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Öèòàòà:
Íó óæ ýòîãî òî÷íî íå íàäî äåëàòü. Ìû âàñ î÷åíü ïðîñèì ýòîãî íå äåëàòü. Ìû âàñ î÷åíü ëþáèì (ïðàâäà). Ïîòåðïèòå íåìíîãî, ìû óæå ãîòîâèì ïîäðîáíåéøèå îòâåòû íà âñå âàøè âîïðîñû. |
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#48
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ß äóìàþ , ÷òî ñïåöèàëèñòû ïî óðèíîòåðàíèè ðàñïîëàãàåþò ïîðòôîëèî íå õóæå , ïîýòîìó âåðíåìñÿ èç ñôåðû îõîòíè÷üèõ ðàññêàçîâ ( Ìýðëèí Ìóðëî êàê õîðîøà áûëà , à òàáëåòî÷êè ñêóøàëà .. ) ê ñåðüåçíîìó ðàçãîâîðó .
Åæèêó ïîíÿòíî . ÷òî ìàëüàáñîðáöèÿ è ðóêàâ âìåñòî ãðåëèíà ìàññó òåëà ñíèçÿò - åìó æå ÿñíî , ÷òî ïî ìåðå íàáèâàíèÿ ðóêàâà òîðòèêàìè îíàÿ âíîâü íàáåðåòñÿ . Îïåðèðóåì íå ñòàðóøåê - èòîãî , ïðöåíò ðåöèäèâîâ îæèðåíèÿ çà 10 ëåò íàáëþäåíèÿ ?
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Ã.À. Ìåëüíè÷åíêî |
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Ïðîäîëæàþ ãàéä ïî êóñêàì - î÷åâèäíî , ÷òî â öåëîì âèäå îíè íå÷èòàáèëåí òàì , ãäå åñòü ïëàêàòû ..
Èòàê , â îòëè÷èå îò îáåùàíèÿ ãðÿäóùåãî ñ÷àñòüÿ , îêàçûâàåòñÿ ìèð ñîâñåì èíà÷å âûðàæàåòñÿ 1.0. Prevention and treatment of weight regain (Wr) 1.1. We recommend that a technically proficient surgical team, preferably accredited by a national certifying organization and an integrated medical support team able to provide dietary instruction and behavior modification be available postoperatively and during long-term follow-up (1| ) . ( èíûìè ñëâîàìè - ïîñëå îïåðàöèè íàó÷èñü âäðóã òîìó , ÷åãî íå äåëàë ðàíüøå - íî êîìàíäà íàó÷èò Èäåÿ óìåþùåé îáó÷èüü êîìàíäû çâó÷èò â ïåðâîì æå ïóíêòå 1.2. We recommend that treatment of WR postoper- atively should include a multidisciplinary approach to medical weight loss, including diet instruction, increased activity, behavior modification, and phar- macological therapy (1| ) . Îé , êàê æå òàê ? Îäíîé îïåðàöèè ìàëî ?? 3.1. We recommend that postoperative glycemic control should consist of achieving glycated hemo- globin (Hba1c) of 7% or less, with fasting blood glucose no greater than 110 mg/dl and postprandial glucose no greater than 180 mg/dl (1| ) . Çíà÷èò , êîíòðîëü ïî ïðåæíåìó íóæåí ? 3.2. We suggest that physicians and floor nurses be familiar with glycemic targets and insulin protocols, as well as the use of dextrose-free iv fluids and low-sugar liquid supplements (2| ) . Ýòî ê ðàçâèòèþ íåçèäèîáëàñòîçà ( êòî íå çíàåò ) 3.3. We recommend that obese patients with type 1 diabetes receive scheduled insulin therapy during their hospital stay, as required (1| ) . Èíûìè ñëîâàìè , áåòà - êëåòêè íå ïîÿâÿòñÿ òàì , ãäå èõ óæå íåò ...
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Ã.À. Ìåëüíè÷åíêî |
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Ñîîáùåíèå îò ïàöèåíòêè ñêðûòî. Äàííûé òîïèê ïðåäïîëàãàåò âðà÷åáíóþ äèñêóññèþ, íåñìîòðÿ íà òî, ÷òî íàõîäèòñÿ â ðàçäåëå Ðàçíîå.
Öèòàòà:
Ìîäåðàòîð. |
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Âû íà âîïðîñû ïðîôåññèîíàëîâ îòâå÷àòü ñîáèðàåòåñü? Èëè ñîáèðàåòåñü èãíîðèðîâàòü íåïðèÿòíûå âîïðîñû, ïðîäâèãàÿ ðåêëàìó?
Êàê ìèíèìóì ýòî íåêðàñèâî. Êàê ìàêñèìóì - òåìû íà ýòîì ôîðóìå ïðåêðàñíî èíäåêñèðóþòñÿ ïîèñêîâèêàìè è âñå ìíåíèÿ, âûñêàçàííûå â ýòîé òåìå, áóäóò âûõîäèòü â ïîèñêå. Âàì ðåøàòü, ÷òî ñ ýòèì äåëàòü. Ðàâíî êàê è àäìèíèñòðàöèè ôîðóìà ðåøàòü, êàê ðàñïîðÿæàòüñÿ íàïèñàííûìè ïîñòàìè. Ìíå ëè÷íî ïîêà Âàøà ïîçèöèÿ âèäèòñÿ òîëüêî â îäíîì ðàêóðñå - Âû õîòèòå ïîâûøåíèÿ îáðàùàåìîñòè íà ïëàòíûå îïåðàöèè. Ìîòèâû ìíå íåèíòåðåñíû, òåõíîëîãèÿ ïðåäñòàâëÿåòñÿ ñîìíèòåëüíîé. Ïîýòîìó ÿ ñ÷èòàþ ñâîèì äîëãîì ïîñòàâèòü íåêîòîðûå âîïðîñû òàêèì îáðàçîì, ÷òîáû ýòà Âàøà ïîçèöèÿ ñòàëà î÷åâèäíîé. Íå ñóìååòå äîñòîéíî íà íèõ îòâåòèòü - Âàøè ïðîáëåìû.
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Lead, follow, or get out of the way. — Thomas Paine |
#52
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Öèòàòà:
Áàðèàòðè÷åñêàÿ îïåðàöèÿ ïîêàçàíà ïàöèåíòó ñ ÈÌÒ (èíäåêñîì ìàññû òåëà) >40.  òîì ñëó÷àå, êîãäà ó ïàöèåíòà èìååòñÿ îäèí èëè íåñêîëüêî âèäîâ êîìîðáèäíîé ïàòîëîãèè, êîòîðàÿ ìîæåò áûòü ñâÿçàíà ñ îæèðåíèåì, óðîâåíü ÈÌÒ, íåîáõîäèìûé äëÿ îïåðàöèè, ñíèæàåòñÿ äî 35. Ñþäà îòíîñÿòñÿ: ñàõàðíûé äèàáåò 2 òèïà, ñîííîå àïíîå, äèñëèïèäåìèÿ, àðòåðèàëüíàÿ ãèïåðòåíçèÿ, äèñòðîôè÷åñêèå çàáîëåâàíèÿ ñóñòàâîâ íèæíèõ êîíå÷íîñòåé.  êîíöå 2010 ãîäà ïîÿâèëîñü êðàéíå âàæíîå äîïîëíåíèå: ðåøåíèåì ñîâåòà FDA (Food and Drug Administration), êîòîðûé ñîñòîÿëîñü â äåêàáðå, èíäåêñ ìàññû òåëà, íåîáõîäèìûé äëÿ áàíäàæèðîâàíèÿ æåëóäêà, ñíèçèëñÿ äî 30. Ýòî îòíîñèòñÿ òîëüêî ê îïåðàöèè áàíäàæèðîâàíèÿ æåëóäêà, êàê îïåðàöèè ñ êðàéíå íèçêèì ðèñêîì. Äëÿ äðóãèõ áàðèàòðè÷åñêèõ îïåðàöèé ïîêàçàíèÿ îñòàþòñÿ ïðåæíèìè. Êàê èçâåñòíî, ðåøåíèÿ FDA íåèçáåæíî ñòàíîâÿòñÿ de facto ñòàíäàðòîì âî âñåì ìèðå*. Âîò ýòèõ ñòàíäàðòîâ, ïðèíÿòûõ âî âñåì ìèðå, ìû è ïðèäåðæèâàåìñÿ**. ---------------- *Íàïðèìåð, â 2010 ãîäó FDA çàïðåòèëà ïðåïàðàò ñèáóòðàìèí (ìåðèäèà) - îäèí èç äâóõ ðàíåå îôèöèàëüíî ðàçðåøåííûõ ïðåïàðàòîâ äëÿ êîíñåðâàòèâíîãî ëå÷åíèÿ ëèøíåãî âåñà, ââèäó áîëüøîãî êîëè÷åñòâà ïîáî÷íûõ ýôôåêòîâ. È âîò, ýòîò ïðåïàðàò óæå ïðàêòè÷åñêè èñ÷åç èç àïòåê ïî âñåìó ìèðó, â òîì ÷èñëå â Ðîññèè, ãäå ðàñïðîäàþò òîëüêî ñòàðûå îñòàòêè, õîòÿ íèêàêîãî çàïðåòà íà íåãî íàø ôàðìêîìèòåò íå íàêëàäûâàë. **Áûâàþò ñëó÷àè, êîãäà ìû áîëåå ëèáåðàëüíî ïîäõîäèì ê îïðåäåëåíèþ ïîêàçàíèé, è ìîæåì ñäåëàòü áàðèàòðè÷åñêóþ îïåðàöèþ ïàöèåíòó ñ ÈÌÒ ìåíüøå 40 äàæå ïðè îòñóòñòâèè êîìîðáèäíîé ïàòîëîãèè - ðå÷ü èäåò î íàøèõ ñ âàìè êîëëåãàõ. Êîãäà ê íàì îáðàùàåòñÿ âðà÷ èëè ìåäñåñòðà, ìû íèêîãäà íå îòêàçûâàåì, íå ãëÿäÿ íè íà êàêèå ôîðìàëüíîñòè. |
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Traci Mann: "Diets are not the answer"
Öèòàòà:
Íà÷íåì ñ ñàìîãî âàæíîãî ôàêòîðà, âîêðóã êîòîðîãî ñëîæèëîñü ìíîæåñòâî ìèôîâ, à âîò íàó÷íûõ äàííûõ, êàê íè ñòðàííî, î÷åíü ìàëî. Ðå÷ü èäåò î äèåòàõ äëÿ ñíèæåíèÿ âåñà. Êàê îêàçàëîñü, ñ ñîâðåìåííûõ ïîçèöèé äîêàçàòåëüíîé ìåäèöèíû, ïî÷òè âñå, ÷òî îïóáëèêîâàíî, íå âûäåðæèâàåò íèêàêîé êðèòèêè.  íàñòîÿùåå âðåìÿ áàçîâîé íàó÷íîé ðàáîòîé ïî îöåíêå âëèÿíèÿ äèåò íà ñíèæåíèå âåñà, ÿâëÿåòñÿ èññëåäîâàíèå ãðóïïû èç Êàëèôîðíèéñêîãî óíèâåðñèòåòà âî ãëàâå ñ Traci Mann. Ðàáîòà ïðîâîäèëàñü ïî çàêàçó Medicare – ñèñòåìû ñîöèàëüíîãî ñòðàõîâàíèÿ, îïëà÷èâàþùåé ìåäèöèíñêèå ðàñõîäû ñðåäè ëèö ñòàðøå 65 ëåò. Ýòà ãðóïïà ïðîâåëà îãðîìíóþ ðàáîòó, ïðîàíàëèçèðîâàâ ïðàêòè÷åñêè âñå äîñòóïíûå îïóáëèêîâàííûå èññëåäîâàíèÿ ïî ïðèìåíåíèþ äèåò äëÿ ñíèæåíèÿ âåñà. Îíè àíàëèçèðîâàëè ïóáëèêàöèè ïî ñèñòåìå GRADE – ñèñòåìå ïî îöåíêå êà÷åñòâà äîêàçàòåëüñòâ è ðåêîìåíäàöèé äëÿ âñåõ òèïîâ ìåäèöèíñêèõ ïðîöåäóð (GRADE Working Group, 2004). Âûâîäû â ýòîé ñòàòüå äåëàþòñÿ íåóòåøèòåëüíûå: In sum, the potential benefits of dieting on long-term weight outcomes are minimal, the potential benefits of dieting on long-term health outcomes are not clearly or consistently demonstrated, and the potential harms of weight cycling, although not definitively demonstrated, are a clear source of concern. The benefits of dieting are simply too small and the potential harms of dieting are too large for it to be recommended as a safe and effective treatment for obesity. (Ïîäâîäÿ èòîã, ïîòåíöèàëüíûå âîçäåéñòâèÿ äèåòû íà âåñ â äîëãîñðî÷íîì ïëàíå ìèíèìàëüíû, äîêàçàòåëüñòâà ïîòåíöèàëüíûõ âûãîä äèåòû â îòíîøåíèè çäîðîâüÿ íåÿñíû è íåñîãëàñîâàííû, à ïîòåíöèàëüíûé âðåä öèêëè÷íûõ êîëåáàíèé âåñà, õîòÿ è íå áûë îêîí÷àòåëüíî äîêàçàí, âûçûâàåò ñèëüíîå áåñïîêîéñòâî. Ïðåèìóùåñòâà äèåòû ïðîñòî ñëèøêîì íåçíà÷èòåëüíû, à ïîòåíöèàëüíûé âðåä äèåòû ñëèøêîì âåëèê, ÷òîáû ðåêîìåíäîâàòü åå â êà÷åñòâå áåçîïàñíîãî è ýôôåêòèâíîãî ëå÷åíèÿ îæèðåíèÿ). In the studies reviewed here, dieters were not able to maintain their weight losses in the long term, and there was not consistent evidence that the diets resulted in significant improvements in their health. (Ñîãëàñíî èññëåäîâàíèÿì, èçó÷åííûì çäåñü, ëþäè, ñîáëþäàâøèå äèåòó, íå ñìîãëè ñîõðàíèòü ñíèæåííûé âåñ â äîëãîñðî÷íîì ïëàíå, íå áûëî îáíàðóæåíî è óáåäèòåëüíûõ ñâèäåòåëüñòâ òîãî, ÷òî äèåòû ïðèâîäÿò ê çíà÷èòåëüíîìó óëó÷øåíèþ çäîðîâüÿ). It appears that dieters who manage to sustain a weight loss are the rare exception, rather than the rule. Dieters who gain back more weight than they lost may very well be the norm, rather than an unlucky minority. If Medicare is to fund an obesity treatment, it must lead to sustained improvements in weight and health for the majority of individuals. It seems clear to us that dieting does not. (Êàæåòñÿ, äèåò÷èêè, êîòîðûì óäàåòñÿ ïîääåðæèâàòü ñíèæåííûé âåñ, – ðåäêîå èñêëþ÷åíèå, à íå ïðàâèëî. Ëþäè, íàáðàâøèå ïîñëå äèåòû áîëüøå âåñà, ÷åì ïîòåðÿëè, âåðîÿòíî, ÿâëÿþòñÿ íîðìîé, à íå ïðåäñòàâèòåëÿìè íåñ÷àñòëèâîãî ìåíüøèíñòâà. Åñëè Medicare ñîáèðàåòñÿ ôèíàíñèðîâàòü ëå÷åíèå îæèðåíèÿ, îíî äîëæíî ïðèâîäèòü ê óñòîé÷èâûì óëó÷øåíèÿì âåñà è çäîðîâüÿ ó áîëüøèíñòâà ëþäåé. Íàì êàæåòñÿ ÿñíûì, ÷òî äèåòà ê ýòîìó íå ïðèâîäèò). Åñëè êîãî-òî çàèíòåðåñóåò ïîëíûé òåêñò ñòàòüè T. Mann íà àíãëèéñêîì ÿçûêå - ïèøèòå â ëè÷êó, ÿ âàì åå âûøëþ íà ýëåêòðîííóþ ïî÷òó. American Psychologist, 2007, Vol.62, 220-233 Medicare’s Search for Effective Obesity Treatments: Diets Are Not the Answer |
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Åùå ðàç- ïðè÷èí , ïî êîòîðûì âíåäðÿåòñÿ âî âñåì ìèðå áàðèàòðè÷åñêàÿ õèðóðãèÿ , ÏÎÍßÒÍÛ è íåóäà÷è êîíñåðâàòèâíîé òåðàïèè ñâÿçàíû ïðåæäå âñåãî ñ òåì , ÷òî ÷åëîâåêó òðóäíî â ñîâðåìåííîì ìèðå ñïðàâëÿòüñÿ ñ æèçíüþ, íå çàåäàÿ è íå çàïèâàÿ íåïðèÿòíîñòè , ïåðåäâèãàÿñü îò ãàìáóðãåðà äî ÷èçáóðãåðà íà àâòîìîáèëå .
Íåïîíÿòíî äðóãîå - ïðîâåäÿ ðåñòðèêòèâíûå , èëè âûçûâàþùèå ìàëüàáñîðáöèþ îïåðàòèâíûé âìåøàòåëüñòâà , ÷åëîâåê îñòàíåòñÿ â òîì æå ìèðå ( âåðîÿòíîñòü ïåðåéòè â èíîé ïî èòîãàì îïåðàöèè êðàéíå ìàëà ) , ïîëó÷èò 1/ íåîáõîäèìîñòü ïîæèçíåííîé ìîäèôèêàöèè ïèòàíèÿ è îáðàçà æèçíè 2/ íåîáõîäèìîñòü êîððåêöèè äåôèöèòà âèòàìèíîâ è ïðîòåèíîâ 3/ ïðîáëåìû ñ êîñòíîé òêàíüþ 4/ ñîõðàíÿþùóþñÿ íåîáõîäèìîñòü âðà÷åáíîãî íàáëþäåíèÿ 5/ âîçìîæíîñòü ðàçâèòèÿ íåçèäèîáëàñòîçà Ïî âñåìó ïîýòîìó çà ïîäâåðãøèìñÿ îïåðàòèâíîìó ëå÷åíèþ ÷åëîâåêîì íàäî áóäåò íàáëþäàòü - è ÈÌÅÍÍÎ ñèþ íåñëîæíóþ ìûñëü - êîãî íàïðàâëÿåì , êòî îïðåäåëÿåò ïîêàçàíèÿ è êòî áóäåò íàáëþäàòü ïîòîì - ÿ è ïûòàþñü ïîëó÷èòü îò ýíòóçàçèñòîâ - îòáðîñèâ êîììåð÷åñêóþ ññîòàâëÿþùóþ , äóìàåòå ëè Âû î ñåäüáå ïàöèåíòîâ ? Ïîêà ÷òî íå ïîëó÷àþ - ñêàæåì , áîäðåíüêîå - îïåðèðîâàòü òó÷íûõ ñ äåòñòâà âûçûâàåò ïî ìåíüøåé ìåðå èçóìëåíèå - Ïðàäåð - Âèëëè ? Ëàóðåíñ - Ìóí - íå ïîáîþñü ýòîãî ñëîâà Áàðäå -Áèäëü ?
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Ã.À. Ìåëüíè÷åíêî |
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Öèòàòà:
1. Ïðîáëåìû, êîòîðûå âû ïåðå÷èñëèëè, îòíîñÿòñÿ òîëüêî ê øóíòèðóþùèì îïåðàöèÿì, îñîáåííî ê áèëèîïàíêðåàòè÷åñêîìó øóíòèðîâàíèþ (ÁÏØ). Êàê èçâåñòíî, ïðè ÁÏØ äëÿ âñàñûâàíèÿ íóòðèåíòîâ ïîñëå îáðàáîòêè ïèùè æåë÷üþ è ïàíêðåàòè÷åñêèì ñîêîì îñòàåòñÿ âñåãî îêîëî 75 ñì òîíêîé êèøêè. Òî åñòü ýòà îïåðàöèÿ ðàáîòàåò èñêëþ÷èòåëüíî çà ñ÷åò ðàçâèòèÿ ñèíäðîìà ìàëüàáñîðöèè. Ñîîòâåòñòâåííî, äåôèöèòû, êîòîðûå âû ïåðå÷èñëèëè, çàêîíîìåðíû è âñòðå÷àþòñÿ ÷àñòî, õîòÿ è íå ó âñåõ. Èìåííî ïîýòîìó ÁÏØ òðåáóåò îñîáåííî æåñòêîãî âðà÷åáíîãî íàáëþäåíèÿ. Ïðè ñòàíäàðòíîì æåëóäî÷íîì øóíèðîâàíèè (ÆØ) âñå ýòè ïðîáëåìû âîçìîæíû, íî ðåäêè è áûâàþò ÷àùå âñåãî â ìÿãêîé ôîðìå, ïîñêîëüêó äëèíà ïåòëè òîíêîé êèøêè äëÿ âñàñûâàíèÿ ñîñòàâëÿåò îêîëî 3 ìåòðîâ, ïîýòîìó äåôèöèòû ðåäêè. Èìåííî ïîýòîìó æåëóäî÷íîå øóíòèðîâàíèå ÿâëÿåòñÿ çîëîòûì ñòàíäàðòîì âî âñåì ìèðå, à ÁÏØ - ýòî óäåë îòäåëüíûõ ýíòóçèàñòîâ. Êñòàòè, íàø ïðåçèäåíò ä-ð ßøêîâ ÿâëÿåòñÿ ñòîðîííèêîì èìåííî ÁÏØ. Ìû ýòó îïåðàöèþ íå ëþáèì, è äåëàåì åå êðàéíå ðåäêî. À âîò æåëóäî÷íîå øóíòèðîâàíèå â ëàïàðîñêîïè÷åñêîì âàðèàíòå ëþáèì è äåëàåì åæåäíåâíî. Ïðè ðåñòðèêòèâíûõ îïåðàöèÿõ ýòèõ ïðîáëåì íå áûâàåò (çà èñêëþ÷åíèåì ìîäèôèêàöèè ïèòàíèÿ). 2. Äåéñòâèòåëüíî, çà ïàöèåíòàìè äîëæíî áûòü ïîæèçíåííîå âðà÷åáíîå íàáëþäåíèå. Ñèñòåìà òàêîãî íàáëþäåíèÿ â íàøåé ñòðàíå îòñóòñòâóåò. Ïîýòîìó íàáëþäåíèå (èëè íåíàáëþäåíèå) çà ïàöèåíòàìè íàõîäèòñÿ íà ñîâåñòè òîãî öåíòðà, ãäå ïàöèåíò îïåðèðîâàëñÿ. Âîîáùå-òî, åñëè ïàöèåíò ìîæåò â ëþáîå âðåìÿ ñâÿçÿòüñÿ ñî ñâîèì äîêòîðîì ïî òåëåôîíó èëè ïî èíòåðíåòó - ýòîãî, êàê ïðàâèëî, äîñòàòî÷íî. Ïðîáëåìû, âîçíèêàþùèå â ïîñëåîïåðàöèîííîì ïåðèîäå, ìîãóò áûòü ñêîððåêòèðîâàíû â ëþáîì ãîñïèòàëå â ëþáîé òî÷êå íàøåé ïëàíåòû, íàäî òîëüêî çíàòü, ÷òî äåëàòü. Ïàöèåíò ïåðåäàåò òåëåôîííóþ òðóáêó äåæóðíîìó äîêòîðó â äàííîì ãîñïèòàëå, è ìû ñîâìåñòíî âûðàáàòûâàåì ïëàí ýêñòðåííûõ ìåðîïðèÿòèé. Ê ñ÷àñòüþ, òàêèå ýêñòðåííûå ñèòóàöèè áûâàþò ðåäêî. Åñëè ïðîáëåìû âîçíèêàþò â ïëàíîâîì ïîðÿäêå, ìû âñåãäà ïðîñèì ïàöèåíòîâ ïðèåçæàòü ê íàì. Ìû äàåì ïàöèåíòàì íàøó êíèãó (ðóêîâîäñòâî äëÿ ïàöèåíòîâ), ãäå èìååòñÿ ñõåìà ðåãóëÿðíûõ îáñëåäîâàíèé, ñïåöèôè÷íûõ äëÿ êàæäîãî âèäà îïåðàöèè. Òåì íå ìåíåå, âîïðîñ î âàðèàíòàõ ñîçäàíèÿ ñèñòåìû ïîæèçíåííîãî íàáëþäåíèÿ îñòàåòñÿ îòêðûòûì è àêòóàëüíûì è âàæíûì. 3. Ïðè ñèíäðîìå Prader-Willi ïàöèåíòîâ èíîãäà äåéñòâèòåëüíî îïåðèðóþò ([Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]), õîòÿ ýòî ñêîðåå ýêçîòèêà. À âîò òî, ÷òî ñåé÷àñ â ìèðå äåéñòâèòåëüíî ðàçâèâàåòñÿ áàðèàòðè÷åñêàÿ õèðóðãèÿ ó äåòåé è ïîäðîñòêîâ - ýòî ôàêò (íàïðèìåð - [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]). Ïî èìåþùèìñÿ ó íàñ äàííûì, ñàìîìó ìëàäøåìó ïàöèåíòó ñ îæèðåíèåì, êîòîðìó ñäåëàíî æåëóäî÷íîå øóíòèðîâàíèå, áûëî 9 ëåò. Ìû íå ïëàíèðóåì è íå õîòèì çàíèìàòüñÿ ïåäèàòðè÷åñêîé áàðèàòðè÷åñêîé õèðóðãèåé ïî öåëîìó ðÿäó ïðè÷èí, õîòÿ íàì èíîãäà çâîíÿò ðîäèòåëè äåòåé è ïîäðîñòêîâ è ïðîñÿò ïîìî÷ü, òàê êàê ðåáåíîê ïðîäîëæàåò íàáèðàòü âåñ è âñå êîíñåðâàòèâíûå ìåðîïðèÿòèÿ íåýôôåêòèâíû. Òåì íå ìåíåå, ìû èì ñîâåòóåì ïîäîæäàòü äî 15 ëåò. Ðîññèÿ - íå Àìåðèêà, è åñëè ìû áóäåì ýòî äåëàòü, ïåäèàòðû íàì ýòîãî íå ïðîñòÿò. |
#56
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"Ìû áîäðû" íàäî ïåòü áîäðåå, "ìû âåñåëû" - âåñåëåå.
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Lead, follow, or get out of the way. — Thomas Paine |
#57
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Öèòàòà:
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#58
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Èëþõèí Åâãåíèé Àðêàäüåâè÷ |
#59
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Öèòàòà:
Ýòî âïîëíå îñîçíàííîå æåëàíèå ïîáûñòðåå ðåøèòü ïðîáëåìû âîçíèêøèå ñ ëèøíèì âåñîì, î êîòîðûõ íå õîòåëîñü çàäóìûâàòüñÿ ðàíüøå è/èëè íå õî÷åòñÿ îñîáî íàïðÿãàòüñÿ, ÷òîáû ðåøàòü ñåé÷àñ. Ïîýòîìó õî÷åòñÿ óçíàòü ïîëíóþ ñòîèìîñòü äàííîé "óñëóãè", êîãäà âñ¸ ñäåëàþò çà òåáÿ áàðèàòðè÷åñêèå õèðóðãè. P.S. Êàê ÿ ãîâîðèë ðàíåå - áîëüíûõ ÑÄ ÿ â äàííîì ñëó÷àå íå ó÷èòûâàþ. |
#60
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Ïðîñüáà ê ó÷àñòíèêàì äèñêóññèè èçáåãàòü ýìîöèîíàëüíûõ êîììåíòàðèåâ, è áîëüøå îïåðèðîâàòü ôàêòàìè.
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