text:
The Centers for Medicare and Medicaid Services (CMS) proposes that National Coverage Determination (NCD) Manual sections 40.5 and 100.1 be modified to be consistent with the following conclusions:
The evidence is adequate to conclude that open and laparoscopic Roux-en-Y gastric bypass (RYGBP) and laparoscopic adjustable gastric banding (LAGB) are reasonable and necessary for Medicare beneficiaries who are under 65 years of age, have a body-mass index (BMI) ≥ 35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity. CMS is seeking comment on this evidence and its implications for coverage, and for the range of patients under age 65 who would be covered. We are particularly interested in comments on the potential to expand coverage for this population under the "Coverage with Evidence Development" (CED) option.
In addition, the evidence is adequate to conclude that approved bariatric surgery procedures for Medicare beneficiaries are reasonable and necessary if the facility performing the procedure meets the following CMS facility standards:
The evidence is not adequate to conclude that open and laparoscopic Roux-en-Y gastric bypass (RYGBP) and laparoscopic adjustable gastric banding (LAGB) are reasonable and necessary for Medicare beneficiaries who are 65 years of age or older; therefore, CMS will non-cover these procedures in this population.
The evidence is not adequate to conclude that the following bariatric surgery procedures are reasonable and necessary and they are therefore non-covered for all Medicare beneficiaries:
The two non-coverage determinations in the National Coverage Determination Manual (NCDM) remain unchanged: Gastric Balloon (NCDM Section 100.11) and Intestinal Bypass (NCDM Section 100.8).
CMS is requesting comment on this proposed decision. We are specifically interested in comments on the potential to cover the 65 and older population under CED. Though we have not finalized the CED Guidance Document, we believe this issue does meet the general guidelines outlined in that draft guidance document. CED would also allow the expansion of national coverage to this older population, with some limitations. Adherence to Departmental regulations including the Health Insurance Portability and Accountability Act (HIPAA, Public Law 104-191) and human research protections (45 CFR Part 46) would, as with all CED, be a requirement.
We are also asking for public comment on the facility criteria to include the potential to establish more definitive bariatric surgery volume criteria for facilities and surgeons. In addition, we believe these standards will best be applied by organizations experienced in this process. Therefore, as part of this proposed decision, we are requesting comment on appropriate entities to apply these standards. We are aware that the American College of Surgeons and the American Society of Bariatric Surgeons have developed accrediting programs and we are specifically asking for comments about their level of competence in performing this facility review.
To: Administrative File: CAG-00250R
Bariatric Surgery in Medicare Beneficiaries - Reconsideration
From: Steve Phurrough MD, MPA
Director, Coverage and Analysis Group
Marcel E Salive, MD, MPH
Director, Division of Medical and Surgical Services
Ross J Brechner, MD, MS(Stat.), MPH
Lead Medical Officer, Division of Medical and Surgical Services
Katherine Tillman, RN, MA
Lead Analyst, Division of Items and Devices
Susan Harrison, MPP
Analyst, Division of Medical and Surgical Services
Deirdre O'Connor, RN, MAS
Analyst, Division of Medical and Surgical Services
Subject: Proposed Coverage Decision Memorandum for Bariatric Surgery for Morbid Obesity
Date: Wednesday, November 23, 2005
The evidence is adequate to conclude that open and laparoscopic Roux-en-Y gastric bypass (RYGBP) and laparoscopic adjustable gastric banding (LAGB) are reasonable and necessary for Medicare beneficiaries who are under 65 years of age, have a body-mass index (BMI) ≥ 35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity. CMS is seeking comment on this evidence and its implications for coverage, and for the range of patients under age 65 who would be covered. We are particularly interested in comments on the potential to expand coverage for this population under the "Coverage with Evidence Development" (CED) option.
The two non-coverage determinations in the National Coverage Determination Manual (NCDM) remain unchanged: Gastric Balloon (NCDM Section 100.11) and Intestinal Bypass (NCDM Section 100.8).
CMS is requesting comment on this proposed decision. We are specifically interested in comments on the potential to cover the 65 and older population under CED. Though we have not finalized the CED Guidance Document, we believe this issue does meet the general guidelines outlined in that draft guidance document. CED would also allow the expansion of national coverage to this older population, with some limitations. Adherence to Departmental regulations including the Health Insurance Portability and Accountability Act (HIPAA, Public Law 104-191) and human research protections (45 CFR Part 46) would, as with all CED, be a requirement.
We are also asking for public comment on the facility criteria to include the potential to establish more definitive bariatric surgery volume criteria for facilities and surgeons. In addition, we believe these standards will best be applied by organizations experienced in this process. Therefore, as part of this proposed decision, we are requesting comment on appropriate entities to apply these standards. We are aware that the American College of Surgeons and the American Society of Bariatric Surgeons have developed accrediting programs and we are specifically asking for comments about their level of competence in performing this facility review.
Obesity is a growing epidemic in the United States with over 60% of the population classified as overweight or obese.1 Overweight and obese persons have an increased risk of a number of diseases compared to those with normal weight and waist circumference. Some of the most important and common co-morbidities include hypertension, dyslipidemia, type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea, respiratory problems, and endometrial, breast, prostate, and colon cancers. Because of the relative lack of success of most weight loss programs, persons with obesity have turned to bariatric surgery at an exponentially increasing rate. Bariatric surgery is the focus of this decision memo.
The National Heart, Lung, and Blood Institute (NHLBI) has classified overweight people into groups based on Body Mass Index (BMI is the body weight in kilograms divided by the body height in meters squared):
By these definitions, approximately 27% of the US population is obese and an additional 34% are overweight. Obesity is more common in women and overweight is more common in men. Obesity is especially common in African Americans, Native Americans, Native Hawaiians, and some Hispanic populations.2 Data for the extent of obesity in the Medicare population indicate that in 1999-2000, 33% of men and 39% of women aged 65-74 were obese as were 20% and 25% respectively over the age of 74.3
Surgical Treatment
Extremely obese persons often do not benefit from the non-surgical treatments for weight loss and weight maintenance.4 The Massachusetts Technology Assessment (TA) reported that weight loss in bariatric surgery studies was of a magnitude greater than weight loss in pharmaceutical or diet studies. It cited a weight loss of 20-40 kg at one or two years in surgical studies versus 2-5 kg in pharmaceutical studies.5
Using data from the National In-patient Survey (NIS), Pope reported that the rate of performing bariatric surgery procedures increased from 2.7 to 6.3 per 100,000 adults from 1990 to 1997.6 During the same time period gastric bypass surgery increased from 54% to 84% of all bariatric surgery in the US.
Several modifications of bariatric surgery have developed over the last several years. Two major types of surgery are now being employed. One diverts food from the stomach to a lower part of the digestive tract where the normal mixing of digestive fluids and adsorption of nutrients cannot occur - a malabsorptive procedure. The other restricts the size of the stomach and decreases intake - a restrictive procedure. Other surgeries combine both types of procedures. Initially, bariatric surgery was developed as an open procedure, but in recent years successful attempts have been made to convert some of the procedures to laparoscopic procedures and new procedures have been developed solely as laparoscopic. The following are descriptions of bariatric surgery procedures:
Roux-en-Y Gastric Bypass (RYGBP) (Open/Lap)
RYGBP achieves weight loss through both gastric restriction and malabsorption. Reduction of the stomach to a small gastric pouch (30 cc) results in feelings of satiety following even small meals. This small pouch is connected to a segment of the jejunum, bypassing the duodenum and very proximal small intestine, thereby reducing absorption. The RYGBP procedure has been performed regularly since the early 1980s and was first performed laparoscopically in the early 1990s. RYGBP is one of the most common types of weight loss procedures in current use, with approximately 50,000 cases performed in 2001.
Biliopancreatic Diversion (BPD) with and without Duodenal Switch (DS) (Open/Lap)
BPD, like RYGBP, combines both restrictive and malabsorptive mechanisms. The stomach is partially resected, but the remaining capacity is generous compared to that achieved with the RYGBP. As such, patients eat relatively normal-sized meals and do not need to radically restrict intake, since the most proximal areas of the small intestine (i.e., the duodenum and jejunum) are bypassed, and substantial malabsorption occurs. Although this procedure is less commonly performed than either banding procedures or RYGBP, the approach is strongly favored by some bariatric surgeons because this procedure appears to yield higher Excess Weight Loss (EWL). The partial biliopancreatic diversion with duodenal switch is a variant of the BPD procedure. Recently, a number of centers in the United States and Canada have begun to perform this procedure, which involves resection of the greater curvature of the stomach, preservation of the pyloric sphincter, and transection of the duodenum above the ampulla of Vater with a duodeno-ileal anastamosis and a lower ileo-ileal anastamosis.
Sleeve Gastrectomy (Open/Lap)
Sleeve Gastrectomy is a 70%-80% greater curvature gastrectomy (sleeve resection of the stomach) with continuity of the gastric lesser curve being maintained while simultaneously reducing stomach volume. It is often the first step in a two-stage procedure when performing RYGBP.
Laparoscopic Adjustable Gastric Banding (LABG) (Lap)
Gastric banding achieves weight loss by gastric restriction, not malabsorption. A band creating a gastric pouch with a capacity of approximately 15 to 30 cc encircles the uppermost portion of the stomach. The band is an inflatable doughnut-shaped balloon, the diameter of which can be adjusted in the clinic by adding or removing saline via a port that is positioned beneath the skin. The bands used today are adjustable, allowing the size of the gastric outlet to be modified as needed, depending on the rate of a patient's weight loss. Today, essentially all of the banding procedures are performed laparoscopically. The open version of adjustable gastric banding (AGB) is not performed at present.
Vertical Gastric Banding (VBG) (Lap)
VBG uses mechanical restriction to cause weight loss, a similar mechanism to that used in LAGB, with no malabsorption component. However, the upper part of the stomach is stapled creating a narrow gastric inlet or pouch that remains connected with the remainder of the stomach. In addition, a non-adjustable band is placed around this new inlet in an attempt to prevent future enlargement of the stoma (opening). As a result, patients experience a sense of fullness after eating small meals. Weight loss from this procedure results entirely from eating less. VBG was one of the more common surgical procedures for weight loss in the late 1980s and early 1990s but has been largely supplanted by LAGB since 1995 and now its role in the treatment of patients with severe obesity is limited. The open version of VBG is no longer performed.
Current Coverage Policies
NCD Manual Section 40.5 Obesity
Obesity may be caused by medical conditions such as hypothyroidism, Cushing's disease, and hypothalamic lesions, or can aggravate a number of cardiac and respiratory diseases as well as diabetes and hypertension. Services in connection with the treatment of obesity are covered when such services are an integral and necessary part of a course of treatment for one of these medical conditions. However, program payment may not be made for treatment of obesity unrelated to such a medical condition since treatment in this context has not been determined to be reasonable and necessary.
NCD Manual Section 100.1 Gastric Bypass Surgery for Obesity
Gastric bypass surgery for extreme obesity is covered under the program if (1) it is medically appropriate for the individual to have such surgery; and (2) the surgery is to correct an illness which caused the obesity or was aggravated by the obesity.
NCD Manual Section 100.8 Intestinal Bypass
The safety of intestinal bypass surgery for treatment of obesity has not been demonstrated. Severe adverse reactions such as steatorrhea, electrolyte depletion, liver failure, arthralgia, hypoplasia of bone marrow, and avitaminosis have sometimes occurred as a result of this procedure. It does not meet the reasonable and necessary provisions of §1862(a)(1) of the Act and is not a covered Medicare procedure. This procedure is not under consideration in this NCD.
NCD Manual Section 100.11 Gastric Balloon
The gastric balloon is a medical device developed for use as a temporary adjunct to diet and behavior modification to reduce the weight of patients who fail to lose weight with those measures alone. It is inserted into the stomach to reduce the capacity of the stomach and to affect early satiety. The use of the gastric balloon is not covered under Medicare, since the long term safety and efficacy of the device in the treatment of obesity has not been established. This procedure is not under consideration in this NCD.
Request for Reconsideration
On May 23, 2005 CMS opened a national coverage determination (NCD) at the request of the American Society for Bariatric Surgery, the American Obesity Association, Ethicon Endo-Surgery Inc. (a Johnson & Johnson company), INAMED Corp., U.S. Surgical, a division of Tyco Healthcare Group LP, and Transneuronix Corp. The requestors asked that Medicare cover the following bariatric surgery procedures:
Surgical treatment for obesity, as addressed in sections 40.5 and 100.1 of the NCD manual, will be reviewed in this NCD. Sections 100.8 and 100.11 were not part of the request and, as we are unaware of any new evidence of benefit from these procedures or the use of these procedures currently, we will not review these sections in this proposed decision memorandum.
Benefit Category Determination
Under 1861(s)(I) bariatric surgery is a physician service and as such qualifies as a benefit.
Bariatric surgery, as considered in this proposed decision memorandum, is used for the treatment of co-morbidities and medical complications related to obesity and, therefore, is not considered cosmetic surgery.
From August 1, 2004 to November 11, 2004 CAG prepared an evidence review and summary of evidence for the MCAC.
On November 4, 2004 the Evidence Review and Summary of Evidence was presented at the MCAC on Bariatric Surgery.
On May 23, 2005 CMS accepted a formal request for reconsideration of the existing policy on gastric bypass and initiated review.
On June 24, 2005 initial comments posted to the tracking sheet available electronically at: http://www.cms.hhs.gov/mcd/viewpubliccomments.asp?nca_id=160.
Surgical procedures are not subject to FDA approval. However, LapBands™ are utilized in some bariatric surgery and the date and content of FDA approval for this device can be found at http://www.fda.gov/cdrh/mda/docs/p000008.pdf
When making national coverage decisions, CMS evaluates relevant clinical evidence to determine whether or not the evidence is of sufficient quality to support a finding of reasonable and necessary. The evidence may consist of external technology assessments, internal review of published and unpublished studies, recommendations from the Medicare Coverage Advisory Committee, evidence-based guidelines, professional society position statements, expert opinion, and public comments.
The overall objective for the critical appraisal of the evidence is to determine to what degree we are confident that: 1) specific clinical questions relevant to the coverage request can be answered conclusively; and 2) the extent to which we are confident that the intervention will improve net health outcomes for patients. A detailed account of the methodological principles of study design the agency staff utilizes to assess the relevant literature on a therapeutic or diagnostic item or service for specific conditions can be found in Appendix 1.
In order to appraise the benefits of bariatric surgery for obese patients in comparison with non-surgical medical management, CMS chose the following outcomes:
The acceptable studies concentrated on these outcomes and our review of the evidence demonstrated these outcomes to be most important when evaluating the effectiveness and impact of bariatric surgery procedures. We also looked for these outcomes in both patients with co-morbidities and without co-morbidities.
We assessed health benefits of bariatric surgery via a review of the literature and through input from the Medical Coverage Advisory Committee (MCAC) that met on November 4, 2004.
Discussion of Evidence Reviewed
1. Questions
Is the evidence sufficient to conclude that the following bariatric surgery procedures will improve net health outcomes for Medicare patients:
The evidence reviewed includes external technology assessments, a CMS internal technology assessment of new or reconsidered evidence, as well as professional society position statements and expert opinion.
2. External Technology Assessments
"Clinical Guidelines On The Identification, Evaluation, And Treatment Of Overweight And Obesity In Adults: The Evidence Report." 1998. National Heart Lung and Blood Institute (NHLBI).
The NHLBI report examined articles from January 1980 through September 1997 regarding gastric bypass, gastroplasty with diet, VBG, horizontal-banded gastroplasty (HBG), BPD, and RYGBP. According to the report, co-morbid conditions improved after VBG and RYGBP. Complications following surgery, however, were frequent and substantial and included readmission, depression, staple line failure, dilated pouch, and dehydration/malnutrition. If less invasive weight loss treatments fail in patients at high risk for obesity-related morbidity or mortality, NHLBI recommended bariatric surgery as an option for carefully selected patients with a BMI >40 or >35 with co-morbidities. There was no discussion of the effects of bariatric surgery of those 65 years of age or older.
"Pharmacological and Surgical Treatment of Obesity." Southern California Evidence-Based Practice Center. RAND Corporation. July 2004: for Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.
Rand reviewed articles dating from 1966 to 2003 regarding gastric banding, VBG and other gastroplasty, jejunoileal bypass, RYGBP, and BPD. The report found that surgery controls obesity-related co-morbid conditions more effectively than non-surgical treatments. No clear differences in mortality or complications exist between different surgical procedures. Overall mortality for bariatric surgery remained between 1 and 2%. No recommendations were made beyond future research priorities. There was limited discussion on bariatric surgery and this assessment did not address bariatric surgery in people 65 years or older.
"Newer Techniques in Bariatric Surgery for Morbid Obesity." The Technology Evaluation Center (TEC) of the Blue Cross and Blue Shield Association. September, 2003.
The Blue Cross Blue Shield TEC examined articles from January 1985 through August 2003 regarding open and laparoscopic gastric banding, BPD, and long-limb gastric bypass. Due to insufficient data, the committee remained unable to confidently evaluate the safety and net health benefit of any of the bariatric surgeries except RYGBP. The TA calculated mortality associated with RYGBP as being between 0.5 and 0.6%. No recommendations were made beyond the acceptance of Roux-en Y as the sole procedure meeting BCBS TEC criteria for coverage. The mean age for study participants did not exceed 50.
"Executive Report." August 4, 2004. Commonwealth of Massachusetts Betsy Lehman Center for Patient Safety and Medical Error Reduction. Expert Panel on Weight Loss Surgery.
The Massachusetts expert panel reviewed articles published between January 1980 and February 2004 regarding RYGBP, VBG , gastric banding, and BPD. The report maintained that laparoscopic and open RYGBP improve or resolve many co-morbid conditions but benefits of LAGB remain unclear. RYGBP risks were reported to be substantial and include pulmonary embolism, intestinal leak, wound infection, staple line failure and long-term nutritional deficiencies. Laparoscopic techniques had a steeper learning curve than other equivalent open procedures. LAGB risks included band and port related problems, GERD, and esophagitis. The LAGB revision rate may have been as high as 10%. LAGB mortality (< 0.5%) was found lower than RYGBP or BPD. The expert panel provided extensive and specific recommendations regarding bariatric surgeons and bariatric surgery programs. There was no discussion of bariatric surgery in the elderly.
"Diagnosis and Treatment of Obesity in the Elderly". University of Pittsburgh. December 18, 2003: for Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.
AHRQ reviewed articles published between January 1980 and February 2003 regarding gastric bypass, LAGB, VBG and DS. According to this assessment, current data were insufficient to evaluate safety or efficacy of bariatric surgery in the elderly. In young obese patients, surgery was shown to improve diabetes, hypertension, dyslipidemia and quality of life (QOL), but higher age increased the perioperative risk of bariatric surgery. The report stated that surgical data was poor and adverse events had the capacity to be very serious, including death. No recommendations were made beyond future research suggestions to analyze effects of surgery in elderly.
"Bariatric Surgery for Obesity". ECRI September 2004: for Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.
ECRI reviewed articles regarding bariatric surgery in persons aged ≥ 18 years, published in 1994 or later having either a randomized controlled trial (RTC) or a before/after comparison with morbid obesity and having sample size of ≥ 10. Concentration was on outcome of QOL and co-morbidity reduction. ECRI found strong evidence that bariatric surgery reduced short-term mortality, labeling it in the range of 0.1 - 1.5%, while data on other outcomes was rated as weak to moderate. This assessment did a separate evaluation of evidence for bariatric surgery in obesity in adolescents (less than 21 years old). This was the only age related assessment of evidence.
"Laparoscopic Bariatric Surgery for Morbid Obesity". ECRI May 2005: for the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.
ECRI reviewed articles regarding a comparison of Laparoscopic to open bariatric surgery published through 1/2005, including studies having an RTC or meta-analysis. The TA concluded that there was not enough evidence to answer the question of outcome differences between open and laparoscopic for the modalities studied. The evidence was not evaluated by age.
3. Internal Technology Assessment
Literature Search
CMS performed a search of the literature using the following terms: Bariatric OR Obesity AND Surgery AND Elderly OR Older. The limitations used were human, English, publication date from 04/04/03 to 09/01/05. The database searched was Medline.
Scientific Articles
Each person on a team of four graded all 213 papers located by our search as either unacceptable or acceptable. Fifty-two papers referenced the elderly and 43 of those papers were published earlier than April 2003. Of all 213 papers, 27 were considered acceptable. Only data from acceptable papers were utilized in our Summary of Evidence. Of special note was that many of the studies reported to date had not had population samples representative of the general severely overweight population with respect to race, ethnicity, cultural or socioeconomic background, gender or age. Also, of note was the paucity of randomized control trials (RCTs), non-randomized control trials (NRCTs), and good quality data for the over age 65 population. Evidence tables for the literature reviewed are in Appendix 2.
Sustained Weight Loss
Five of 27 acceptable articles contained data on sustained weight loss and 1 of 27 articles had data on sustained weight loss in persons over the age of 65. Of the 7 TAs, none had sustained weight loss data on persons over age 65 and 5 of 7 had data on sustained weight loss. We did not find data comparing sustained weight loss in persons having bariatric surgery and at least one pre-op co-morbidity with those having bariatric surgery and no pre-operative co-morbidities.
The Swedish Obese Subjects (SOS) study, a case-control study with respect to outcomes from bariatric surgery,7 reported statistically significant long-term weight loss after different types of bariatric surgery (banding and gastric bypass) as compared to controls (non-surgical management). The study matched subjects at baseline on 18 variables, including gender, age, height, and weight. At eight years of follow-up, among 251 surgically treated patients, the average weight loss was 20 kg (or 16 percent of body weight) as compared to no change in the control group of 232 medically treated patients. Weight loss in the operated group ranged from 4.4-35kg. The SOS study, the only carefully controlled trial with long-term results, also demonstrated that there was approximately 8-9 kg more sustained weight loss in gastric bypass as compared to VBG. Their results provided strong evidence of the superiority of surgical treatment for the patients that were enrolled (37-57 year olds with an average BMI of about 41kg/m2).
The NHLBI TA reported that bariatric surgery (gastric restriction [vertical gastric banding] or gastric bypass [Roux-en Y]) could result in substantial weight loss, and therefore is an available weight loss option for well-informed and motivated patients with a BMI ≥ 40 or ≥ 35 with co-morbid conditions and acceptable operative risks. They also added that RYGBP produced greater long-term weight loss than gastric partitioning alone or VBG and was substantially safer than jejunoileal bypass. The Massachusetts TA reported that open and laparoscopic RYGBP produced short-term weight loss and improvements in co-morbid medical conditions. Dolan reported that BPD with or without DS was effective in producing weight loss. LAGB produced variable short-term weight loss and improvements in obesity-related co-morbidities and had higher average mortality rates than RYGBP or malabsorptive procedures In a case-control study by Dolan et al., it was determined that weight loss was higher in BPD than in LAGB, 64% excess weight loss (EWL) vs. 48%EWL at 24 months.8 In a study by Shen, LAGB was compared to RYGBP and it was pointed out that in LAGB, if patients had more than 6 visits postoperatively, they had 8% more EWL (50% vs. 42%), whereas there was no difference in the RYGBP group.9 Chau, in a study of LAGB, reported that after adjusting for demographics, older patients and patients with pre-existing diabetes mellitus or COPD had greater odds of above average %EWL after bariatric surgery, whereas being female, having a higher BMI, and having hypertension were risk factors for a lower %EWL result.10 Suter, in a prospective randomized study comparing LAGB to the Swedish Adjustable Gastric Band (SAGB), reported that evaluation of short and midterm results of these two modalities showed an equivalent %EWL.11
The one acceptable paper that we found with sustained weight loss in persons close to age 65 was authored by Sugerman (2004). He reported on a cohort of 80 patients over age 60 with an average age of 63 years. His paper reported that, at 5 years after bypass surgery, there was an average of 27% weight loss, and 50% EWL.12 Finally, in the Gonzalez study of bypass surgery for obesity in persons over age 50, weight loss plateaued at 18 months with EWL averaging 68%, similar to that in younger age groups.13
Short-term mortality
In our CMS overall review, 8 of 27 acceptable papers and 4 TAs reported data on short-term mortality results, two of which pertained partially to persons over 65. We were unable to locate any data comparing short-term mortality in persons having bariatric surgery and at least one preoperative co-morbidity, with those having bariatric surgery and no preoperative co-morbidities. The Buchwald article reported the rates of short-term mortality to be 0.1% for purely restrictive procedures, 0.5 % for gastric bypass, and 1.1% for BPD or DS.14 Flum reported a short-term mortality rate in Medicaid bariatric surgery (gastric bypass) patients of 1.9% and that 81% of the short-term mortality cases were associated with surgeon inexperience. Inexperienced bariatric surgeons, defined in this study as a bariatric surgeon who had performed less than 20 operations, performed nineteen percent of all surgical cases in that study.15 Data from that paper yielded approximately 6.0% short-term mortality rate in the hands of inexperienced surgeons, while the rate for experienced bariatric surgeons was 0.5%. In another paper analyzing compete Medicare claims data from 1997 to 2002, Flum reported that the short-term mortality rate in persons over age 65 was 4.8% as compared to 1.7% for those under age 65. This paper also found a reduction in all-cause mortality directly associated with surgeon experience.16 Livingston recently reported a rate of 3.2% in persons over 65 as compared to 1% for those under age 65.17 In Herron's review, short-term mortality relating to gastric banding and gastric bypass was in the range of 0.0-1.0%, while in BPD or DS, it was higher at 0.5%-2.5%.18 In the Pope study of the National In-hospital Survey (NIS) in-hospital mortality for all bariatric surgery was reported to be 0.37% from 1990 to 1997. In the Massachusetts TA, LAGB had a short term mortality rate of < 0.5%. The overall VBG range of short-term mortality was 0-1.4%14, 19and for all of bariatric surgery, short-term mortality ranged from 0.1% to 2.0%.14,18,19
In two cohort studies by Fernandez, risk factors for peri-operative death in open or laparoscopic gastric bypass were postoperative leak, pulmonary embolus, higher pre-operative weight, and hypertension. Other risk factors for mortality were age, male gender, having diabetes, and having had a specific surgical procedure with RYGBP having a 2.7% short-term mortality rate, open RYGBP a 1.5% short-term mortality rate and LRYGBP a 0.5% rate. There were no deaths in persons older than 60 (number of cases over age 60 not shown in paper) despite the fact that being a higher age was predictive of a higher chance of mortality.20,21 Livingston found that male gender is a predictor of mortality for patients undergoing gastric bypass surgery.22
With respect to longevity, 4 of 27 of our acceptable articles had data on longevity and 2 of 27 had longevity data on persons over the age of 65. Of the 7 TAs we reviewed, none had any data on longevity. We were unable to locate any data comparing longevity in persons having bariatric surgery and at least one pre-operative co-morbidity, with those having bariatric surgery and no pre-operative co-morbidities.
There was some evidence that bariatric surgery patients had prolonged longevity and less Years of Life Lost (YLL). Black males aged 30, with a BMI of 40, had 8YLL as compared to 5YLL for white males aged 30 with the same BMI. White females aged 30, with BMI of 40 had roughly the same YLL as white males (4-5). These differences almost disappeared for persons aged 60 and above with a BMI of 40, with black females actually having negative years of life lost at higher ages.23 Flum reported an increase in longevity in those post-bariatric surgery Medicaid patients given that they survived to year one after the surgery.
Nine of 27 of our acceptable articles had data on co-morbidities; however, none had co-morbidity data on persons over the age of 65. Of the 7 TAs we reviewed, none had co-morbidity data on persons over age 65 and 4 of 7 had data on co-morbidities in the general population.
Regarding the prevalence of co-morbidities in the population eligible for bariatric surgery, Pope demonstrated that the percentage of persons that had obesity surgery and had at least one major pre-operative co-morbidity was estimated to be 20.8% in 1990 and 31.4% in 1997. Yet in Gonzalez' cohort study, for persons 50 years old or older, 47 of 52 (90%) had co-morbidities such as degenerative joint disease 60%, diabetes and gastroesophageal reflux disease (GERD) 40%, and hypertension 56%. Approximately 90% of each type improved post-operatively with the exception of hypertension where 56% improved. In a study by Residori, 57% of patients had at least one metabolic complication with 30% having diabetes, 38% dyslipidemia, and 38% hypertension.24 Approximately one-third of the diabetes cases and one-half of the dyslipidemia and hypertension cases were previously undiagnosed. Dindo calculated, after adjustment for BMI and age, that the occurrence of dyslipidemia was higher in Caucasians than Hispanics or African Americans, while hypertension rates were about the same.25
In the Swedish Obesity Study (SOS), ten-year follow-up of 1006 post-bariatric surgery patients aged 37 to 57 years showed that the two-year incidence rates of diabetes, hypertension, and low high density lipoprotein (HDL) were statistically significantly higher in the control group (diabetes 16% vs. 0.5%, hypertension 23% vs. 6.0%, and elevated HDLs 16% vs. 5.0%). From the SOS, Sjostrom/ reported that the post-op prevalence of hypertension, after 8 years follow-up, showed no difference between VBG cases and controls, while there was a statistically significant lowering of hypertension in the group that had GBP as compared to the control group. One important study, the Adelaide Study (Dixon-1988), showed that medical co-morbidities ether improved (47%) or resolved (43%) in all but 4 cases (9% of patients had unsatisfactory weight loss). They reported that 60 percent of the patients who initially had any obesity-related co-morbidity were free of medication for those co-morbidities 3 years after surgery. Buchwald reported that for all types of bariatric surgery, diabetes completely resolved in 77% of cases, and improved or resolved in 86%; hypertension completely resolved in 62% and improved or resolved in 78%; hyperlipidemia improved in 70%; and obstructive sleep apnea (OSA) was resolved in 85%. In Dolan's case-control study the resolution of co-morbidities was similar across groups having BPD as compared to those having LAGB, ranging from 66% in hypertension to 100% of OSA.
In our CMS review, 6 of 27 acceptable papers and 4 of 7 TAs reported data on complications in patients, while 2 of 27 acceptable papers and no TAs reported data on persons over 65 years. We were unable to locate any data comparing complication rates in persons who had bariatric surgery and at least one pre-op co-morbidity, with those having bariatric surgery and no pre-op co-morbidities.
In a study by Shikora, involving a series of 750 consecutive patients undergoing LRYGBP at a high volume academic center, the complication rate was reduced by more than 50% when comparing the first 100 cases against the next 650 in the program regardless of performing surgeon experience.26
The Massachusetts TA reported that laparoscopic adjustable silicone gastric banding (LAGB) had a lower complication rate than the other bariatric surgery procedures. The Dolan study showed that LapBPD had a markedly higher rate of complication (56%) as compared to 6.3% in LAGB. Heron's review underscored the difference in rates of complications from RYGBP and BPD versus VBG. For example, bypass procedures had lower re-operation rates and LAGB had lower wound infection rates. In that study, the LAGB complications were somewhat lower than those in either RYGBP, BPD, or VBG and a known complication of LRYGBP was conversion from LRYGBP to the open procedure during surgery. A study by Felix showed that 3% of laparoscopic procedures were converted to open, while other studies showed a range of 1.6% re-operations in RYGBP, 11.3% in VBG, and 7.7 to 10% in LAGB.27 In the converted group, risk factors for conversion were higher age, higher weight, and male gender.
In other types of complications, Fernandez identified risk factors for having a leak as male gender, having diabetes, and RYGBP; both LRYGBP and open RYGBP. In general, the NHLBI reported that wound infections ranged from 2.3% in laparoscopic cases to 11.4% in open cases. In the Livingston study on procedure and in-hospital complication rates using NHIS data, risk factors for complications were higher age, and being male. In that study, the most frequent complication was pneumonia (at 2.6%), while the short-term mortality rate was 0.4%. Over the 1990 to 1997 period, Pope found significant decreases of in-hospital re-operations for bleeding, abscess, or dehiscence (2.2% to 1.4%); respiratory complications (7.4% to 5.9%); and a trend toward decreased in-hospital complications. The Rand TA reported reduced occurrence of wound and incisional hernia complications in patients treated laparoscopically, compared to open procedures. Malnutrition occurred in 2.5% in VBG to 16.9% in RYGBP and 5.8% for all bariatric surgery.1,2 Notable in another Livingston study was that male gender was a predictor of morbidity for patients undergoing gastric bypass surgery.28
4. Medicare Coverage Advisory Committee (MCAC) - (See Questions in Appendix 3)
At the MCAC meeting on bariatric surgery held on November 4, 2004, a number of questions were presented to the committee for consideration. CMS created a Summary of evidence for the MCAC and it is available at Summary of Evidence. A summary of the MCAC recommendations is presented below.
5. Guidelines
Evidence Based - After vigorous search on the terms "Bariatric Surgery", "guidelines" AND "evidence-based", CMS was unable to locate true evidence-based guidelines for bariatric surgery. There were consensus-based guidelines. For example, a search of the National Guideline Clearinghouse website yielded "Guidelines for the Clinical Application of Laparascopic Surgery" published by Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) based on expert consensus.
Certification/recertification - The American College of Surgeons, the American Society of Bariatric Surgeons and SAGES have published criteria for certification and recertification. These criteria can be found at the following urls:
6. Professional Society Statements
CMS received comments from three professional societies.
The American College of Surgeons (ACS) commented that the evidence is adequate to evaluate the following bariatric surgery procedures: open and laparoscopic Roux-en-Y gastric bypass, adjustable gastric banding, biliopancreatic diversion with duodenal switch and vertical banded gastroplasty. ACS does not feel it is necessary for CMS to define a list of co-morbid conditions to qualify patients for bariatric surgery. ACS urges CMS to limit coverage to those facilities and surgeons meeting specific standards. They suggest that the standards they have established for their Bariatric Surgery Center Network are appropriate for all patients. In addition, ACS recognizes the limited data available on outcomes of bariatric surgery on the elderly and supports the need for continuous monitoring and evaluation of the surgical care for the morbidly obese. ACS has developed a Bariatric Surgery Module under its National Surgical Quality Improvement Program (NSQIP) registry and is prepared to modify it to collect any additional data. ACS does note that preoperative psychiatric evaluation and pre- and postoperative nutritional counseling are essential parts of any successful bariatric surgery program. Finally, ACS recommends that CMS cover bariatric surgery limited to programs with the necessary resources and standards and offers the College's Bariatric Surgery Center Network to serve as a basis for identifying and approving qualified programs.
The North American Association for the Study of Obesity (NAASO) offered that surgery is appropriately placed in the continuum of obesity treatments. NAASO feels that the evidence is adequate to support the safety and effectiveness of the surgical options included in the requested NCD. They agreed with listing the currently known co-morbid conditions related to obesity with the understanding that the list continues to expand as research continues to expand knowledge on this issue. Concern was expressed that obese patients should not be denied access to care because the condition is not included on the list. NAASO supported the inclusion of criteria for surgeons and facilities and suggested the use of the criteria used by the surgical societies. Finally, NASSO supported the need for the collection of data especially in the elderly population. However, they expressed concern about making sure the data collection process did not become so burdensome that it might reduce the number of participating providers. They suggested collaboration with physicians on the data collection process. NASSO also encouraged the inclusion of coverage for perioperative care to ensure the best outcomes.
The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) strongly endorsed coverage of Bariatric surgery. They stated that "It will be critical to identify centers with good outcome data and to use that to channel patients for care to ensure the best value for our healthcare dollars".
7. Expert Opinion
None received
8. Public Comments
Initial Public Comments
After initiating the NCD process, the tracking sheet was posted marking the initial 30 day public comment period which began May 24, 2005. CMS utilizes the initial public comments to inform its proposed decision. We will respond in detail to the final public comments on this proposed decision.
In addition to general concerns, CMS requested public comment on the following issues.
CMS received one hundred and sixty nine public comments; seventy-eight percent are positive comments in support of providing coverage for bariatric surgery for obesity and twenty-two percent are negative and opposed to coverage by Medicare of bariatric surgery. The comments that specifically addressed the four issues posted on the tracking sheet are summarized separately.
The general comments in support of coverage of bariatric surgery are numerous and varied. There are a number of comments that declared that obesity is a disease not a choice. A common theme throughout many of the positive comments is that many of the co-morbid conditions associated with obesity (e.g., diabetes, hypertension, sleep apnea, reflux disease, high cholesterol, debilitating joint pain, and many others) are either greatly relieved or even eliminated after successful weight loss surgery. There are cost benefit references that state that the cost of treating the co-morbid conditions that plague the morbidly obese are greater than the cost of the surgery. There is also reference to the fact that people who successfully undergo this surgery are able to get off of disability and return to work. One commenter feels that "Cost and clinical data unequivocally supports coverage for weight loss surgery." Another commenter stated "Co-morbidities of obesity are costly and bring suffering and enormous expense to all involved. WLS [weight loss surgery] is the only research proven, successful treatment for weight loss."
There are a number of comments stating that weight loss surgery is the only effective means for weight loss for the morbidly obese. There are a large number of testimonials in support of coverage from people who have had weight loss surgery and health care professionals who have been involved in the care of these patients. There are many references to the improved quality of life that this surgery offers.
There are suggestions about also including coverage for mini-gastric bypass procedure as well as long term follow up care. Some comments reflect that this is a great tool for preventive medicine. (This procedure is statutorily prohibited as a preventive measure.)
The Blue Cross and Blue Shield Association (BCBSA) comments that in June of 2005 the Technology Assessment Center (TEC) Medical Advisory Panel (MAP) reaffirmed a previous assessment that available evidence for laparoscopic adjustable banding, biliopancreatic diversion, and long-limb gastric bypass was not sufficient to form conclusions on the benefits and risks compared to open gastric bypass. BCBSA further states that the MAP will review the reassessment of laparoscopic gastric bypass at its fall, 2005, meeting. The MAP also expresses concerns about the number of bariatric surgery procedures performed outside of multidisciplinary programs. BCBSA feels that studies are needed to compare outcomes for bariatric surgery to those of non-surgical alternatives. Further, BCBSA lists in their comments the draft programmatic requirements for bariatric centers of excellence. Finally, BCBSA cites the need for a national registry to promote quality improvement which will require funding, management, and oversight. More specific comments from BCBSA to each of the posted questions are incorporated into to summary for each question.
Several of the negative comments suggest that there is a prejudice and bias toward the obese and that providing coverage supports that bias. A number of the commenters cite recent information from the CDC and other sources that contradicts the impression that obesity and premature mortality are linked. There are a number of comments referencing that the support of this surgery is influenced by the potential profit that can be made and that organizations other than the surgeons and companies that financially benefit should be consulted prior to any coverage decision.
The feeling that life style interventions and non-surgical services such as nutritional counseling, physical therapy and non-weight bearing exercise are a better alternative is identified. Providing subsidized nutritious foods and safe places to exercise is also suggested. Many express thoughts that surgery is a bad idea. Some consider this surgery an amputation and mutilation of major organs of the body which can not be a good thing.
Twenty-one negative comments cite that this is a dangerous surgery with one comment calling it "a dangerous procedure with horrific side effects". The feeling that this surgery is still experimental in terms of whether it achieves long term health improvements and objections to spending Medicare funds is expressed in a number of the comments. Some also refer to problems of weight loss in people over 60 and that it might increase the risk of serious illness in this age group. There is also reference to the fact that the weight loss after surgery is not sustained and much of the weight is regained.
Comments specific to each of the four questions that were posted are summarized as follows.
Question 1. Is the evidence adequate for evaluating health outcomes of the Bariatric surgery procedures listed in the request? Of the 169 comments, we received twenty comments that specifically addressed this question. Of the twenty comments, twelve commenters suggest that there is not adequate evidence for evaluating health outcomes of the bariatric surgery procedures listed in the request. Seven commenters specifically note an absence of long-term data and studies on bariatric surgery. One commenter suggests that the rate of complications for bariatric surgery is unacceptable. Of the twenty comments, ten commenters suggest that there is adequate evidence for evaluating health outcomes of the bariatric surgery procedures listed in the request. Commenters note improved outcomes and fewer co-morbidities as evidence that bariatric surgery is an effective treatment.
Question 2. Should CMS define the list of co-morbid conditions that qualify a patient for Bariatric surgery? Of the 169 comments, we received eight comments that specifically addressed this question. Seven commenters suggest that CMS should define a list of co-morbid conditions that qualify a patient for bariatric surgery. One commenter suggests that CMS should not create a list of co-morbid conditions that would qualify a patient for bariatric surgery because over time science could reveal more obesity related conditions that would not be on the list of conditions.
Question 3. Should CMS adopt criteria for facilities or surgeons who deliver these procedures? Twenty comments posted to the web site in some way reference the adoption of criteria for facilities or surgeons who are involved in these procedures. All are generally supportive of the development of criteria/guidelines; however some commenters feel that CMS should not be developing the criteria/guidelines. There are a number of suggestions to use the qualifications set up by the bariatric surgery specialists specifically mentioning the American Society of Bariatric Surgery. Some of the comments reference Centers of Excellence as providing safe and effective provider and facility choices because they have rigorous standards and verified results.
Question 4. Is there a need for routine data collection on the delivery or outcomes of bariatric surgery? Seven comments posted to the web site reference the need for data collection. Generally, these comments are supportive of the need for collecting data. It is suggested that this should be a condition of coverage with a public-private collaboration to establish a national registry. Some feel this would promote quality improvement and provide information on the optimal procedure for the different types of patients. One commenter expresses concern because the Medicare population makes up a very small percentage of the focus population and this might cause a redirection of resources that should be aimed at the non-Medicare population. The question was presented, "If CMS allows coverage and links it to collection of evidence, how will CMS target such research and what clinical questions will CMS seek to answer?" This commenter feels that "CMS should refrain from applying coverage with evidence development (CED) until its guidance document has been finalized and the appropriate application of CED is defined through the public comment process." Additionally, concern is expressed about CMS creating policy that will limit access for patients who need such important treatment.
National coverage determinations (NCDs) are determinations by the Secretary with respect to whether or not a particular item or service is covered nationally under title XVIII of the Social Security Act § 1862(l)(6)(A). In order to be covered by Medicare, an item or service must fall within one or more benefit categories contained within Part A or Part B, and must not be otherwise excluded from coverage. Moreover, with limited exceptions, the expenses incurred for items or services must be "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member." § 1862(a)(1)(A) of the Act.
Medical treatment for obesity includes dietary manipulation, behavior modification and medication. These therapies have been tried individually and in combination, but with only limited long-term success. However, based on the lower risk-benefit ratio for medical treatment, we believe it should be routinely attempted and shown to be unsuccessful before considering a patient for bariatric surgery. There are no consistent standards in the literature regarding length of a medical treatment trial and, therefore, we are unable to specify a specific time interval. A number of trials and guidelines recommend 6 to 12 months and we believe that to be reasonable.
In our review we found, in the general population, that post-surgical sustained weight loss may be an attainable goal with combination or malabsorptive procedures showing greater weight loss than restrictive procedures, which, in turn, demonstrate significantly more weight loss than no surgery. The NCD requestors recommended that bariatric surgery procedures be covered for beneficiaries with a BMI ≥ 35% with at least one co-morbidity or with a BMI ≥ 40% without any co-morbidity. In general, for outcomes of short-and long-term mortality, improvement in co-morbidities, sustained weight loss and complications of surgery, we found there is little or no data enabling comparisons of persons who had at least one pre-operative co-morbidity with those who had none. We did find supporting evidence that sustained and sufficient weight loss may improve or resolve co-morbid conditions. Buchwald et al., in their JAMA metanalysis, reported that overall, bariatric surgery resulted in a 61.2% (58.1 -64.4) EWL. They also reported that, as a result of that EWL, co-morbidities such as diabetes, hyperlipidemia, obstructive sleep apnea and hypertension improved or resolved in a majority of patients. The data are consistent with the conclusion that health benefits of surgery are limited to those persons with one or more co-morbidities related to obesity. Therefore, we believe that bariatric surgery should be reserved for that group.
With respect to Medicare beneficiaries under the age of 65 years, we found that there was sufficient evidence to support open and laparoscopic RYGBP and LAGB as reasonable and necessary for selected patients in this younger population. For these two modalities, sustained weight loss was well documented (ranging from an approximate mean of 50% EWL in RYGBP to approximately 30-50% in LAGB) and short-and-long-term mortality were low (<2%).1,4,14,5,7 However, we found that data supporting open vertical banded gastroplasty, laparoscopic vertical banded gastroplasty, open sleeve gastrectomy, laparoscopic sleeve gastrectomy, open adjustable gastric banding and open and laparoscopic biliopancreatic diversion with or without duodenal switch are generally sparse and not adequate to draw conclusions in this population. Thus, we non-covered these procedures; i.e., they are not reasonable and necessary in this group of beneficiaries. We will review any additional data submitted during the public comment period to determine possible revision of this noncoverage.
With respect to the Medicare population age 65 years and older, we were unable to find adequate data that either demonstrated a net health benefit of bariatric surgery in this population or enabled generalization of data for younger persons to this population. The one TA addressing the older Medicare population was also unable to locate sufficient data. Though the MCAC recommended, with a moderate level of confidence, that the results from trials in younger populations could be generalized to the population ≥65 years of age, subsequently published data on the higher surgical risks in this population demonstrated a higher surgical risk than the data available to the MCAC, with one exception. The overall surgical risk in persons over 65 years of age is higher than that in the younger population. Flum reports mortality rates in the 65 and older population to be 2.8 times higher at 30 days, 3 times higher at 90 days and 2.85 times higher at one year, when compared to the population under age 65. Surgeons in the highest quartile of bariatric surgery procedure volumes had similar rates of early mortality in both age groups (1.8 % 90 day mortality in patients less than 65 years and 1.1 % mortality in patients greater than 65 years). Since there are no clinical trial data in the older population and the surgical risk is significantly higher we believe that it is inappropriate to perform this surgery in this population and thus do not believe that, with the data available that any bariatric surgery procedure is reasonable and necessary for the Medicare population age 65 and older.
CAG commonly reviews published data that include patients younger than 65. In those cases if we determine a benefit in that younger population, we then evaluate the potential of generalizing this data to the 65 or over Medicare population. We look at a number of factors and include biologic and pathophysiologic as well as adverse outcome data. For bariatric surgery in the older age group, the higher surgical risk makes generalization of data on bariatric surgery to that population difficult. Thus, we are proposing noncoverage of this population. CMS has developed a concept known as "Coverage with Evidence Development (CED)". (See http://www.cms.hhs.gov/coverage/guidance.asp.) Some commenters recommended that option for this decision. We are requesting public comment on the potential to revise this noncoverage and apply this CED concept through clinical trials and/or prospective cohort studies comparing surgery with non-surgical management for the age 65 and older population and to potentially broaden coverage of the under 65 population. Adherence to Departmental regulations including the Health Insurance Portability and Accountability Act (HIPAA, Public Law 104-191) and human research protections (45 CFR Part 46) would, as with all CED, be a requirement.
We also found that while short-term mortality is low, experienced surgeons performing bariatric surgery have a lower rate of short-term mortality than inexperienced surgeons. Flum also found an indication that longevity was decreased in persons with high BMI, and increased in persons having bariatric surgery if they survived to one-year post surgery. In the younger age group, in addition to the limitations above, we are also concerned with the significant variation in outcomes among surgeons. Higher short-term mortality is also of particular concern in the elder population. Both Flum and Livingston have demonstrated the increased mortality in the older population undergoing bariatric surgery and Flum has demonstrated the marked variability in outcomes based on surgical experience.16,17 This increased risk has led the American College of Surgery and the American Society of Bariatric Surgeons to develop criteria for facilities performing this surgery. They, along with numerous other commenters, strongly support CMS limiting coverage of these procedures to centers of excellence. In addition to surgeon qualifications, the Societies and the commenters list other facility criteria crucial to good outcomes. We have integrated these comments into our proposed standards. Thus, we have determined that bariatric surgery procedures are reasonable and necessary only if performed in facilities that have demonstrated competence in managing patients preoperatively, perioperatively and postoperatively. Therefore, for all Medicare beneficiaries undergoing RYGBP or LAGB, these procedures must be performed in facilities that have met the following facility standards:
We are asking for public comment on these criteria to include the potential to establish more definitive bariatric surgery volume criteria for facilities and surgeons.
We believe these standards will best be applied by organizations experienced in this process. Therefore, as part of this proposed decision, we are requesting comment on appropriate entities to apply these standards. We are aware that the American College of Surgeons and the American Society of Bariatric Surgeons have developed accrediting programs and we are specifically asking for comments about their level of competence in performing this facility review.
The Centers for Medicare and Medicaid Services (CMS) proposes that National Coverage Determinations (NCD) Manual sections 40.5 and 100.1 be modified to be consistent with the following conclusions:
1 Pharmacological and Surgical Treatment of Obesity. Southern California Evidence-Based Practice Center RAND Corp. May, 2004: for Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.
2 NHLBI - CLINICAL GUIDELINES ON THE IDENTIFICATION, EVALUATION, AND TREATMENT OF OVERWEIGHT AND OBESITY IN ADULTS The Evidence Report - NHLBI - 1998 - NO. 98-4083 SEPTEMBER 1998 NATIONAL INSTITUTES OF HEALTH National Heart, Lung, and Blood Institute in cooperation with The National Institute of Diabetes and Digestive and Kidney Diseases.
3 Flegal KM, Graubard BL, Williamson DF. Methods of calculating deaths attributable to obesity. Am J Epid.2004;4:331-338.
4 Livingston EH. Procedure incidence and in-hospital complication rates of bariatric surgery in the United States. Am J Surg. 2004 Aug;188(2):105-10
5 Commonwealth of Massachusetts Betsy Lehman Center for Patient Safety and Medical Error Reduction Expert Panel on Weight Loss Surgery Executive Report August 4, 2004.
6Pope GD, Birkmeyer JD, Finlayson SR. National trends in utilization and in-hospital outcomes of bariatric surgery. J Gastrointest Surg 2002;6:855-860;discussion 861.
7 Sjostrom CD, Peltonen M, Wedel H, Sjostrom L. Differentiated long-term effects of intentional weight loss on diabetes and hypertension.Hypertension. 2000 Jul;36(1):20-5.
8Dolan K, Hatzifotis M, Newbury L, Fielding G. A comparison of laparoscopic adjustable gastric banding and biliopancreatic diversion in superobesity Obes Surg. 2004 Feb;14(2):165-9.
9 Shen R, Dugay G, Rajaram K, et al. Impact of patient follow-up on weight loss after bariatric surgery. Obes Surg. 2004 Apr;14(4):514-9.
10 Chau WY, Schmidt HJ, Kouli W, et al. Patient characteristics impacting excess weight loss following laparoscopic adjustable gastric banding. Obes Surg. 2005; 15:346-350.
11 Suter M, Guisti V, Worreth M et al. Laparascopic Gastric Banding: A prospective randomized study comparing the Lapband and the SAGB: early results. 2005:241;1:55-62.
12 Sugerman HJ, DeMaria EJ, Kellum JM, et al. Effects of bariatric surgery in older patients. Ann Surg. 2004 Aug;240(2):243-247.
13 Gonzalez R, Lin E, Mattar S et. al. Gastric bypass for morbid obesity in patients 50 years or older: is laparoscopic technique safer? Am Surg. 2003 Jul;69(7):547-53; discussion 553-4.
14 Buchwald H, Avisor Y, Braunwald E, et. al. Bariatric Surgery: a systematic review and meta-analysis;JAMA 2004;292:14:1724-1737
15 Flum DR, Dellinger EP Impact of gastric bypass operation on survival: A Population-Based Analysis. J Am Coll Surg 2004;199:543-551.
16 Flum DR, Salem L, et al., Early mortality among Medicare Beneficiaries undergoing bariatric surgery. JAMA, 10/2005; In press
17 Livingston E, NHIS data from 2001-2002 analyzed for bariatric surgery outcomes. Archives of Surgery: 2005
18Herron DM. The surgical management of severe obesity. Mt Sinai J Med. 2004 Jan;71(1):63-71.
19 Bariatric surgery for morbid obesity, Medical Advisory Panel, June 2003
20 Fernandez-Lobato R, Cerquella C, Serantes A, et al.M Multivariate analysis of risk factors for death following gastric bypass for treatment of morbid obesity. Ann Surg. 2004 May;239(5):698-702; discussion 702-3.
21 Fernandez AZ, DeMaria EJ Tichansky DS et al.. Experience with over 3000 open and laparoscopic bariatric procedures:multivariate analysis of factors related to leak and resultant mortality. Surg Endosc. 2004 Feb;18(2):193-7. Epub 2003 Dec 29.
22 Livingston EH, Huerta S, Arthur D, Lee S, De Shields S, Heber D. Male gender is a predictor of morbidity and age a predictor of mortality for patients undergoing gastric bypass surgery. Ann Surg. 2002 Nov;236(5):576-82.
23 Fontaine KR, Redden DT, Wang C, Westfall AO, Allison DB. Years of life lost due to obesity.JAMA.2003;289:2:187-193.
24 Residori L, Garcia-Lorda P, Flancbaum L, Pi-Sunyer FX, Laferrere B. Prevalence of co-morbidities in obese patients before Bariatric Surgery: effect of race.Obes Surg. 2003 Jun;13(3):333-40.
25 Dindo D, Muller MK, Weber M, Clavien PA. Obesity in general elective surgery. Lancet. 2003 Jun 14;361(9374):2032-5.
26 Shikora SA, kim, JJ, Tranoff ME et al. Laparoscopic roux-en-y gastric bypass:results and learning curve of a high-volume academic program. Arch Surg.2005;140:362-367.
27Felix EL, Swartz DE. Conversion of laparoscopic Roux-en-Y gastric bypass. Am J Surg. 2003 Dec;186(6):648-51.
28 Livingston EH, Huerta S, Arthur D, Lee S, De Shields S, Heber D. Male gender is a predictor of morbidity and age a predictor of mortality for patients undergoing gastric bypass surgery. Ann Surg. 2002 Nov;236(5):576-82.


text:
NTSB Votes To Recommend Lowering DUI Limits
(Washington, DC) -- The National Transportation Safety Board is recommending states lower the blood alcohol limit for DUI cases. The new threshold would be .05-percent. All 50 states currently have a limit of 0.8. The move would put the U.S. in line with European countries, Australia and most of South America. The NTSB estimates it would save hundreds of lives every year.
It would be only a recommendation, but the agency has been able to influence policy in the past. The .08 standard was finally adopted across the board in 2004 in all 50 states.

subset: commoncrawl


text:
Report: Ray J Strikes Plea Deal For Probation, Anger Management
Listen to Ray J Radio on iHeartRadio
Ray J is reportedly escaping jail time for the assault case stemming from an incident at a Beverly Hills hotel in May.
TMZ says the singer's attorney struck a plea deal on Thursday. He's pleading no contest to misdemeanor trespassing, while the three other charges of sexual battery, assault on a police officer and resisting arrest have all been dismissed.
Ray J has been given three years probation, and must complete 50 hours of community service as well as 12 courses on anger management and alcohol therapy.
Ray was arrested earlier this summer at the Beverly Wilshire Hotel for causing a disturbance and allegedly groping a woman. He reportedly kicked a police car window and became violent with police on his way out.
Photo: Getty Images


description: How we taste and enjoy food is largely based on our sense of smell. Richard Ambrose and Jonny Phillips conduct a taste test while plugging their noses, as well as present their own flavored potato chips to a panel of professional food tasters.

is_us_only: false

title: I Didn't Know That: Food Tasters

allowUserEmbed: True

credit: National Geographic

transcript:
NARRATOR: On average we spend 6 years eating. Chomping through 60 tons of food. The same weight as an adult sperm whale.
JONNY PHILLIPS: Rich, it's in a lifetime, not one sitting.
RICHARD AMBROSE: One.
JONNY PHILLIPS: No, don't do it to yourself.
RICHARD AMBROSE: They're so good.
JONNY PHILLIPS: Oh no.
NARRATOR: The reason we enjoy gorging ourselves is because food tastes so nice. And the thing that helps you taste is actually your nose.
RICHARD AMBROSE: When you chew food, vapor is released up the back of the nose, in a process called retro-nasal olfaction. Basically it fools you into thinking you're tasting a flavor, when actually you're smelling.
JONNY PHILLIPS: And we've set up a little test to demonstrate this point.
NARRATOR: We're going to get Richard to drink from 3 beakers containing 3 different liquids wearing a nose clip.
RICHARD AMBROSE: Does my nose look big in this?
NARRATOR: So, what does he think is in beaker 1?
RICHARD AMBROSE: I have no idea what that is. Er, it's wet.
JONNY PHILLIPS: Anything, anything coming through?
RICHARD AMBROSE: Mildly citric, maybe lemon.
NARRATOR: Beaker 2.
RICHARD AMBROSE: I'd say that's squash because it's quite a strong flavour.
NARRATOR: And beaker 3.
RICHARD AMBROSE: Ooh that's quite sour. Lemon.
JONNY PHILLIPS: OK. Take the nose clip off please. And just quickly taste them in order again.
RICHARD AMBROSE: That's cold tea.
RICHARD AMBROSE: Orange juicy squash isn't it.
JONNY PHILLIPS: You got that one right.
RICHARD AMBROSE: Yes yes. And this one?
JONNY PHILLIPS: You guessed lemon juice.
RICHARD AMBROSE: Uur, uur.
JONNY PHILLIPS: Ha ha, and it is malt vinegar.
RICHARD AMBROSE: Ur.
NARRATOR: Now the boys are going to design their own food and subject it to scrutiny from professional food tasters. These people have made a career out of eating. They're paid by food manufacturers to give early feedback before a product is launched. And it's their heightened sense of taste that can make or break a new snack.
JONNY PHILLIPS: We're going to make our own flavoured crisps using these special powders. What do you fancy?
RICHARD AMBROSE: Er I don't know.  Cola crisps possibly. We need to revolutionize the flavors of crisps.
JONNY PHILLIPS: Brown pickle is my first choice.
RICHARD AMBROSE: [ICD] Tutti Frutti. That sounds like a classic to me I tell you.
JONNY PHILLIPS: Okey dokey.
RICHARD AMBROSE: I'm going for aniseed and Mediterranean herbs. Tastes good!
NARRATOR: With such strong artificial flavours only tiny amounts are required for explosive results.
RICHARD AMBROSE: Hmm, I might skip, I might skip on those.
NARRATOR: But what about Jonny's tutti frutti and pickle flavor? It's time for the tasting panel to apply their professional tastebuds to the boys' crisps. What on earth will they make of the weird flavours? First up is Jonny's horrific sounding tutti frutti and pickle delight.
JONNY PHILLIPS: Here we go. The crunch.
Q OOV: Do you like it?
PANEL MEMBERS: No. No. Too much confusion on the flavors. Unpleasant flavor.
RICHARD AMBROSE: Jonny...
JONNY PHILLIPS: Did he say it's unpleasant?
RICHARD AMBROSE: Yes.
JONNY PHILLIPS: How dare he.
NARRATOR: And now it's Richard's turn to face the panel.
RICHARD AMBROSE: All right, here we go.
Q  OOV: First reactions?
PANEL MEMBER: I quite like it.
RICHARD AMBROSE: Hey.
JONNY PHILLIPS: No! I don't believe it.
PANEL MEMBER: Is it rosemary or something like that?
RICHARD AMBROSE: I balanced it, you see, I balanced those herbs.
Q OOV: Would you buy it?
PANEL MEMBERS: No. No. No.
NARRATOR: Sorry boys. When it came to the crunch you just didn't have what it takes.


text:
On July 21 at CityCenter of CityNorth, Blue Martini hosted its popular Little Black Dress event, considered one of its largest events of the year. Ladies slipped into their sexiest LBD looking to sip on some specialty drinks, enjoy some live music by the Instant Classics (followed by DJQ), and cross their fingers in hopes that their name is called as one of the lucky raffle winners. But this wasn't an ordinary raffle, mind you.
The Little Black Dress event was created as a getaway, an oasis for ladies to beat the heat, while also offering the chance to win some incredibly luxurious prizes, ranging from the $100s to $1,000s — including a Louis Vuitton Handbag, Christian Louboutin stilettos, JW Marriott Desert Ridge "staycation" spa package, a rejuvenation package by Perfect Skin Laser Center and more.
And, at the bar, Blue Martini had American Harvest Bottle specials, 42 superior martinis as well as a new tapas food menu. (You'll have to head over to Blue Martini to find out what's on the menu!)


text: Macintosh computers are great machines, but like all of them, they do need repairs, upgrades, and regular maintenance. That's where San Diego Computer Repair comes in. We can do just about anything to your MacBook, MacBook Pro, iBook, PowerBook, iMac, Mac Pro, or whatever flavor of computer you've got. Everything from LCD screen repairs on the notebooks to upgrades in hard drive sizes and memory. The best part about our services for Macs is that unlike most Apple specialty shops (and the Apple stores themselves), we don't mark up our hardware. Underneath the hood, many PCs and Apples use exactly the same components, so why should you have to pay double? You shouldn't. Contact us to get a quote and find out how we can fix your computer and save you money at the same time.


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Mukilteo Garden &Quilt Tour: The biennial tour, sponsored by Mukilteo Lighthouse Quilters and the Mukilteo Way Garden Club, is set for 11 a.m. to 4 p.m. July 21 and and noon to 4 p.m. July 22. This is slef-guided tour by car to seven locations featuring more than 100 handmade quilts. Tickets are $15 in advance and $18 on the days of the tour at Rosehill Community Center, Lincoln Ave., Mukilteo. Website sales: www.mukilteogardenandquilttour.org. Also onsale now in Mukilteo at Ace Hardware, Barbara's Floral, Mukilteo Art and Frame, and Papa Murphy's, and at Aunt Mary's Quilt shop (Smokey Point), My Garden Nursery (Mill Creek), Pacific Stone and the Needle and I (Everett), Sunnyside Nursery (Marysville), Sky Nursery (Shoreline), and Pacific Fabric outlets.
Snohomish Garden Tour: The Snohomish Garden Club self-guided tour is from noon to 5 p.m. July 28, featuring eight urban and suburban gardens. Tickets are $12 and will be available in early July at Annie's on First, Curly Willow, Joyworks, Kusler's, McAuliffe's Valley Nursery, Machias Nursery, McDaniel's Do It Center, Molbacks, My Garden Nursery and Sunnyside Nursery. Day of tour tickets will be available at the above outlets as well as the Snohomish Library after 10:30 a.m. See www.snohomishgardenclub.com/ for more information.
Deadheading and rhodie care: Meerkerk Gardens nursery manager Susie Reynolds conducts this class at 10 a.m. July 26 at 3531 Meerkerk Lane off Resort Road in Greenbank. The class costs $10. Reservations suggested as the class size is limited to 25. Call 360-678-1912 or 360-222-0121.
Fuchsia show and sale: The Sno-King and the Marysville Pilchuck fuchsia societys hold their annual judged show and sale 11 a.m. to 5 p.m. Aug. 10 and 11 at Country Village. Experts will answer questions and visitors can see a display garden and more than 25 hardy fuchsias. Country Village is a mile south of Canyon Park on Bothell-Everett Highway. Call Eva Fisher at 206-920-9888 or Julie Simmons at 425-760-3061, or see the website snokingfuchsiasociety.yolasite.com/.
Blue Grass in the Garden: Meerkerk Rhododendron Garden's annual festival featuring Whidbey bands and set amid the garden surroundings goes from 11 a.m. to 4:10 p.m. Aug. 10 at the gardens, 3531 Meerkerk Lane, Greenbank off Resort Road. Admission is $15 Children under 15 are admitted free, and dogs on leashes are welcome. 360-678-1912 or 360-222-0121 or see www.meerkerkgardens.org.
Arboretum tours: Reservations are now being taken for 2013 custom group tours of the Evergreen Arboretum &Gardens. The group tours are available all year by calling 425-257-8597. There is no charge, but donations to the Evergreen Arboretum Foundation are welcome. The arboretum is at 145 Alverson Blvd., Everett. Go to www.evergreenarboretum.com or email email@example.com.
Drip irrigation class: Master gardner Jeff Thompson's workshop will show you how to make a drip irrigation system from 1 to 6 p.m. July 11 at the Snohomish County WSU Extension office at McCollum Park, 600 128th St. SE, Everett. The class is $20 a person or $25 for two people sharing materials. To register call Karie Christensen at 425-357-6039, or download the brochure at http://snohomish.wsu.edu/garden/workshops/DripIrrigation2013.pdf.
Evergreen Arboretum and Gardens 2013 lectures: Noon to 1 p.m. select Saturdays, at the arboretum, 145 Alverson Blvd., Everett, either in the indoor classroom or, when appropriate, outside on the arboretum grounds. All the classes are free. Seating is limited and some classes require registration. Call 425-257-8597 to register. Go to www.evergreenarboretum.com to learn more.
— July 20: Summer care of Japanese maples with Trevor Cameron of Sunnyside Nursery
— Aug. 17: Native plants with Andy Sudkamp, a horticulturist and biology teacher. Meet at the arboretum entrance for a tour.
— Sept. 21: Fall/winter containers with Dee Drake, arboretum volunteer. Registration necessary. Meet at the arboretum entrance.
— Oct. 19: Putting your Garden to Bed with Wink Cushman, master gardener. Meet at the arboretum entrance.
— Nov. 16: Holiday natural centerpieces with Marylou Hart, arboretum board member and master gardener. Registration necessary.
— Dec. 7: Arboretum gift-making workshop for kids, noon to 2 p.m., with Hap Wertheimer, past arboretum president and art teacher. Registration necessary.
Nursery classes
These local nurseries feature gardening classes, guest speakers and special events throughout the year, often for no charge. Check their websites or call for details.
Christianson's Nursery and Greenhouse: 15806 Best Road, Mount Vernon; 360-466-3821; www.christiansonsnursery.com
Falling Water Gardens: Free classes in creating and caring for a pond, 17516 Highway 203, Monroe; 360-863-1400, www.fallingwatergardens.com.
McAuliffe's Valley Nursery: 11910 Springhetti Road, Snohomish; 360-862-1323; www.mcauliffesvalleynursery.com
Molbak's Garden &Home: 13625 NE 175th St., Woodinville; 425-483-5000; www.molbaks.com
My Garden: 17414 Bothell-Everett Highway, Mill Creek; 425-402-1842; www.mygardennursery.com
Pine Creek Nursery: 23225 Sofie Road, Monroe; 360-863-8866; www.pinecreeknursery.com
Plant Shack: 2829 164th St. SW, Lynnwood; 206-390-1422; www.plantshacknursery.com/
Sky Nursery: 18528 Aurora Ave. N., Shoreline; 206-546-4851; www.skynursery.com
Sunnyside Nursery: 3915 Sunnyside Blvd., Marysville; 425-334-2002; www.sunnysidenursery.net
The Plant Farm at Smokey Point: 15022 Twin Lakes Ave., Marysville; 360-652-3351; www.theplantfarm.com
Wight's Home &Garden: 5026 196th St. SW, Lynnwood; 425-775-3636; www.wights.com
Plant Clinics
Got a gardening question? Consult a local master gardener at a public plant clinic. If you have a plant with a problem or disease, bring in a fresh plant sample that, if possible, includes the diseased area, a transition area and a healthy area. Photos are also helpful. You can also call the master gardener hotline from 9 a.m. to 4 p.m. April through September, and from 10 a.m. to 4 p.m. October through March at 425-357-6010 or visit the Home &Garden section at snohomish.wsu.edu.
Arlington Hardware: 215 N. Olympic Ave., Arlington; 10 a.m. to 2 p.m. Saturdays, July 20, Aug. 3 and Sept. 7.
Edmonds Farmers Market: 100 block of Fifth Ave. N. in front of Log Cabin; 10 a.m. to 3 p.m. Saturdays through Oct. 5, except Aug. 10.
Everett Farmers Market: Everett Waterfront near Marina Village; 11 a.m. to 4 p.m. Sundays through Sept. 29.
Everett Lowe's: 2505 Pacific Ave., Everett; 10 a.m. to 2 p.m. Saturdays through July 20.
Marysville Jenning Park Demonstration Garden: 6915 Armar Road, Marysville; 10 a.m to 1 p.m. Saturdays through Aug. 31.
Mill Creek My Garden Nursery: 17414 Bothell Everett Hwy., Mill Creek; 10 a.m. to 2 p.m. Saturdays through July 20.
Monroe Evergreen State Fair: Fairgrounds, Monroe; 10 a.m. to 8 p.m. Aug. 22 to Sept. 2.
Mukilteo Farmers Market: Mukilteo Lighthouse; 3 p.m. to 7 p.m. Wednesdays through Sept. 25 .
Snohomish Farmers Market: First and Cedar streets, Snohomish; 3 p.m. to 8 p.m. through Aug. 29.
To submit an item for the Home &Garden calendar, e-mail firstname.lastname@example.com.


text:
The UNLV Intramural Sports program provides UNLV students, faculty, and staff the opportunity to participate in a variety of organized, competitive activities throughout each academic year. Activities are organized on both a team and individual basis.
Registration forms for this activity are available at the front desk of the Student Recreation & Wellness Center.
Registration begins Sept. 10 and ends Sept. 21; Play starts Oct. 2
For more information on future intramural activities visit the Student Recreation and Wellness Center Intramural website.


text:
In Proust's LibraryBy Anka Muhlstein
Whether they follow an established tradition or rebel against it, whether they are authors of classics or are considered innovators, rare are the writers who were not also great readers. Proust was no exception to this rule; reading had always been his earliest and most important source of pleasure and stimulation, and it remained as such. He is distinguished from his colleagues, however, by the immense role that literature plays in his oeuvre.
Proust seemed incapable of creating a character without putting a book in his hands. Read More


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Results 1 to 2 of 2
- Join Date
- Jul 2010
- Posts
- 1
1st Annual 3-D Bow Shoot, GA/NC area FREE ADMISSION
***Free Admission!!!!!!!***
1st Annual C.A.M.O. 3-D Archery Bow Shoot
Lots of free door prizes from Mathews, Mossy Oak, Real Tree, Bass Pro Shop, and more!!!!!!!!!!!
__________________________________________________ ________________
Where: Archery Barn ( just off the 411 Georgia Road in the Otto, NC area )
When: AUGUST 21st
Who: Open to all ages
*****Open Registry*****
__________________________________________________ __________________
Pine Grove Baptist Church from the Franklin, NC area would like to invite everyone out to their 1st Annual C.A.M.O. 3-D Archery Bow Shoot on August 21st at the Archery Barn. This event is in support of our C.A.M.O. Ministry (Christians Actively Ministering Outdoors). There will be a number of door prices for the participants, BBQ lunches available, and much more. We hope to see you there.
Classes will range from Pee Wees (up to y.o.) to Seniors (60y.o. and up). We will be following ASA scoring rules 14/12/10/8/5. Targets will be 3-D Animals.
.More to come
- Join Date
- Dec 2009
- Posts
- 7
I would love to come shoot. Could you give me some direction from Rock Hill SC
Similar Threads
2nd annual jamie rus memorial shootBy XFHUNTER in forum General Archery ForumReplies: 9Last Post: 01-29-2009, 10:50 PM
4th Annual N.Y.B. 3D shoot and RendezvousBy UltraElite 06 in forum Tournament DiscussionsReplies: 3Last Post: 08-12-2008, 09:48 PM
1st Annual Thumb Area Triple Crown ! BABY !By H&S Archer in forum Tournament DiscussionsReplies: 1Last Post: 06-11-2008, 05:09 PM
J.P.'S 8th Annual 3D Bow Shoot Aug 11thBy whitetail99 in forum Tournament DiscussionsReplies: 1Last Post: 07-23-2007, 12:07 PM
8th Annual Memorial Heart Shoot AlabamaBy bowtoon in forum Tournament DiscussionsReplies: 0Last Post: 04-21-2006, 06:13 PM


text:
KatieandLouie's Mom Answers Activity
KatieandLouie is a star in these topics:
Pregnancy > Nutrition & Weight (1 helpful answer)
Recent Activity | Asked | Answered
I'm 26 weeks pregnant and I have only gained 12 pounds, is that healthy? Watch this
Most recent answer (11/03/2012):
I have already given birth but it is very healthy i only gained 16 pounds my whole pregnancy i was losing weight. as long as my child was...posted by natalia_fugel


text:
rose study # 6
painting by artist Parastoo Ganjei
9 in X 9 in (22.9 cm X 22.9 cm)
acrylic on board
This painting is already sold. However, I may have other paintings available.
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A Romney relative has an eye on the Senate. The Mormon surprise on immigration reform. The Legislature's last four days.
Happy Monday. It looks like the Romneys are not done with politics after all. Mitt Romney's older brother Scott is eyeing the Senate seat that Michigan's Carl Levin will vacate after next year's election. [CBS]
Topping the news: Utah's members of Congress pan President Barack Obama's outline for an immigration bill, but LDS Church leaders have a different take. President Dieter F. Uchtdorf, second counselor to the First Presidency, met with Obama on Friday and afterward said the faith's values are in line with comprehensive immigration reform, which he stressed should focus on compassion. [Trib]
-> The Trib's Brooke Adams explores the temptations and realities surrounding a proposal to move Utah's prison and free up some prime Draper real estate. [Trib]
-> Utah is one of only two states that require lawmakers to vote even on items that directly affect them and their families. A detailed analysis shows that one in five bills before the state Legislature this year raise conflicts of interest for its sponsors. [Trib]
-> Amidst political satire and Washington banter, the Trib's Thomas Burr was presented as a new member of the Gridiron Club an elite group of 65 political journalists during its annual dinner in D.C. It's been 100 years since the Tribune last had a member of the Gridiron. [Trib]
-> The Gridiron Club doesn't allow cameras in its dinner, but here's a good recap of the jokes told by President Barack Obama, Gov. Bobby Jindal and Sen. Amy Klobuchar. [WaPost]
Tweets of the day: From @TheFix: "Is Huntsman in the top 15 candidates likely to win GOP nod in 2016? I don't think so. Might emphasis on "might" be in top 20."
From @RSSNewsmaster: "While not a believer, I'll thank God and whomever else is responsible for delivering the @sltrib news reporting to me every morning"
Happy birthday: To the National Press Club's Sarahanne Driggs (a Utah native!).
From the Hill: Here's your daily legislative schedule. [Trib]
-> As the Legislature begins its last week, lawmakers are close to wrapping up their work on the state's $13 billion budget, with education getting a big boost. [Trib]
-> When it comes to education spending, the key word to get a lawmaker salivating is STEM. [Trib]
-> The Legislature is poised to give another $300,000 to an anti-wolf group linked to Don Peay and his Big Game Forever group. [Trib]
-> The Utah House has more freshman this session than it has in two decades. [APviaDNews]
-> Restaurant-goers may soon be able to have a drink before ordering food, thanks to a new bill that passed the Senate unanimously. [Trib]
-> Utah Moms for Clean Air handed over a list of ideas to reduce air pollution to Gov. Gary Herbert, urging him to create a task force to tackle the inversion issue. [Trib]
-> House lawmakers moved to assert the state's gun laws over federal gun laws, despite facing a tough challenge in the Senate. [Trib] [DNews] [UtahPolicy]
-> The statewide anti-discrimination bill meant to protect gay Utahns for housing or employment discrimination appears dead as the Legislature approaches its last four days. [UtahPolicy]
-> A group of conservative lawmakers argue that if Utah accepts a Medicaid expansion it would strain the nation's finances. [Trib] [DNews]
-> A bill that would allow professional hair braiders to work without undergoing the same rigorous training and licensing hours required of beauticians is on its way to Gov. Gary Herbert's desk. [Trib]
-> The state forester will be able to restrict target shooting in areas with high wildfire risk, thanks to a new bill that made it through the Legislature. [Trib]
-> Lawmakers passed a resolution urging federal wildlife officials to refrain from designating some 145,500 acres in San Juan County as protected habitat for the endangered sage grouse, saying that 95 percent of the area is privately owned. [Trib]
-> After merging with the College of Eastern Utah, Utah State's Price campus will now be known as "Utah State University Eastern" thanks to a new bill passed unanimously by the Senate. [Trib]
-> Leaking information from Utah's concealed carry permit database would now be a class A misdemeanor under a new bill that passed the House. [Trib] [DNews]
Opinion section: Paul Rolly says that school voucher proponents and their allies are dangerous to a robust public education system. [Trib]
-> And Rolly says Rep. Mike Noel bullied a witness at an environmental hearing, proving a lot about his character. [Trib]
-> George Pyle blasts the Legislature's rejection of a plan to expand preschool for at-risk kids. [Trib]
-> The publisher of Moab's Canyon Country Zephyr pays tribute to Edward Abbey on the 24th anniversary of the environmental writer's death and looks at the 21st century West through his eyes. [Trib]
-> An attorney for Utah Physicians for a Healthy Environment says the state refuses to sanction "big polluters" instead shifting the blame for Utah's murky air onto citizens. [Trib]
-> Utah GOP chairman Thomas Wright blasts Rep. Jim Matheson for sponsoring legislation that would ban straight-ticket voting in federal elections, saying Utah's lone Democrat is wasting his time in Congress. [Trib]
-> However, Matheson says the legislation benefits independent voters and those who want to see an end to rabid partisanship. [Trib]
-> Layton's city manager sets the record straight on UTOPIA. [Trib]
-> Sherri Park from Mormons Building Bridges says it's time to welcome LGBT churchgoers into the flock. [Trib]
-> A former Republican legislator says politics isn't about all-or-nothing it's about compromise. [Trib]
-> A Salt Lake City blogger says the Postal Service isn't living up to its constitutional duty in a heart-wrenching tale. [Trib]
-> LaVarr Webb and Frank Pignanelli preview the last four days of the winding-down Utah Legislature. [DNews]
-> John Florez says lawmakers are experiencing a disconnect between values and rhetoric when it comes to rejecting SB71, which would expand preschool for at-risk kids. [DNews]
-> A Utah businessman urges lawmakers to support STEM education, saying it builds a stronger, more competitive workforce. [DNews]
-> Former state Sen. Dan Liljenquist applauds state auditor John Dougall's audit of the Utah Retirement Systems. [DNews]
-> Jay Evensen imagines how former President Calvin Coolidge would have approached the sequester. [DNews]
-> Former Sen. Bob Bennett says the founders would be appalled at how the Congress has abdicated its responsibility for the federal budget. [DNews]
Weekend in review: Members of Utah's congressional delegation are feeling the sting of sequestration in their offices, with staff cuts and penny pinching. [Trib]
-> Army Special Forces Green Berets nixed plans to do a role-playing parachute exercise in Utah's mountains saying this summer, after some citizens raised concerns about ulterior motives. [Trib]
-> About 100 protesters hit the streets of Salt Lake City, calling for an end to Chinese human rights violations against Tibetans. [Trib] [DNews]
-> Take a look back at the last 100 years of the Utah State Capitol's history in a new exhibit set up to commemorate the beginning of construction of the iconic building. [Trib]
Where are they?
Rep. Jason Chaffetz is in New York for media hits with CNN, Fox News and MSNBC before he visits with executives from Google.
Gov. Gary Herbert meets with legislators and West High School students and drops in on a Capitol Hill Working Group.
Salt Lake County Mayor Ben McAdams meets with his senior office staff, has a scheduling meeting, has a legislative briefing and meets with Utah Partners for Health and Association for Community Health.
SLC Mayor Ralph Becker is in Washington for the National League of Cities Congressional City conference.
President Barack Obama lunches with Vice President Joe Biden.
Got a tip? A birthday, wedding or anniversary to announce? Email us at firstname.lastname@example.com. If you haven't already, sign up for our weekday email and get this sent directly to your inbox. [Trib]
Matt Canham and Emily Andrews Twitter.com/mattcanham and Twitter.com/emilytandrews


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Argentina 2008 Climacool long sleeve shirt with embroidered Argentina team badge in gold, 2 championship stars and logo at front. Mesh ventilation.Sublimated AFA logo founded 1893 in front. 100% polyester.Comes with official licensed N&N of Tevez #11.
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text:
Blake Shelton & Luke Bryan to host 50th Annual ACM Awards
Listen to Blake Shelton on iHeartRadio | Listen to Luke Bryan on iHeartRadio
The Academy of Country Music is sticking with "Bluke." Blake Shelton and Luke Bryan have already been tapped to host the 2015 ACM Awards, which will mark their third consecutive year at the helm for the ceremony. And the Academy is making big plans for next year's 50th anniversary event.
To honor the occasion, the Academy is leaving Las Vegas to hold the ceremony at AT&T Stadium in Arlington, Texas. Festivities surrounding the awards event will include the 3rd annual ACM Party for a Cause: 50 Years of Music & Memories, taking place at Arlington's Globe Life Park on April 17th and 18th, 2015.
The 50th annual ACM Awards will air on CBS on April 19th, 2015. Tickets for the awards show go on sale to the public next Tuesday, April 15th, 2014.
Photo Credit Getty Images


text:
I kid bro...
I mentioned frost because frost is a weed man.
what is that from? oh and i'm still missing a lot of your portraits from the big pic
oh wait that's bam margagagagarita isn't it
That face has seen vore.
And That video about some brony jizzing to a toy pony.
That would be a great reaction pic.
They've been released. Hope you guys like these.
From memory
Weird art - Super detailed textures next to really low resolution ones. On the same models even
Load of bugs - getting stuck on maps, falling trough maps, not triggering quests etc
Awful quest log - not updated on quest progression
One single quest hub
majority of quests are fetch quests spawned from overhearing conversations
most side quests (which aren't fetch quests) happen on multiplayer maps which are only about killing of enemies
renegade replaced from the soldier that does necessary things to just a bad person. It even shows in quests that would previously be renegade which turned into paragon choices (saving an admiral as opposed to his crew). Also renegade choices tend to give you less war assets than paragon choices.
abilities sometimes not happening
one button to fuck them all over (space is for rolling, running, reviving, starting convos, going into cover etc etc) people die because instead of rolling they go into cover and similar
charge up gun cannot be charged in cover
loads of conversations replaced with auto convos where you have no choice
only two enemy sets (gets for a short time, but well it's really a short time)
conversations changed from choice into saying the same thing differently
dodgy animations - verner I mean you
etc etc etc
Also made this.
And because I know he won't make his
Alright updated. Still got a lot of space, I know there are more of you out there who still haven't made one. If someone isn't around you guys can always make one for another person.
Not proud of it though, but I'm going to blame Photoshop Elements 6 for it's inability to make nice outlined text with an easy-to-use method.
May you replace mine with this, please:
And if you want, add Steve:
Thank you.
Oh, damn, I forgot about this. <.< I'll go make one and then fiddle around in GIMP until I can make it look nice.
Who is Steve?
My unknown nigga.
Alright updated. Sorry MLC I'm not adding peoples fictional characters :P
Make it seperate then.
(I know I'm not the one in control, Rusty is, it just seems ridiculous)
However, you could add him under a title "Sidekicks/Army" or something, because I'm sure Tbone and Xana would like to add their forces.
ATP feels lonely without his anime bitch huehuehuehuehue
Isn't the limit to get gold membership 5 years, even if I don't have 2000 posts?
He's probably playing cowadoody or something
Thanks again for the hack atp, it'll be cool to see it used in that comic your making
Unlike ATP's assistant, my assistant is actually a real person.
She just doesn't post, or have gmod. She just draws.
Maybe it depends on date as well?
[sub][sub][sub]No offense minimole, i'm sure the doctor can take care of those pesky things[/sub][/sub][/sub]
Nah, it's not that big of a deal anyway.
What about Clappy?