relaxation of the abdominal muscles, will be asked to perform deep inspiration-expiration movements, which will allow for an accurate liver palpation in order to assess the consistency of the liver. During deep inspiration, the liver will descend (pushed by the diaphragm) and will be easily accessible. After several inspiration/expiration movements, based on palpation, a doctor with good clinical experience will be able to assess if hepatomegaly is present or not, as well as the liver consistency (clinical elastography). We insist on the adequate and correct palpation of the liver, for this method is superior to certain imaging methods used in order to evaluate liver size. Ultrasound examination in liver cirrhosis may reveal multiple changes, but in some cases it can be normal (in up to 20% of cases). Caudate lobe hypertrophy the caudate lobe or the first hepatic segment suffers from hypertrophy in the evolution of liver cirrhosis; therefore it will be frequently enlarged in patients suffering from this condition. Several ways of evaluating the caudate lobe have been described; for example, the calculation of its volume or its relation with the size of the right hepatic lobe. In current practice, the easiest method is to measure the anteroposterior diameter of the caudate lobe by means of ultrasound. In order to differentiate the anteroposterior diameter of the caudate lobe in healthy and cirrhotic subjects, we performed a prospective study which included 200 healthy subjects (126 women and 74 men). Enlarged caudate lobe By comparing these results with a group of 24 cases of known liver cirrhosis, we found that the mean diameter of the caudate lobe in cirrhosis was 47 mm (p<0. These data led us to use the 19 caudate lobe hypertrophy as a sign of liver cirrhosis (Fig. Based on a long ultrasound experience and personal studies, we consider the upper normal limit for the anteroposterior diameter of the caudate lobe to be 35 mm. However, there is an overlapping of normal and cirrhosis cases, so that we generally consider a size of the caudate lobe greater than 40 mm as relevant for cirrhosis (Figs. In current ultrasound practice, approximately 2/3 of cirrhosis cases have a hypertrophic caudate lobe; sometimes with a typical ultrasound appearance (a large, globulous appearance being particularly useful for diagnosis). The caudate lobe size will be used for the diagnosis of liver cirrhosis only in a well known clinical context. Subsequently, the maximum anteroposterior diameter of the caudate lobe should be measured. Measurement of the caudate lobe can be difficult in cases of marked steatosis (ultrasounds are strongly absorbed by fatty tissue) or, more rarely, in the case of ascites. Heterogeneous liver echotexture Liver echotexture changes, particularly hepatic heterogeneity occur in approximately half of cirrhotic cases (Fig. Hepatic heterogeneity is the consequence of fibrous changes that lead to the formation of regenerative nodules. However, there are liver cirrhosis cases without imaging changes of the hepatic echotexture. Liver micronodulation is a histological reality in cirrhosis, but ultrasound cannot evidence these small nodules. The way to accurately diagnose hepatic nodules by ultrasound is to evaluate the liver surface in cases with ascites (Figs. The anterior and, to a smaller extent, the posterior liver surface are easy to examine if ascites is present.

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