I thought it might be helpful to describe what to expect, from an Anesthesiologist point of view, on the day of your surgery. It’s a big day for you. A day you have probably been thinking about for a long time. It is completely normal to be nervous, excited, anxious, and even calm. Different people react differently to unknown situations. My hope is to arm you with knowledge about what to expect. It should help to ease some of the anxiety you may have. I am going to walk you through a day in the life of a patient at Wayzata Plastic Surgery.

Typically we ask patients to arrive an hour before their scheduled operation. You will meet with one of our nurses who will do your intake. This is similar to being admitted at a hospital except it doesn’t take hours to accomplish or require loads of paperwork. Next, you will meet with me, your Anesthesiologist. I will take a short history, explain what type of anesthetic you will be having and answer any questions you have about the sleeping portion of your day. No questions are “dumb questions” and I am happy to spend as much time as needed to help you feel comfortable with the process. Being a bit of a control freak myself, I know how difficult it is to give up that sense of control and let someone who was a complete stranger only minutes ago, take care of you in your most vulnerable state. I have been on the other side as a patient and it is not an easy thing. After we are done talking, your surgeon will visit with you and answer any remaining questions you have about the surgery.

During your time in the preoperative room we ask that you stay nice and warm by using blankets and a space heater. When the nurse brings you into the operating room you will understand why this is so important. The operating room is kept very cold! This is not done intentionally to make you feel uncomfortable. There are a couple of good reasons for it. The first is for infection control. Infectious organisms cannot live in a cold environment so it is protective against postoperative infections. The other reason is your plastic surgeon and his assistants will be standing under hot lights in a large sterile robe for a long period of time and it keeps them comfortable.

Once you are in the room we will ask you to lie down on the operating room table. We will place warm blankets on you and introduce you to the any of the operating room staff you haven’t met yet. There will seem to be a flurry of activity as there are usually at least four people in the room and each of us has a job to do. I will work on getting a line placed in your arm to give you fluids and medications. I have a few tricks to help make the line placement less traumatic. If this is something you are worried about, please let me know when we meet. The nurses will put on several monitors. Booties will be placed on your feet to give you a massage during the surgery and to help to prevent blood clots.

Once I have taken your baseline vital signs, and everyone in the OR is ready, we will place a mask on your face that contains oxygen and ask you to take some nice big breaths. It’s time to go to sleep! I will give you medications thru the IV line to accomplish this and it typically takes about five to ten seconds for you to fall asleep. During the entire duration of your surgery I will be continuously monitoring your vital signs and giving you medications to keep you asleep, reduce your pain, and prevent postoperative nausea.

Once your surgery is complete I will gradually wake you. It is common to feel as if no time has passed because patients don’t typically dream. It will seem as if you were asleep for a second or two, regardless of the length of the surgery. You may also be surprised by how good you feel upon waking. We are lucky here at Wayzata Plastic Surgery that we are not obligated to give the cheapest anesthetic. We give the best anesthetic, using the best medications, and that usually means quite a different experience upon waking than you may have had with previous surgeries performed at a hospital. In fact, most patients with a history of nausea and vomiting postoperatively are amazed that they can go to sleep here and wake up feeling great. A recovery nurse will stay with you until you feel ready to sit up, get in a wheelchair, and head for home.

That’s all there is to it! Hopefully having some “inside information” will help ease your nerves when your surgery day finally arrives! Until then, I’ll look forward to meeting you in person. Annie Burton, MD (Your Anesthesiologist) September, 2010

What is the sleep assessment process?

Referral

Your General Practitioner (GP) or specialist will forward a referral to us. When this referral is received, a letter will be sent to you to acknowledge the receipt of the referral.

Assessment and Consultation

Once an appointment becomes available you will be notified. This appointment will either be for a sleep study or physician review depending on what your GP or specialist has requested in the referral letter. Often patients will have a sleep study first with a follow up appointment in our clinic to discuss the results.

If you are diagnosed with obstructive sleep apnoea, you may have a further treatment study and then referred for CPAP (Continuous Positive Airway Pressure) therapy. For provision of CPAP machines, Veterans or Health Care Card holders will be referred to our CPAP nurses at the Repatriation General Hospital while others (non-Veterans and those without Health Care Cards) will be referred to private CPAP outlets to purchase or rent their CPAP machines.

Waiting Times

Currently the waiting time for a public patient appointment at the RGH is approximately 4 months. We have provisions for urgent appointments, subject to discussion with your referring GP or specialist. If you are referred for an overnight sleep study by an external specialist, the waiting time is approximately 3 weeks.

Private patients attending the Ashford Hospital will have minimal waiting times of approximately 2-3 weeks.

Assessment

Assessment of your sleep patterns can be done via several different methods:

Polysomnography (PSG): This test monitors sleep and breathing patterns overnight using simultaneous recordings of brain wave activity (EEG), eye movements, muscle tone and breathing movements.

Sleep studies are performed on adults and 12-18 year old children. The same type of measurements and application of sensors (non-invasive) are used for both adults and children.

Patient Information Sheet (AISH): Polysomnography

More information about sleep studies performed on adults and children can be found on the Facilities and Services and Ashford Sleep Service pages.

Multiple Sleep Latency Test (MSLT): The MSLT is a series of 4-6 nap opportunities (5 naps are performed in our laboratory) presented at 2 hour intervals. The test is used to index a patient’s sleepiness and to identify abnormal REM sleep tendencies.

Patient Information Sheet: Multiple Sleep Latency Test

Maintenance Wakefulness Test (MWT): This test is designed to measure a patient’s ability to stay awake in conditions in which sleepy patients have difficulty maintaining wakefulness. Unlike the MSLT in which the patient is instructed to allow themselves to fall asleep, during a MWT the patient is instructed to attempt to remain awake.

Patient Information Sheet: Maintenance of Wakefulness Test

Treatment

Your treatment options will be discussed at your follow-up appointment. Some of these may require further visits to the laboratory:

CPAP Titration Study: Continuous Positive Airway Pressure (CPAP) is the main treatment for obstructive sleep apnoea. It is a pump which uses a gentle stream of air to splint open the airway at night. Depending on the case an overnight study may be conducted at the laboratory or in the home to determine the most effective setting for the machine to alleviate symptoms of apnoea.

Patient Information Sheet: Continuous Positive Airway Pressure

Insomnia Treatment Program: This program utilises non-drug approaches to treating insomnia. It takes clients through an intensive 5 week treatment program with reviews to monitor progress. Read more about the Insomnia Treatment Program.

Being overweight or obese is a major risk factor for the development of obstructive sleep apnoea.

Weight loss is an effective means of treating or reducing the severity of sleep apnoea. A 10% weight loss can lead to a 26% reduction in the severity of OSA.

Lifestyle modification is the cornerstone of weight control, and works best in combination with other therapies tailored to your individual needs.

Surgery is currently the most effective treatment for severe obesity.

Why obesity is bad for your health and sleep?

Being overweight or obese changes the nature of the upper airway tissues. Patients with OSA have been shown to have thicker pharyngeal walls, and excess tongue and soft palate tissues. These changes appear to be more pronounced in males compared to females with OSA, and result in a smaller airway due to overcrowding of the airway by these structures.

Excess body weight reduces lung volume when lying on the back (supine posture). This can result in a decrease in the traction or normal ‘tug’ on the upper airway as the diaphragm and inter-connected structures inside the chest are displaced upward, effectively causing the upper airway to become more floppy.

Will my sleep apnoea improve with weight loss?

1. How is obesity measured?
2. CATEGORY BMI* Underweight Less than 18.5
3. Normal 18.5-24.9 Overweight 25.0-29.9 Class 1 obesity 30.0-34.9 Class 2 obesity 35.0-39.9 Class 3 obesity (extreme)
4. 40 or more

Weight loss management program

• How much weight to lose.
• How to lose weight.
• How much weight to lose?
• How to lose weight?
• Diet and exercise

Expert dietary advice to help restructure your diet.

An increase in physical activity either by way of incidental activity (daily activities such as walking and climbing stairs), and/or specific exercise program.

• Attending support groups such as Weight Watchers.
• Medications
• Weight loss (bariatric) surgery

Click on the links to be directed to the sections below. Being overweight or obese is an increasingly serious health burden in Australia and worldwide. In the Australian adult population, an estimated 67% of males and 52% of females were classified as overweight or obese in 1999-2000. Excess body weight poses a significant risk of developing chronic illnesses particularly diabetes, high blood pressure, high cholesterol, heart disease and some cancers. As such, those who are overweight or obese may die younger than those of normal body weight.In a recent update of US data (Framingham study), an average reduction in life expectancy of 5.8 and 7.1 years may be seen in 40 year old non-smoking males and females respectively compared with those of normal body weight of the same age.Although obstructive sleep apnoea (OSA) may result from a combination of several different causes, obesity remains the dominant risk factor. How then does obesity increase the likelihood of the upper airway collapsing repeatedly during sleep?

Thus obesity can result in a more floppy and smaller upper airway. To make matters worse, muscles that work to hold the airway open are also less effective in patients with OSA. The end result is that the upper airway in an obese person tends to collapse more easily in sleep. All these effects can be improved by weight loss.There is now very little doubt that losing excess body weight is an effective way of treating or reducing the severity of OSA in most people. In one study, a 10% weight loss predicted a 26% reduction in the severity of OSA. In our experience a loss of weight of this degree may be enough to reduce the need for the use of therapies such as continuous positive airway pressure (CPAP) in some patients.The most common method of measuring obesity in the clinic is by use of the body mass index (BMI). This is a standardised calculation of your height and weight measured as part of your medical consultation. The BMI is a product of your weight in kilograms divided by your height in metres squared, weight/(height)2. Click here to calculate your BMI.*BMI ranges may differ for non-caucasian groupsOur clinic is currently expanding the range of specialties involved in treating obesity. This will eventually culminate in a multidisciplinary team aimed at providing a holistic weight loss service. Our team will work closely with your general practitioner who will continue to have a key role in your care.

The fundamental aim of a weight control program involves determining:The simplest answer to this question is the more the better, to a normal weight range (see BMI above). Studies have shown that even a modest weight loss of 5–10% of body weight can produce significant health benefits with cardiovascular risk reduction and control of diabetes, not to mention improvements in control of OSA. As such, an initial goal to reduce 10% of body weight over 6 months would be reasonable for most patients. This goal may change over time depending on your progress. A realistic expectation and regular review of progress are key aspects of the treatment process. Lifestyle factors underlie the vast majority of cases of obesity in our society with rarer contribution from genetic and medical causes. Therefore, a successful weight control program needs to focus on lifestyle modification in combination with other interventions tailored to an individual patient’s needs. Current options for weight loss are diet, exercise, medications and surgery. This is usually the starting point in the treatment program. It makes sense that for weight loss to occur, a decrease in caloric consumption would work best when coordinated with an increase in the energy expenditure. A lifestyle modification program needs to be tailored, taking into account the motivational level and specific health problems of each patient.

This may involve: Regular reviews are required to ensure that strategies are implemented and that necessary alterations to the plan are accommodated. Our team is also considering instituting psychological intervention for more structured behavioural techniques in selected cases.No one medication for weight loss may be recommended as a stand-alone treatment, and if used should be in combination with diet and exercise. As there may be unpleasant or unwanted side effects, a doctor’s supervision is essential when these medications are used. These medications are also fairly expensive.Medications used to treat obesity work by decreasing energy intake or increasing energy expenditure, or both. Currently, the following drugs are available in Australia for weight control:: acts to prevent absorption of up to 30% of dietary fat. In clinical trials, when combined with a low caloric diet, an average weight loss of 10% over 1 year may be expected. The major side effects are due to fat malabsorption, causing diarrhoea or fatty stools in 20% of patients. These side effects may be reduced by combining orlistat with a low fat diet.: an appetite suppressant. It can result in a weight loss of 5-8% when used alone. Minor side-effects of headache and dry mouth may occur in 20-30% of patients. Of more concern is the occurrence of a small increase in blood pressure and heart rate in some patients. It is therefore not recommended for those with unstable heart disease or high blood pressure. If used, regularly monitoring of blood pressure will be required.: acts as a stimulant. It is not recommended for continued use for more than a month and is therefore not part of a longer-term weight loss treatment.Newer drugs are currently being tested in research studies but have not reached mainstream prescription yet. Over-the-counter medications (not prescribed by your doctor) are not recommended as there is no evidence that these will work or how long their effects will last.

There has been considerable interest in this area as surgery is currently the most effective treatment for severe obesity. The surgical techniques usually result in some form of gastric restriction to limit food intake. In motivated and morbidly obese patients, surgical procedures can result in weight loss in the order of 16-43% (varying between 22 and 63 kilograms) over 1 to 2 years. The weight loss needs to be maintained with a closely supervised weight management plan thereafter. Laparoscopic banding (a form of ‘key-hole’ surgery) is now the most commonly used procedure in Australia, although other techniques (such as gastric bypass) are also available.

Who should go for weight loss surgery?

Prevention is better than cure

Surgery is currently indicated for those patients with a BMI greater than 40, or with a BMI greater than 35 and serious medical problems including OSA. These patients would usually have been unsuccessful in achieving weight loss by diet and exercise. Should surgery be considered, it is crucial that other health problems such as diabetes, blood pressure, heart disease and OSA are well controlled prior to the procedure to limit complications. There are very few of these surgical procedures being performed in the public health system and access to these operations is improved if you have private health cover.The major challenge in weight loss treatment is achieving sustained weight control. It also makes perfect sense to prevent obesity than to treat it. This will require individuals, the community, health care professionals and the government to put in a concerted effort to effect changes in our lifestyle and environment for a healthier living.

The basal ganglia, interconnected brain areas within the cerebral cortex, were originally thought to involve motor control. These nuclei have since been proven to affect learning and focus, form good and bad habits, and contribute to addictive disorders. The inhibitory neurotransmitter GABA plays the most important role in the basal ganglia.

Corpus Striatum

The largest nuclei group, the corpus striatum, includes the caudate nucleus, putamen, globus pallidus, and nucleus accumbens. The caudate sends messages to the frontal lobe (particularly the orbital cortex), and seems responsible for informing us that something is wrong and needs correction. An overactive caudate may result in obsessive compulsive disorder (OCD).

Problems with Overactive Basal Ganglia

“Disturbances involving the neural circuits between the cortex and basal ganglia, similar to those found in patients with OCD, may also be present in anorexic patients,” says Dr. Paolo Cavedini, a psychiatrist in Milan. A recent positron emission tomography (PET) study showed overactive dopamine receptors in the basal ganglia of anorexic patients. Such overactivity may result in obsessive feelings about food as well as rewardlike releases from the neurotransmitter dopamine during starving behaviors. Dopamine surges may perpetuate those behaviors into habit.

Effects of Inactive Caudate

If the caudate is inactive, various disorders such as ADD, ADHD, schizophrenia aspects, depression, and lethargy may result. Caudate nucleus damage may result in PAP (or Athymhormic) syndrome, wherein one experiences an ususual lack of motivation. One extreme example is non-motivation to save one’s own life!

Putamen and Basal Ganglia

The putamen, under and behind the front of the caudate, appears to affect automatic behaviors such as driving or bike riding. Problems in this area may result in Tourette’s symptoms. The globus pallidus receives inputs from the caudate and putamen and provides outputs to the substantia nigra. The accumbens receives signals from the prefrontal cortex and returns them via the globus pallidus. The pars compacta in the substantia nigra uses dopamine neurons to signal the striatum, which may involve reward circuits. The pars reticulata controls eye movements and may affect Parkinson’s and epilepsy. Huntington’s disease, cerebral palsy, dystonia, and hemiballismus (uncontrollable movement on one side of the body) are thought to be other conditions of this dysfunction.

Treatment for Basal Ganglia Dysfunction

While basal ganglia dysfunction can have severe consequences, treatment plans offer hope to those who suffer from such disorders. Several methods have been effective.

Gene therapy, in its infancy but promising, replaces diseased phenotypes with new genetic material. This treatment appears viable for neurodegenerative disorders. One example is implanting genetically modified cells that convert to dopamine.

Lesioning destroys neuronal cells in a particular area. Ablation can be likened to removing a faulty piece of a circuit. When this occurs, the healthy area of the circuit functions normally.

Deep brain stimulation inserts electrodes that emit high-frequency stimulation to the implanted areas in the brain’s sensorimotor area. Adjusting stimulation protocols, thereby altering the activity of basal ganglia circuits, lends this treatment to a variety of disorders.

Most New Yorkers can’t get on a subway without reading some kind of healthcare advertisement; and yet somehow so many people are unaware of exactly what a podiatrist is. Our podiatrists at Midtown Podiatry came up with a few facts that will answer some of your questions!

1. Podiatrists must be educated. It’s true of all podiatrists — New York and otherwise — but people in NYC are much more likely to believe that it’s possible to ‘cheat the system’. Fortunately, that’s almost impossible — there’s a basic State exam that every podiatrist has to pass; and if you have been to one (or are currently going to one) that can’t show you their certificate, find a new podiatrist, plain and simple.

2. Your feet are critically important to your overall health. Especially in the Big Apple where we all walk everywhere and there’s precious little soft ground to be found, even a minor maladjustment in your foot can cause everything from back pain to intestinal distress.

3. Your feet are not made to walk in shoes. Of course, it’s not exactly hygienic to walk around without shoes on, especially in a densely-packed city, so shoes have their purpose — but studies have shown that bare feet actually deal better with the millions of tiny impacts against hard surfaces that city life forces on them. The podiatrists at Midtown Podiatry are trained to deal specifically with the kinds of small problems that creep up when you wear shoes for your entire life.

4. Podiatrists are health-care professionals. Podiatry, NYC‘s opinions aside, isn’t just about bunions and ingrown toenails. Podiatrists are intimately familiar with the effects that foot health has on the entire body, and as such they have just as much if not more anatomical and systemic understanding as a general practitioner. They treat infections, diseases, and deformities of the foot just like a GP treats any general infection, disease, or deformity — just with more focus and thus greater clarity.

5. The foot is the early-warning system for your entire body. Think about gravity. The fact is that because of that ubiquitous force, many diseases from heart disease to diabetes often leave telltale signs in the foot before they appear anywhere else in the body. That makes the podiatrists at Midtown Podiatry a lot more than just someone who helps you walk right — he can and does save lives on a regular basis.

If you would like to meet with one of Midtown Podiatry’s trained podiatrists, with locations in Midtown, Gramercy Park, Wall Street, Union Square and Glen Cove, you can conveniently make an online appointment, or call us at any of the locations.

Throughout history, gout has been associated with rich foods and excessive alcohol consumption. Because it is clearly associated with a lifestyle that, at least in the past, could only be afforded by the affluent, gout has been referred to as the “disease of kings”.The first documentation of the disease is from Egypt in 2,600 BC in a description of arthritis of the big toe.

The directions for Relacid call for using 50 drops each day in water or juice. How and when you take Relacid can make a big difference as to how soon you will see results and stop suffering from gout. For best results we recommend mixing 10 drops in 8oz of water 5 times spread throughout the day. Consistency is the key with using Relacid gout treatment. If flavor is an issue, mix 25 drops in 8oz of juice taken morning and night. You may take with or without meals. If mild detoxification symptoms result, reduce dosage temporarily. No refrigeration required.After 90 days when gout relief has been achieved, reduce to a maintenance dosage of just 1 serving of 25 drops each day. Each bottle will then contain a 6 month supply.

The key ingredients in Relacid are Dissolved Oxygen, Amino Acids, Plant Enzymes Magnesium, Calcium, Chromium, Copper, Iron, Manganese, Molybdenum, Nickel, Potassium, Phosphorus, Selenium, Zinc plus over 60 trace minerals. These nutrients are highly concentrated and just 50 drops a day will raise the pH in the body and dissolve the uric acid crystals in the body.No, they will not. Relacid gout treatment nutrients are recognized by the body as a food and have no side effects and no toxicity. You can continue to take any kind of medication without fear of these nutrients interfering or causing negative reactions. There is technically no cure for gout. However, when you able to reduce the build-up of uric acid crystals through the use of Relacid and you are free of pain and swelling, one may consider themselves cured from gout.

You should continue to take any medications that have been prescribed by your physician. What will normally happen is that your pain and swelling will begin dramatically decrease. You should inform your physician that your taking Relacid and that you pain and swelling has decreased. Inform the doctor that you want to reduce the amount of medications you are taking accordingly.Relacid is manufactured in a FDA compliant and inspected facility that adherers to all of the guidelines under current GMP standards. The ingredients in Relacid have a history of safe use with over a 100,000 bottles sold yearly for the last 8 years.It depends totally upon the state of your body and your metabolism when you take Relacid gout treatment. First you may notice an increase in energy within a couple of days.

For those who are less healthy due to a prolonged battle with gout, the benefit of taking Relacid gout treatment may be experienced from the first month of taking it. Given the proper nutrients, the body starts its own repairing process, which is noticeable very shortly, depending on the individual and his/her particular bodily requirements.It is important to compare labels when choosing a gout treatment. Other products on the market may be priced 10%-15% less. Relacid gout treatment on the other hand is highly concentrated with each bottle containing 30 servings which is a 1 month supply. At $89.95 Relacid is a great value.Every order of Relacid gout treatment is shipped using the United States Postal Service so that every package can be tracked. Normally your order will arrive anywhere in the United States within 4 days.