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The Value of Ongoing Psychological Support for the Bariatric Patient, Surgeon, and Multidisciplinary Team
by Carol Bradley, RN, CS, MSN
From the Saint Mary's Regional Medical Center; Adjunct Clinical Professor, Orvis School of Nursing, University of Nevada, Reno, Nevada
There is increasing consensus that bariatric surgery is superior to medical intervention for long-term weight loss in morbidly obese persons.[1] Most postoperative patients are able to lose a significant amount of weight, profit from reduced or resolved comorbidities, and have an improved quality of life (QOL).
Despite these anticipated benefits from bariatric surgery, studies indicate that 5 to 30 percent of patients either lose little weight or are unable to maintain their weight loss over the long term.[2] Aside from medical or surgical complications, postoperative weight loss success depends upon the patient's abilities and willingness to follow the prescribed nutritional and lifestyle guidelines. Whereas the surgery provides the "tool" for weight loss, the patient must provide the motivation and ability to obtain the ultimate long-term success.
Numerous experts agree that psychopathology and various psychological difficulties existing prior to the surgery can have direct adverse effects on the postoperative outcome. However, findings of studies investigating underlying psychopathology or other emotional obstacles have yielded inconsistent results.
Whereas earlier studies gave little indication of higher incidence of psychopathology in obese persons, more recent studies suggest that morbidly obese patients may have significant symptoms of depression, evidence of eating disorders, negative body image, low QOL, and other coexisting mental disorders.[3-10] Moreover, various studies of bariatric surgery candidates have identified a variety of psychiatric and behavioral problems, including but not limited to anxiety, depression, eating disorders, and history of sexual abuse.[8,9,11-13]
In addition to the lack of identified factors predicting postoperative success, there are inconsistencies in the nature of the clinical interview, as well as the lack of a standardized protocol for postoperative assessment. The value of particular symptom inventories or other structured tests is continuing to be considered in the literature.[14, 15] Whereas results of the Mental Status Exam (MSE) and various structured psychological tests may prove valuable, there is concern that such might only give a circumscribed and "limited" view of the patient's readiness for bariatric surgery. These inconsistencies yield questions regarding the usefulness of the preoperative psychological assessment.[16]
The Problem in Clinical Practice
These varied research findings and interview inconsistencies have led to differing conclusions and diverse clinical practices by surgeons and other policy-making groups. With the adolescent population, preoperative evaluation seems to be a more common practice.[17] On the other hand, with evaluation of adult patients, various attitudes and practices abound. Although many may recognize the value of having a behavioral expert or mental health professional (MHP) available to the multidisciplinary team, there is some disagreement as to whether the MHP should be part of the team. Furthermore, there is a lack of agreement as to whether it should be required for the patient to receive a psychosocial assessment prior to surgery and what the nature of the behavioral/psychosocial evaluation should be.[2, 18, 19] Such diversity in opinion has resulted in an equivalent diversity in practice ranging from the position that a routine psychosocial evaluation of any surgical candidate is not necessary to the position that all preoperative patients should be required to obtain a preoperative evaluation.[8, 14-16, 18, 20] This diversity in opinion and in preoperative practice makes it less likely that the patient will obtain ongoing postoperative support from a MHP.
The Proposal for Clinical Practice
It is not the purpose of this article to evaluate the methodology of previous studies or debate the merits of specific structured tests or symptom surveys. Rather, the purpose is to recognize the relevance of pre-existing cognitive, psychological, social, or emotional issues as possible obstacles for postoperative success. This article also seeks to emphasize the value of a comprehensive and population-specific preoperative assessment of the obese patient seeking bariatric surgery.
Determining the patient's cognitive, psychological, social, and emotional capabilities, as well as assessing motivation for undertaking the necessary postoperative lifestyle and nutritional changes, is critical prior to undergoing bariatric surgery. This assessment should be performed by an experienced MHP with extensive knowledge of the bariatric surgery experience, the surgical procedure, and postoperative outcomes. Only with this extensive knowledge base and expertise in bariatrics can the MHP sufficiently evaluate the myriad number of important issues for the bariatric patient, including but not limited to realistic expectations for postoperative weight loss, understanding of possible postoperative complications, motivation to undertake the necessary nutritional and lifestyle changes, and proclivity toward emotional or psychological obstacles to postoperative success.
The Benefits of Ongoing Support
Beginning with this preoperative connection with an informed MHP, the benefits of ongoing support for many patients can be ascertained. With preoperative contact with a MHP, the MHP is more likely to anticipate and intervene with any emotional, psychological, or social obstacles that might occur prior to surgery. Continued MHP support will provide the patient with structured postoperative contacts and allow the MHP to more immediately identify obstacles to postoperative success. With the ready access and ongoing relationship with the MHP, family obstacles to postoperative success can be more readily identified and effectively dealt with, either directly by the MHP or as result of referral by the MHP to other professionals. Equally important, in addition to the myriad patient and family benefits, the expert MHP can be a valuable support to the surgeon and multidisciplinary team in providing both preoperative and postoperative consultation, collaboration, and intervention.
The Value of Preoperative Assessment, Interventions, and Support
Identifying psychopathology in the bariatric patient's preoperative assessment is critical. The value of the preoperative assessment by a MHP to identify such pre-existing psychopathology or other psychiatric issues may already be recognized by the surgeon. Even so, a short-sighted surgeon may only see need for the psychiatric assessment as merely providing a "yes" or "no" answer to the question of appropriateness for surgery. Assessment, however, is not only looking at this dichotomous variable, but is also providing a richer source of data. It is important to identify severe psychopathology in order to possibly avert a postoperative psychiatric crisis or to possibly deter legal proceedings in the event of an adverse outcome. It may be obvious that the chances for an adverse outcome with increased proclivity for litigation would be more likely if questions regarding preexisting psychopathology, inadequate cognition, or poor motivation were not adequately answered prior to the surgery.
As one example, the patient with untreated bipolar illness may not have the judgment or readiness to commit to the lifestyle changes necessary for a successful postoperative outcome. However, the MHP can be helpful in ways beyond the evaluation of frank psychopathology. A legal proceeding can unfortunately be driven for a myriad number of reasons, ranging from an adverse surgical outcome to ineffective communication. Such possible occurrences are mentioned regularly at bariatric conferences and within the literature.[27-32] The prudent clinician is undoubtedly cognizant of such a possibility. Claims that consistently emerge against surgeons who perform bariatric procedures result not only from adverse surgical outcomes, but from issues related to improper patient selection, lack of informed consent, and lack of adequate postoperative follow-up.[31] Such an unfortunate circumstance pertaining to these last three issues could possibly be prevented by the interventions and ongoing relationship with a MHP sensitive and knowledgeable in bariatrics. Specifically, a comprehensive preoperative assessment by such a MHP can evaluate the patient's postoperative expectations, adequate cognition, and degree of motivation to undergo the surgery. As part of the assessment, the MHP can refute myths and reinforce education for nutritional and lifestyle changes toward postoperative success. As examples, the patient who believes that the "weight will just fall off without exercise" or thinks that she "will never have to think about food intake again" after a laparoscopic gastric banding procedure has unrealistic expectations and needs reinforcement of the necessary postoperative lifestyle and nutritional requirements. Likewise, the patient who chooses the laparoscopic gastric banding procedure "in order to lose the weight and then have the band removed within a couple of years" or the patient who believes that bariatric surgery "is a cosmetic surgery that really isn't as serious as other surgeries" lacks important detail in order to truly give informed consent. In these ways the evaluating MHP can assist the surgeon with proper patient selection, reinforce the patient's knowledge base, and ensure a more informed patient.
Moreover, the relationship and the documentation maintained by the MHP provides the surgeon with another professional's opinion, expertise, and investment in the surgical outcome for clinical follow-up as well as in the event of a legal proceeding. Equally important regarding follow-up, the ongoing relationship with the experienced MHP will help to reinforce the patient's knowledge base and lifestyle changes, anticipate emotional obstacles for postoperative success, and provide a valuable resource to the patient and support system during postoperative visits. Finally, in varied ways the MHP can assist the surgeon in identifying collaborative strategies and implementing preventative measures to reduce risk exposures in the bariatric program.[29] The MHP can be invaluable in identifying the preoperative patient at risk for miscommunication or psychological distress, in circumventing possible emotional obstacles to postoperative success, and in intervening in the event of an adverse postoperative outcome. In summary, the ideal outcome would be the prevention of legal claims, rather than the need for another professional's support and testimony with a legal event. Regardless, the communication skills and clinical expertise of the MHP knowledgeable in bariatrics could be crucial in reducing both the frequency and severity of claims or in sitting with the surgeon at counsel's table if the situation warranted.
Additional problems can be identified by the MHP experienced in bariatrics that could pose additional challenges for postoperative weight loss success. The list of possible reactions typically experienced postoperatively can be viewed in the subsequent section, "Usual Postoperative Issues Benefiting From MHP Support." Equally important, if the preoperative assessment is limited to identification of pre-existing psychopathology alone, with a "yes" or "no" verdict, then the completion of the assessment will most likely signify the "end" of the relationship with the MHP with no expectation for follow-up or structure for continued support or interventions.
Even if preoperative or postoperative psychiatric treatment is indicated, it may not be with the initial assessor, but rather with an independent practitioner pre-designated by insurance for mental health services only. This insurance-mandated MHP may not have knowledge of bariatric surgery or expertise in dealing with the usual postoperative challenges faced by the bariatric patient with its required nutritional or lifestyle changes. Again, this limits the postoperative patient from benefiting from the expertise and continuity with a MHP experienced in the field of bariatrics. Moreover, the surgeon may not be in a team situation or have complete compliance from the patient for postoperative office visits in order to early identify emotional challenges or to provide long-term follow-up for his or her bariatric surgery patients.[2, 21]
The value of the preoperative psychosocial assessment of the bariatric surgery candidate should not be "the end in itself," but rather the "means to an end." Rarely should the outcome of a preoperative psychosocial assessment be limited to the statement, "Patient is not appropriate for the surgery" without more detail. The MHP should be in a position to make specific recommendations for treatment, either as a preoperative condition for the surgery, or as a postoperative intervention if an identified problem surfaces. Preexisting psychopathology may require preoperative treatment either as a prerequisite for the surgery and/or as a means of helping the patient deal with his or her psychological impairments. As an example, a history of childhood sexual abuse may prompt the MHP to educate the patient regarding possible emotional obstacles to postoperative success. With increasing weight loss, the patient with a history of abuse may discover that he or she is increasingly uncomfortable, even feeling vulnerable, as a result of the typically increased attention and compliments from others. If such issues have been resolved, education alone by the MHP with encouragement for regular support group attendance and follow-up visits with the MHP may be all that is indicated. However, with a history of untreated sexual abuse, perhaps in the face of guilt and anxiety following the death of the abuser, the MHP may discuss the need for beginning therapy preoperatively in order to recognize unresolved issues that might interfere with the patient's postoperative progress.
Also, a patient with diagnosed bipolar disorder may need further evaluation for medication management. Another example would be the spouse in need of grief counseling following the unexpected death of her husband. In each instance, the patient may be too psychologically or emotionally impaired to grasp the nutritional principles or lifestyle changes necessary for effective postoperative outcome.
Exploring a history of abuse, psychiatric treatment, psychotropic medications, coping style, depression, and suicidal behavior can yield a wealth of information regarding the probability of patients making the dramatic postoperative changes that bariatric surgery requires. Moreover, knowledge about the surgery and postoperative expectations for lifestyle and nutritional changes can ensure a more comprehensive evaluation by the MHP. With knowledge of the surgery, the MHP should be able to evaluate the patient's responses to ensure that the patient is truly making an informed decision, has realistic expectations for the postoperative outcome, and is motivated to make the necessary lifestyle and nutritional changes for postoperative success.
In order to adequately evaluate the patient's knowledge base and to assess the patient's willingness and readiness to make postoperative changes, the MHP should ask open-ended questions in a semi-structured interview. This type of interview might cover the following:
1. The patient should be able to describe the surgery. The patient should also be able to compare it to other surgical choices if they are available. The knowledgeable MHP might ask, "Describe the surgery for me . . . Tell me why you chose the Lap-Band over the gastric bypass surgery. How are the two surgeries different? What are the pros and cons of each?" Specific questions regarding the "best" and "worst" outcomes can reveal deficits in the patient's knowledge base and unrealistic expectations for postoperative outcome. The patient who says, "I don't want the Lap-Band because I don't like the idea of a tube hanging out of me!" does not have correct information in order to make an informed
2. The patient should be able to describe the postoperative requirements and anticipated behavioral changes for postoperative success. It is best to begin with general questions, such as, "How will your lifestyle be different after the surgery?" or "What will change after the surgery?" These can lead to more specific questions regarding amounts and categories of food at varying points postoperatively. Questions like the following can be helpful: How big is your stomach pouch after the surgery? How much food can you eat/liquid can you drink on the day after surgery, two weeks after surgery, three months after surgery, one year after surgery? How much protein do you need to have in the course of a day after the surgery? How much water do you need to drink? In response to the question, "How important is exercise?" the unmotivated yet "prepped" patient will tout the value of postoperative exercise, yet may refute the need for preoperative activity. Asking the patient if he or she has already started making any changes in anticipation of the surgery will yield increased clues as to his or her readiness for change. The "last supper" mentality is not unusual and the patient may rationalize the intent to "hit every buffet in town" before going on the preoperative liquid diet.
In my practice, I once assessed a woman who exclaimed with delight, "I can't wait to have this (gastric) bypass. Once I have the surgery, I won't have to think ever again about what I eat!" Fighting the impulse to ask her if she had fallen asleep during the educational seminar, I outlined the dramatic postoperative nutritional changes needed, including the need to focus on protein and liquid quality and quantity "for the rest of one's life." Needless to say, she was overwhelmed with the information and elected not to have the surgery. Another example of unrealistic expectations regarding postoperative outcomes would be uncovered with a patient's ignorance regarding the value of exercise. Such patients may refuse to do exercise, expecting the weight to just fall off after the surgery..The patient who states, "Oh, the weight will just come off quickly, maybe 10 pounds a week with the Lap-Band!" has unrealistic expectations for the banding procedure. A similar example would be the patient who claims, "I hate exercise and I hate to sweat. I heard from a Lap-Band patient at the support group last night that he has lost 40 pounds in the last two months and hasn't exercised a lick!" This patient has unrealistic postoperative expectations and may need to demonstrate willingness and motivation for change prior to the surgery. The MHP is in a position to recommend such interventions and to re-evaluate the patient's progress prior to the surgery.
3. Questions regarding the patient's support system can help identify emotional deficits or conflictual relationships. For instance, the MHP may ask, "You say your husband is your best support. How does he feel about the surgery? Does he expect his life to change after the surgery?" The patient might respond, "Oh, sex is going to be wonderful!" Or, "He can't wait to show me off at the holiday party!" Such statements may indicate that the patient is psychologically unsophisticated or at least unaware of possible postoperative problems. This may be particularly true if, respectively, there is a history of sexual abuse for either party or if neither the patient nor the spouse has considered the likelihood of unsettling reactions to the patient's changing physical appearance, such as feelings of insecurity experienced by the spouse. The latter instance may be particularly relevant if the spouse is obese and chooses to remain so or is unable to lose weight. In my practice, I frequently quote Barbara Thompson with the following: "What this weight loss surgery (WLS) does for married couples is that it makes a good marriage better and a bad marriage worse."[22] That quote alone may prompt a barrage of comments about the spouse's reluctance to change eating or exercise habits or statements already made by the spouse "in humor" about fears that the patient "will fall in love with another and leave." Information obtained by the MHP regarding body weight and typical activities when the patient and spouse first met can yield projections for postoperative marital adjustment to the patient's changing body image and lesser size.
As discussed, in addition to referrals for psychiatric treatment, the MHP's recommendations could involve increased visits with the dietitian, maintaining a "log" of food intake with correlating emotions, enrolling in gym membership, and initiating a regular exercise regimen following clearly spelled out behavioral objectives, such as "a minimum of three days weekly for at least 30 minutes." The patient's motivation for postoperative lifestyle change could be called into question with statements such as, "I'll never be able to do any exercise, even after bariatric surgery, with my bad knees." In order to validate such a complaint, the MHP might recommend as a prerequisite for the surgery, "Patient must have evaluation by physical therapist or orthopedist." With any of the above recommendations, the MHP can then re-evaluate the surgical candidate at designated preoperative time intervals to ensure that the patient has benefited, as relevant, from the therapy (e.g., individual or couples) as recommended or that the deficits (e.g., nutritional knowledge base or exercise regimen) have been remedied.
In addition to the above, the MHP can be helpful to the patient in dealing with certain preoperative concerns. Such concerns could include anxiety related to anesthesia induction or family questions regarding how best to be of support to their loved one. An ongoing relationship between the MHP and the family can more readily make available interventions and support to the patient. Rather than waiting to make the referral or trusting that the patient will call if problems arise, the enhanced relationship with the MHP from the get-go can provide greater possibilities for more immediate and comprehensive intervention.
The initial MHP contact may offer an additional benefit to the patient, regardless of the assessment outcome. Whereas the content of the interview and the assessment outcome are certainly important, the process between the patient and MHP is equally valuable. The nature of the interview provides an opportunity for a significantly personal and positive connection between the MHP and the patient undergoing bariatric surgery. It is the MHP's first and possibly only opportunity to "connect" with the patient prior to the surgery. It may be the patient's first contact with any MHP and thus may allow the only opportunity for the patient to establish a positive experience with any MHP. The knowledgeable MHP who is familiar with the prejudice, discrimination, and usual negative life experiences of the morbidly obese has a unique opportunity to use sensitivity and knowledge with positive results.
These benefits would be reaped postoperatively if the surgery is deemed appropriate. However, even if the patient is deemed inappropriate for the surgery, there may be accompanying benefits in making the patient more amenable to future therapy contacts if such become needed. Depending upon the style and skill of the MHP, this first contact with the surgical candidate can either set the stage for a hastened end to the relationship or yield an opportunity for a continued and productive relationship.
As mentioned previously, in a semi-structured interview format, the MHP should explore information germane to the assessment of the bariatric patient. Incorporating that information and the relevant clinical details into a typewritten report with subcategories, such as Cognitive Abilities, Emotional Capabilities, Motivation, Support System, and Summary or Recommendations, can help to demystify any psychiatric terminology, delineate areas for improvement or treatment, and yield a more "user-friendly" tool for communication with the surgeon and multidisciplinary staff.
The Value of Postoperative Evaluation, Interventions, and Support
Existence of emotional issues, pre-existing knowledge deficits, or psychopathology that could pose obstacles for postoperative success can be identified in the preoperative assessment and dealt with by the MHP either preoperatively or postoperatively. Various studies have identified less successful postoperative outcomes due to nonadherence with behavioral recommendations for postoperative change.[4, 23, 24] The patient's nonadherence to behavioral recommendations could benefit from interventions with the MHP. Such issues that could compromise postoperative progress include untreated psychiatric illness, eating disorders, or history of abuse. In particular, patients with a history of sexual abuse, even if resolved with years of therapy, may experience feelings of vulnerability that prompt patients to slow down or even sabotage their postoperative success.[25, 26] Regardless of a psychiatric history or pre-existing psychopathology, patients may readily experience unsettling effects from their changing body image and may not always welcome the attention that their more physically appealing bodies receive from others.
Usual Postoperative Issues Benefiting from MHP Support
Discussion continues at conferences regarding the question, "What is success?" following bariatric surgery. The obvious answer would involve sufficient weight loss or improvement or resolution of serious comorbid conditions. However, even if there is initial progress in these areas, the patient and surgeon may not recognize underlying psychological issues or emotional obstacles that may impede continued postoperative success. The patient who initially loses the weight only to then later regain may not seek any professional help until it is too late or until the challenge for reversal becomes a daunting one. Such underlying psychological issues or emotional obstacles may include the following:
• "Normal" depression with loss of the "familiar" body
• "Normal" depression and adjustments with a change in relationships
* As a result of jealousy from coworkers
* As a result of unsettling reactions from friends or family who cannot adjust to the new body or lifestyle of their loved one
* As a result of reactions by the spouse or partner due to feelings of jealousy or insecurity, particularly if the spouse is obese or has never known the patient at a lesser weight
• Anxiety as a result of increased attention from others
* Particularly from the opposite sex
* Especially if there is a history of sexual abuse
• Eating challenges related to "mind hunger" or loss of "comfort" eating.
In addition to these typical issues outlined above, for a more select sub-population, obstacles may be the loss of the usual way of giving or receiving caring by loved ones. As examples, if the patient no longer needs oxygen, use of a wheelchair, diabetes medications, or other self-management practices, the patient may lose the means or focus by which family members or friends previously demonstrated their "love" or "caring" for the patient. Reactions to such a loss may require family interventions in the immediate or long-term sense to help sustain the patient's postoperative progress. At the very least, patients who were identified preoperatively with tendencies toward passivity and dependency may need additional support while developing more adaptive coping mechanisms or a new interactional style with others. Again, these tendencies may have been identified in the preoperative evaluation by the MHP. However, the actual "loss" (of coping mechanism or interactional style) may not be experienced or identified by the patient until he or she begins the dramatic postoperative weight loss and related changes. Only at that time might the patient and/or significant others experience their unsettling reactions to the patient's behavioral or emotional changes. The MHP can help the patient and family to understand that loss of secondary gain, to appreciate how the roles of passivity or dependency had heretofore played in their relationships prior to the surgery.
Finally, there are positive outcomes that may seem to the uninformed observer to be a "given" as welcomed opportunities following WLS. Such outcomes could include increased mobility, a sense of wellbeing, increased self confidence, and increased opportunities for life-changing events, such as with increased fertility and the opportunity to become pregnant. These positives for increased activity and new roles may be accompanied by unfamiliar emotions for patients and their loved ones. Even seemingly less serious activities, such as taking airplane rides (without having to purchase a second seat or requesting a seatbelt extension) or enjoying theme park rides, may yield unexpected emotional discomforts and accompanying emotional challenges as well.
As one such example from my practice, a shy 40-year-old who initially lost 140 pounds following her gastric bypass surgery began to regain her weight. In exploring with her the various reactions she had received at work and in social situations, she was able to describe her preoperative "comfort" with "being invisible." She had no history of abuse or mental disorder (e.g., symptoms of Avoidant Personality Disorder or similar behaviors) that might contribute to an unconscious need to sabotage her new lifestyle and social activities. However, she was aware of her discomfort with the increasing attention by others and acknowledged that she might have "slipped" in various ways postoperatively in order to recover some of her former "invisible self." She has identified several behavioral objectives and agreed to work with the MHP and dietitian to get herself back on track (e.g., maintain a food and exercise log with correlating emotions, call with weekly progress reports, meet with the MHP following her monthly dietitian appointments, attend the support group for regular attendance, and identify a "buddy" to accompany her on this renewed weight loss journey). Prior to her surgery, she had attended only one group as the preoperative requirement, stating she was "too shy" to become more involved as "a groupie."
The Value of a Required Postoperative Visit with the MHP
Any of these issues may be difficult to predict in the initial assessment. For that reason, having at least one "automatic" postoperative appointment scheduled prior to the surgery date can ensure the MHP has the potential to more reliably identify postoperative challenges. In my practice, it seems that the patient can recognize the unsettling reactions of a changing body image or slimming face reflected in the mirror as early as 4 to 6 weeks after the surgery. For this reason, at the preoperative assessment visit, I ask that the patient return for the first postoperative visit at this 4- to 6-week point.
Attempts are made to coordinate the appointment with the patient's follow-up visit with the surgeon and/or dietitian to make "one stop shopping" a greater convenience for the patient and to ensure better adherence with follow-up appointments. (As a Center of Excellence [COE], having the surgeons, dietitians, and CNS located in the same building at Saint Mary's makes this "requirement" a more appealing and convenient option for the patient. This geographic handiness makes for more immediate and convenient collaboration among the disciplines as well.) At this visit, it might be easier for the MHP and the patient to begin to identify the previously outlined postoperative issues that could be less recognized or even denied with the "thrill" of the initial postoperative weight loss. Moreover, with a prescheduled postoperative appointment time, reticent patients are more likely to feel continually supported and less intimidated to make that call to the MHP on their own.
This postoperative connection might more readily help the surgeon, dietitian, and other multidisciplinary staff to identify difficult patient behaviors or nonadherence to postoperative treatment guidelines. If needed, the surgeon or multidisciplinary team members can readily contact the MHP for an immediate consultation on the patient. Integrated treatment plans and collaborative interventions can provide the surgeon and team with the added benefit of the MHP's expertise and proposal for behavioral interventions. Moreover, difficulties for the surgeon with postoperative follow-ups and patient retention issues could more likely be helped by the additional connection and ongoing relationship with the MHP.[24]
The Value of the Support Group
Patients should be referred to an ongoing support group beginning preoperatively and continuing through at least the first year postoperatively. This group of the patient's peers who have also undergone bariatric surgery with its dramatic lifestyle changes can be very helpful in order to sustain the patient's self-management practices and to identify any symptoms of adverse outcome. Unfortunately, there may be deterrents to this recommendation. First of all, the surgeon or other treatment providers may have negative expectations regarding the ongoing value of a support group. Second, even with a preoperative requirement by the surgeon to attend at least one support group with encouragement to attend regularly postoperatively thereafter, the patient may hear this as, "I only have to attend one group in order to get the surgery." Third, if patients attend only one group and that experience is a negative one, the patient is less likely to consider regular attendance. As one example, if in that particular session there are one or more patients who monopolize the group discussion or impart a similarly negative tone, the prospective patient may base the value of group attendance on that one limited experience. The patient may surmise that the group in general is "only a bitch session." Finally, the patient may refute the need for the group, stating that he or she has "enough supports in my friends and family." Regardless, the value of the group experience cannot be overemphasized. (Moreover, the MHP who has an ongoing relationship with the patient can further promote the value of regular group attendance for the patient and his or her significant others.
In summary, the MHP knowledgeable in bariatrics offers more than just a preoperative "yes or no" decision regarding a patient's appropriateness for bariatric surgery. An ongoing relationship with the MHP can provide valuable preoperative education and support to the patient and family, identify emotional and psychological obstacles to postoperative success, intervene with patients' postoperative difficulties, provide postoperative care to the patient and family, and both preoperatively and postoperatively serve as a valuable resource for the surgeon and multidisciplinary team.
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3. Kurian MS, Thompson B, Davidson BK, Roker A. Weight Loss Surgery for Dummies. Hoboken, NJ: Wiley Publishing Inc., 2005.
4. Moorehead MK, Alexander CL. Transfer of addiction and considerations for preventive measures in bariatric surgery. Bariatric Times 2007;4(1):22–5.
5. Sarwer DB, Thompson JK, Cash TF. Body image and obesity in adulthood. Psych Clin North Am 2005;28(1);69–87.
Category: Past Articles, Review
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text:
Creepypasta and its demise: a sign of the times?
Published in Issue 2, 15 October 2019 29 October, 2019
Credit: Harem Malik/Flickr
Paul Dawson
As the decade draws to a close, our writer Paul Dawson discusses the rise and fall of creepypasta alongside the growing social-media movement when it comes to our worldwide political instability.
During the early years of the 2010s, a virtual craze began to gain rapid traction, and over a short spell of two years became a cornerstone of internet culture. This craze, of course, was creepypasta.
For those unaware, a creepypasta is an online horror tale which usually explores the more supernatural elements of horror. These stories are often written in both first and third person, with some notable tales ranging from the lurking Slenderman to the terrifying Jeff the Killer. Intriguingly, creepypasta lacks an agreeable origin, which only serves to intensify the allure associated with them. However, creepypasta could arguably be traced all the way back to the early 90s with detailed stories similar to their modern interpretation being found in internet forums as well as chat rooms – though there has never been extensive proof to confirm this theory.
As we can see, creepypastas are an intriguing form of storytelling. Their intense details of gory and disgusting events have, in fact, interesting similarities to traditional mythology – or, for a slightly more modern example, the stories of the Brothers Grimm. The case for this comparison comes in the form of these stories having an underlying message of caution. Resemblances between these storytelling forms are striking, more so than just the factor of the hidden messages within their narratives.
Both the Brothers Grimm and old school mythology had a large boom period which saw their stories become interwoven into mainstream consciousness. Many creepypasta saw similar success, with a prime example being the previously mentioned Slenderman. This particular creepypasta saw both a widely successful video game and feature film made, capitalizing on the want for the mythology of this character to be explored further.
Despite the clear success and modern exposure that creepypasta has had, the term is now not commonly used and many would struggle to tell you exactly what a creepypasta is. The most likely reason for this is that most internet-dwellers simply became bored of these stories as they became repetitive in nature, or found a new source for the creepy content that they desired.
However, I feel like the departure of creepypasta within mainstream media is due to a much more psychological reason. As previously mentioned, creepypasta is composed of stories which follow a cautionary tale or a lesson based narrative. In theory, as time passes, lessons change along with culture – so these stories fade into irrelevance, much like mythology and the Brothers Grimm. The messages of these tales became outdated and no longer concurred with the modern issues of the time period, thus became unrelatable to readers. This is why creepypasta is much less important within the modern day.
In the early 2010s, the world was in a state of social change, despite being seemingly politically secure. People began to speak out on prominent issues, meaning that they didn't have to use a platform of anonymous stories to expose their problems. Previously, many creepypasta had dealt with the fear of the unknown as well as issues such as identity. These ideas weren't prominently spoken about within public as they were still seen as risque and questionable, but through this medium these themes could be addressed without public harassment. However, as the sheer amount of people speaking out on issues such as identity began to rise, in particular with the LGBTQ+ community, the relevance of creepypasta decreased.
An important factor of this are sites such as Tumblr, Reddit (specifically the /r/nosleep subreddit) and creepypasta.com. All of these webpages were extremely valuable for those who lacked the confidence to speak out on key issues, and were once all key players in the spread of creepypasta stories. None of these sites now have quite the pull they once had.
Personally, I relate this to people being much more comfortable with discussing important issues online. This left creepypasta useless, as people were no longer hiding their issues within creative narratives. People are also more politically involved. During the early 2010s, there was a general feeling of political security, but now we find ourselves within a horrendous period for modern politics – people do not have to look far for horror tales when most are told every evening on the 7 o'clock news.
The time period during which creepypasta rose to fame was one of social media silence. Now, we live in a generation where those stories are no longer needed. Though they may be revisited in the future with fond nostalgia, they are now a relic of a recent past which most have forgotten.

redpajama_set_name: RedPajamaCommonCrawl


text:
Q: .htaccess rewrite clashing with $_GET parameters So, integrating this third party tracking service that passes a $_GET parameter to our product pages.  The page is rewritten in .htaccess and they pass the query string starting with a question mark (?) and $_GET doesn't pick it up unless its an ampersand (&).
So this is the htaccess rewrite.
RewriteRule ^the-url/(.*?)/(.*?)/?$ /the-page.php?slug=$1/$2 [L]

This works
http://www.site.com/the-url/someones-name/a-title&something=4
This does not (but I need it to. Notice the question mark rather than ampersand)
http://www.site.com/the-url/someones-name/a-title?something=4
Thanks

A: I guess you have to use the [QSA] flag:
RewriteRule ^the-url/(.*?)/(.*?)/?$ /the-page.php?slug=$1/$2 [L,QSA]

If this flag is set, the given query string will be appended (QSA = Query-String Append), not removed.

redpajama_set_name: RedPajamaStackExchange


and dwell in it forever.
and their tongues speak what is just.
their feet do not slip.
or let them be condemned when brought to trial.
when the wicked are destroyed, you will see it.
though I looked for him, he could not be found.


The test for Provisional Special Agent requires more study than you may expect. It is suggest that you print out the form, study, and then proceed with the test when your confidence has developed. Certain sections require exacting knowledge of this web site. ALL QUESTIONS MUST BE ANSWERED!
One of the above items is not a sock?
One of the above socks is not a solid color sock?
Which sock above has polka dots?
Only one of the above objects is commonly associated with socks?
Which of the above is least likely to purchase more than one pair of socks a year?
Which of the above fabrics has a striped pattern?
Which of the above pairs do not match?
When you see a person wearing droopy socks are you?
When you see a person wearing mismatched socks are you?
When you see a person violating the rules of sock attire are you?
When you see a person badly soxed do you?
When you lose a sock do you?
How many hours do you spend searching for a lost sock?
If female would you marry a man who wore brown socks with black shoes?
If male would you marry a woman who wore socks to bed?
All the answers to the following can be found in the Bureau of Missing Sock's web site.
The Bureau's Museum contains a sock belonging to?
How many silk worms were used to make a pair of socks for Grover Gransmithe?
In The Tale of the Purloined Sock Charlie Chan could tell that Ernest Blake Rutherford was not a woman because of?


As Mainers, we're known for our resourcefulness and tenacity in getting things done our own way. But if you haven't the skills or training in professional writing, it will hurt your brand if you try and do it yourself. Every business needs content writing that is clear and concise. Don't lose your audience's interest with insider's jargon or with awkwardly composed sentences. Copy should connect and resonate with your readers. The more perceptive the tone of the writing, the more personal the brand. Content should be thoroughly proofread. Nothing weakens your brand's credibility more than grammatical errors, spelling errors, punctuation mistakes and typos. Every single message you put out in the media becomes part of your brand's resume--so make the best impression you can.
First Impressions Count. Don't Make The Wrong One.
As small entrepreneurs, we're all in the same boat to get noticed. But there are some rules to getting your message out there. Copyblogger's Seven Harsh Rules of Social Media Marketing paints that picture. You definitely don't want to start your campaign off the wrong way and be perceived as a tremendous annoyance nor do you want to spend hours of your precious time doing it the right way, but failing to reach the right audience. Recently I heard about a story where the media director of a major conference got into a Twitter huff with someone who criticized some aspect of that conference. It didn't end well. A natural response to criticism online is to fire back, but if you are the representative of organization, you will invite unbelievable vitriol and scorn if you even make the snippiest of comments online. You have to react to the negative with more positive. This is why having someone with interpersonal skills along with writing skills represent your business is crucial to your online perception.


I like my netbook because it's faster then a book and a pencil. I like my netbook because paper gets messy and I like my netbook because if I get words wrong I can change things. Sometimes I can lose my books and pencils.
It frustrates me when things do not work. On my netbook if it just shut down. It frustrates me when tuxpaint doesn't work.
When I did not have a netbook I got words wrong and my book got messy and now that I have my netbook it's easier to write on.


text:
'Divide and conquer': fracking developers campaign to Indigenous groups
Traditional owners say a lack of information, the promise of cash and the sheer size of potential land to be fracked are creating confusion in Western Australia.
Brendan Foster
The Kimberley region of Western Australia is a popular tourist area. (Image: AAP/Diana Plater)
Indigenous traditional owners from a remote part of Western Australia fear developers will use strong-arm tactics to get consent to frack their land for gas.
The Western Australian Labor government recently lifted a statewide moratorium on fracking after a WA Environment Protection Authority report found the risks to people and the environment was "low". The controversial drilling process — which involves injecting very large amounts of water with a small amount of chemicals deep underground — will be allowed on existing petroleum licences covering 2% of WA.
But that area covers a whopping 5.1 million hectares and includes the gas-rich Canning Basin, near Broome and around 1500km north of Perth.
Farmers, landowners and native title holders can refuse fracking. But Bardu and Nyul Nyul traditional owner and Kimberley elder Albert Wiggan said the veto rights meant little, as developers would "assert themselves" into remote Aboriginal communities and offer traditional landowners "huge amounts of cash".
"It will create division among family groups and the developers will then only work with the families who are pro-fracking," he told Crikey.
"It's divide and conquer — it's terrible, but the industry is just so powerful. There are some Indigenous groups that want the employment benefits. But there are new industries been developed by Indigenous groups which complement and sustain our heritage, but they are not even being looked at."
Nyikina traditional owner Anne Poelina said some Indigenous landowners in the Kimberley were simply unaware of the environmental impacts of fracking.
"Fracking raises the question of informed consent," Poelina, the deputy chair of the Walalakoo Aboriginal Corporation told Crikey. "We had a members' forum recently and most of them knew nothing about the impact of fracking. But it's not just the Indigenous community, it's the broader public as well. We want to know how the state government is going to regulate the industry. And if fracking is not bad for the environment why is it banned in so many places like Ireland and Victoria?"
Conservation Council WA president Piers Verstegen said landowners might have the right to veto but that provided no comfort to families in nearby properties.
"In the midwest, gas companies have already been buying farms so that they can avoid protracted negotiations with farmers seeking to protect their land and water," he said.
"But the surrounding landholders and community who will bear the impacts from pollution, noise and other loss of amenity will be given no such veto. It also appears that the veto will only apply to the production phase, so any number of wells can be drilled and fracked during exploration, without consent, establishing a physical presence that will be very difficult to unwind."
The highly contentious issue of fracking is not confined to WA. The process of ripping gas from the ground has alarmed environmentalists around Australia over fears drinking water and aquifers could be contaminated during the process.
There has been more than a dozen inquiries into fracking in Australia and the results are almost always identical: there needs to be strict regulations and conditions, but the risks are low.
Many of the states are divided over the drilling process. Victoria has outlawed it, Tasmania has introduced a moratorium while New South Wales has placed certain restrictions on fracking. South Australia went one step further recently, imposing a 10-year ban in the south-east of the state.
In Queensland there is no restriction on unconventional gas exploration and development, and early this year, the Northern Territory lifted a two-year moratorium on fracking, claiming it will create hundreds of jobs. The "more gas is good for jobs" is also the mantra of the federal government.
But WA Greens MLC Robin Chapple believes very few Indigenous people will be employed in the industry.
"A recent report by the Australia Institute has revealed that despite the oil and gas industry employing a marginally higher rate of Aboriginal people compared to other sectors, a fracking industry would likely only create between three and 19 full time jobs for Aboriginal people, based on sector wide employment rates," he said.
"Only one group in the Kimberley has indicated support for fracking based on the promise of jobs in an agreement with Buru Energy. The Yawuru, Nyikina Mungala and Walmajarri traditional owner groups, that have native title within the area that the government proposes to open up for fracking, have formally voted to oppose fracking."
A spokesperson for the Minister for Mines and Petroleum said job creation figures were unclear.
"Those numbers can't be confirmed until all approvals are obtained, Aboriginal landowners agree to fracking on their lands and the project is proved to be commercially viable. If it's a small industry, it'll create a small number of jobs. If it proves to be a large industry it will employ more," he said.
"In any event it's important that government does what it can to assist in the creation of jobs in regional and remote Western Australia, particularly if those jobs are available to Aboriginals and assist in supporting their communities.
Fetch your first 12 weeks for $12
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If you haven't joined us yet, fetch your first 12 weeks for $12 and start 2021 with the journalism you need to navigate whatever lies ahead.
Encryption legislation is nothing but 'security theatre', and Australians will pay the price
Comments, corrections, clarifications and cock-ups
Pyne warns MPs to stay away from Dutton
Crikey Worm: ScoMo's curious gift to the NT
ian kemp
As someone who wirks in the natural gas industry, and I have actually been in the field and witnessed a frac spread (in west texas) articles like this just leave me bemused. What exactly do people think that fracking 3km below the surface is actually going to do? There have been a lot of enquiries and when people have been actually informed about the process they agree there is no problem. Quote from your own article "There has been more than a dozen inquiries into fracking in Australia and the results are almost always identical: there needs to be strict regulations and conditions, but the risks are low."
PeripateticPhil
Reply to ian kemp
I appreciate your honesty in declaring you work in the gas industry, with the implication you have a vested interest.
So fracking is safe? A series of earthquakes in Canada last week being caused by fracking was "very high", according to a research scientist with the Geological Survey of Canada. In the UK earth tremors started less than a week after the energy firm Cuadrilla began fracking. The British Geological Society said the seismic activity was "not unexpected" as fracking was "generally accompanied by microseismicity". The 2009–18 Oklahoma earthquake swarms are a series of fracking-induced earthquakes affecting central Oklahoma, southern Kansas, and northern Texas. Scientific studies attribute the rise in earthquakes to the disposal of wastewater produced during fracking that has been re-injected into the ground.
In the Kimberley there are three exploratory fracking sites and we know of five reportable safety breaches: two cases of radioactive water in excess of safe human standards coming to the surface, two cases of methane gas leaks, and one case of a pond full of toxic waste water overflowing. That is from three sites and now one company (Buru Energy, out of seven that have leases) who have at least stated their intentions publicly want to drill 80 wells at just one site (Yulleroo). If they can't get it right in the exploratory phase doesn't give confidence of 'low risk' in full production.
There are many other reasons why fracking should not proceed, sufficient to point out there is no social licence. The people who live here overwhelmingly do not want it – they know tourists won't come to look at drilling rigs.
Reply to PeripateticPhil
you are right, Fracking has many problem associated with no doubts about it.
Me and my company Annsca Energy( just research and development of new technology) has spent 5 year and milions of dollars to develop a new technology to ensure a 100% safe extraction for water table and air. Unfortunately there is no chance for us here in Australia to prove our system.
Fortunately we are started now in Europe
where the Goverments are supporting more new and safe technique
R. B
klewso
Let's hope they've learned from past "deals" – that now they can see through the Forrest to the suckers.
Reply to klewso
Roebourne, March 16 2011 – Federal Court Justice Steven Rares' judgement July 2015?
Unlike Split Enz – "History does repeat"?
I love the concept of 'waste water' in this particular continent – after using vast quantities from ancient aquifers it is so toxic that it has to be… err, disposed of.
And for what?
More greenhouse gas production and export dollars – unarguable apparently.
Even highly regulated it isn't a low risk operation, unless you don't care about fugitive emissions, turning ground water into waste water that always seems to have much higher concentrations of toxic substances than is ever admitted to by industry. Then there are all the examples in the great artesian basin where water despoliation cannot be restricted to the area being mined. The industry is replete with examples of dodgy projects and outcomes, and then not paying any tax just to top it all off.
And for what, gas we don't need and spoiling water reserves that we may well do. All at a time when carbon emissions need to be reduced and then eliminated in a hurry.
It's beyond brain dead. It's callous in its indifference.


What organization is behind Transfaith?
Are you an official non-profit organization?
Are you a fiscal sponsor?
Transfaith is a trademark of the Interfaith Working Group (IWG). IWG is the non-profit organization behind Transfaith Online and all of our Transfaith programming.
Our board of directors takes overall responsibility for the health and well-being of the organization.
Chris Paige is the founder of Transfaith Online and was hired as executive director of IWG beginning January 1, 2012.
Louis Mitchell became executive director in 2017, when Chris asked to step down to the role of Operations Director.
Chris and Louis are considered co-founders of Transfaith due to the way they partnered in the process of bringing IWG and Transfaith Online together to emerge as a new organization.
Volunteers fulfill many roles in our work.
We welcome your financial support for this important work!
IWG had a previous life advocating for separation of church and state, reproductive freedom and rights for lesbian, gay, bisexual, and transgender people, but shifted to focus on transgender communities in 2007.
Yes! Contributions to the Interfaith Working Group (or Transfaith) are fully tax deductible to the extent allowed by law.
The Interfaith Working Group (IWG) is a Pennsylvania Corporation, registered with the Pennsylvania Bureau of Charitable Organizations. IWG has federally exempt status under section 501(a) of the Internal Revenue Code as an organization described in section 501(c)(3), of the type described in sections 509(a)(1) and 170(b)(1)(A)(vi).
We are registered with the state as "doing business as" Transfaith and can also receive payment as Transfaith (e.g. checks made out to "Transfaith").
Yes. Transfaith supports other related community groups through formal fiscal sponsorship arrangements and sometimes more informally incubates projects as they are getting started.
To inquire about fiscal sponsorship or other partnership opportunities, please be in touch!
You can contact us at 844-2-T-FAITH (844-283-2484) or use our online form.


text:
Wegmann Automotive ist ein deutscher Automobilzulieferer mit Sitz in Veitshöchheim. Das Unternehmen ist Teil der Wegmann-Gruppe und nach eigenen Angaben Weltmarktführer für Auswuchtgewichte und Batteriepolhülsen. Produkte von Wegmann Automotive sind in zwei von drei Neufahrzeugen verbaut und finden Anwendung im Rennsport.

Neben Auswuchtgewichten für Fahrzeugräder, Wellen, Kupplungen und Ventilatoren in Fahrzeugen sowie Batteriepolhülsen produziert das Unternehmen auch Reifenventile.

Einzelnachweise

Organisation (Veitshöchheim)
Produzierendes Unternehmen (Landkreis Würzburg)
Automobilzulieferer

redpajama_set_name: RedPajamaWikipedia


A native of Indiana, her first love was found on the stage. Sarah has been awarded several vocal and performance awards through the years. At 8 years old, Sarah took center court at the Pacers vs. Bulls basketball game, looked up at Michael Jordan and belted out the National Anthem. She was a TV Host for Inside Silvertown, "Belle" in Disney's Beauty and the Beast and "Dorothy" in the Wizard of Oz over a 10 year period at the Indianapolis Civic Theatre. Sarah was Miss Indiana in 2004 and traveled to Atlantic City, representing her Hoosiers on the Miss America stage where she won a talent award, paid her way through college and gained valuable life lessons that have molded her into the person she is today.
In 2005, Sarah left the corn fields of Indiana and moved to the hills of Tennessee where she was the Marketing & Events Director for the Wild Horse Saloon and Gaylord Entertainment. Sarah was responsible for marketing, planning and executing all events, leading a team, and auditioning and booking artists who performed at the venue.
Sarah has over 20 years of experience in event planning and flower production, but more than the experience, Sarah wanted to create something that would impact the lives of those around her. In May of 2007, Sarah created Regalo Design; a planning and floral studio.
Since that time, Sarah has planned and executed over 350 weddings and proposals, made over 2,500 bouquets, 10,000 arrangements and served over 100,000 guests across the United States. Sarah's work has been featured on Buzz Feed, Popsurgar, MSN Lifestyle, The Huffington Post, Every Last Detail, Wedding Chicks, Desiree Hartsock, Southern Weddings, Green Wedding Shoes and Borrowed and Blue. Regalo Design has also won several industry awards including best planner and florist in Nashville.
Sarah's favorite moment on a wedding day is one that very few actually get to see. When a bride is standing behind the closed doors, waiting to take her first step down the aisle, you can't help but think of all of the steps in her life that led to this. In that moment, there is joy.


Tonight's episode runs the gamut on topics. Kay welcomes returning guests, Doc Marquis and Dr. David Schnittger, of South West Prophecy Ministries (SWPM). They discuss the blessings God is bestowing upon the ministry and the wonderful things to come. Also, politics are put on the table. 2 of the 3 topics we are taught as children to never bring up in a group setting or one on one, they do it. Faith and politics. This makes for an exciting interview with lots of insight. Listen in on this ... Más informaciones timely and interesting talk. Grab your Bible, cup of coffee, kick back in your favorite chair and get comfy as Kay and guests promise you another interesting and important broadcast.


text:
Q: Received Notification of my server be involved in "DNS amplification attack". How can I stop? I just received an email from my website internet provider that my server has been "involved as open resolvers in DDoS attacks (DNS Reflection) over the past few weeks."
Here is the full email:

Subject: DNS amplification attack  Dear Sir or Madam,
We have received spam/abuse notification. Please take the necessary
  steps to prevent this from happening again in future.
Furthermore, we would request that you provide both ourselves and the
  person who has submitted this complaint with a short statement within
  24 hours. This tatement should include details of the events leading
  up to the incident and the steps you are taking to deal with it.
Next steps:
  - Solve the problem
  - Send your statement to us
  - Send your statement to the person making the complaint per email
The details will then be checked by a colleague, who will coordinate
  further proceedings. In the event of several complaints, this may lead
  to the server being locked.
  ----- attachment -----
Dear Sir or Madam,
We have been informed that IP addresses from your network range have
  been involved as open resolvers in DDoS attacks (DNS Reflection) over
  the past few weeks.
Please see the attachment to this message for the IP addresses of the
  open DNS servers in your network range.
----- log file -----
Affected IP: 176.9.1.67
Thank you,

What can I do to confirm this and to identify the origin of this attack?
Thanks
Eco

A: You can't identify the origin of the attack-- the packets your DNS server is receiving are from spoofed source addresses.
Basically, an attacker is sending packets with forged source addresses to your DNS server. They're asking it questions that will result in it sending large responses. To use your DNS server as an attack tool the attacker is spoofing the source address of a host that they want to flood with garbage traffic and directing large numbers of DNS servers, just like yours, to bombard that host with bogus responses. Your DNS server isn't compromised or doing anything wrong, per se, but you shouldn't allow your DNS server to send these large responses to arbitrary questions to the Internet.
Basically, you need to reconfigure your DNS server not to provide recursive resolution services to the Internet. Your DNS server should answer requests only for the domains it is authoritative for.


text:
Q: Measure length and diameter of objects in an image I am new to Mathematica, and I am trying measure length and diameter of rectangular objects in an image. I wanted to fit rectangles in the objects, and then get the values.
Can I do that with ComponentMeasurements? how does the {"Rectangle"} command work? How can I set aspect ratio, or verticality selection rules? or other types conditions to rectangle fit?
What I did so far is as follow:
image = Import["http://i.stack.imgur.com/5WGzV.jpg"]

imageNS = ImageCrop[image, {1024, 650}, Bottom]

so far I just removed the bar at the bottom.
imageA = ImageMultiply[imageNS, 2.8] // ImageAdjust;
imageB = MeanShiftFilter[imageA, 5, 0.03, MaxIterations -> 20] // ImageAdjust;

in this way I have enhanced the contrast of the image.
binaB = MorphologicalBinarize[imageB, {0.4, 0.7}];

Then I binarize the image. since in the binarized image there is no bottom line for the "trees", I try to find it as follows:
imageR = RidgeFilter[imageB, 1.5] // ImageAdjust;
binaE = MorphologicalBinarize[imageR, {0.075, 0.7}];
a = EdgeDetect[binaE, "StraightEdges" -> 0.55];
b = Closing[a, 6];
c = GradientFilter[b, {{1, 100}, 10}];
d = Binarize[ColorNegate[Dilation[c, {{1}, {1}, {1}, {1}, {1}}]]];
ebin = Closing[ImageMultiply[binaB, d], 1]

Now I have the bottom line of the trees, although the problem is that morphologically the trees still belong to the same domain, they are all "connected". This makes the problem more complicated since ComponentMeasurements[ebin,"BoundingBox"] fit bigger rectangles that groups bunches of trees...
Any idea how to fit these rectangles into the trees?
I have tried a different approach to get at least the length of these structures.I use a derivative filter and horizontal erosion to get the top of the structures. Then I get the position of the top of the strcuture with Pixelvalue positoin, get the y coordinate, and subtract it to the bottom line.
qr = Binarize[Erosion[DerivativeFilter[ebin, {1, 0}], {{1, 1, 1, 1}}]]

get the max points positions
ebinm = PixelValuePositions[qr, "Max"];
ebinmy = Table[ebinm[[i]][[2]], {i, 1, Length[ebinm]}];

sum the raws of the matrix to get the baseline
ebinmm = Total[ImageData[qr], {2}];

get the baseline position
baseline = Position[ebinmm, Max[ebinmm]] [[1]][[1]];

get the length of the nws by doing the difference between
lenghts = Subtract[baseline, ebinmy];
Histogram[lenghts]

Still, how do I get the diameters?
I found a nice approach in:
Image processing: Floor plan - detecting rooms' borders (area) and room names' texts
I tried to implement it as follows:
distTransform = DistanceTransform[ebin] // ImageAdjust;
centerAreas = ImageDifference[GeodesicDilation[distTransform, ebin],distTransform];
watershed = ImageMultiply[Dilation[WatershedComponents[centerAreas] // Image,{{1},{1}}],ColorNegate[qr]]
rooms = ComponentMeasurements[watershed, "BoundingBox"];

Although the fact that the trees are not individually morphologically defined gives me troubles, and no rectangles are fit into it.This is what I get:

Anybody able to fit rectangles into it?
Cheers!

A: I have a function to measure a distance. Below I give first a description, and then a function code.
Description
The function measureDistance[image] enables one to get the locators placed into any 2 points of an image, and memorizes them in a global variable entitled "poinTs" and the distance between them - in a global variable "diStance"
Parameters:
image is any image. It should have Head=Image, if it is a Graphics object wrap it with Image statement. The code uses specific Image properties during the rescaling.
Controls:
The Checkbox "whiteLocatorRing" defines, if the locators are shown by a single color ring (unchecked), or with two rings, the outer having a color defined by the ColorSlider (see below), the inner one being white. This may be helpful, if working with a too dark image.
size controls the size of the image. The default value is 450. This slider is used to adjust the size to the one to enable the most comfortable work with the image plot.
opacity controls the opacity of the line connecting the locators
thickness controls the thickness of the double ring that forms each locator.
lineThickness controls the thickness of the line connecting the locators
color is the colour slider that controls the colour of the outer ring forming the locator and the line connecting them. The inner locator ring is always white or no white ring at all.
radius controls the radius of the locators.
InputFields: 1) The input fields Subscript[x, 1] and Subscript[x, 2] should be supplied by the reference points x1 and x2.
                     2) The input fields "Locators coordinates" and  "The inter-locator distance" serve to show the output. The
                         corresponding figures may be copied from these input fields. Alternatively one can evaluate the variables
                         poinTs
                         or
                         diStance
Buttons: The button
"Memorize the scale"
 should be pressed after the first two locators are placed on the corresponding reference points. The button
 "Pick up the coordinates of locators and evaluate the distance between them"
 should be pressed at the end of the session. Upon its pressing the actual list of points representing those of the curve is  assigned to the global variable "poinTs", and its norm to the global variable "diStance".
Operation sequence:
Step 1: Evaluate the function
Step 2: Enter the reference points at the plot x axes into the input fields. Press Enter.
Step3: Alt+Click on the point with x-coordinate x1. This brings up the first locator visible as a circle. Alt+Click (Command + Click for Mac OS X) on that with x2 which gives rise to the second locator. Adjust the locators, if necessary. Press the button "Memorize scale".
Step 4: Move the two already existing locators to the points of the image the distance between which should be measured.  Adjust locators, if necessary.
Step 5: Press the button "Pick up the coordinates ...". This assigns the captured coordinates to the global variable "poinTs" and the distance between them to the global variable "diStance". Done.
The results can be read in and copied from the InputFields "Locators coordinates" and "The inter-locator distance", or can be accessed by evaluation the variables "poinTs" and "diStance".
The "poinTs" and "diStance" are a global variable. They can be addressed everywhere in the notebook.
The function measureDistance
Clear[measureDistance];

measureDistance[image_] :=

  Manipulate[
   DynamicModule[{pts = {}, x1 = Null, x2 = Null, \[CapitalDelta]X, X1, X2, g,
      myRound},

    myRound[x_] := Round[1000*x]/1000 // N;

    (* Begins the column with all the content of the manipulate *)
    Column[{
      (* Begin LocatorPane*)
      Dynamic@LocatorPane[Union[Dynamic[pts]],
        Dynamic@
         Show[{Image[image, ImageSize -> size],
           Graphics[{color, AbsoluteThickness[lineThickness],
             Opacity[opacity], Line[Union[pts]]}]
               }], LocatorAutoCreate -> True,
        (* Begin Locator appearance *)
        Appearance -> If[whiteLocatorRing,
          Graphics[{{color, AbsoluteThickness[thickness],
             Circle[{0, 0}, radius + thickness/2]}, {White,
             AbsoluteThickness[thickness], Circle[{0, 0}, radius]}},
           ImageSize -> 10]
          ,
          Graphics[{{color, AbsoluteThickness[thickness],
             Circle[{0, 0}, radius + thickness/2]}}, ImageSize -> 10]](*
        End Locator appearance *)
                              ],(* End LocatorPane*)

      (* Begin of the block of InputFields *)
      Row[{ Style["\!\(\*SubscriptBox[\(x\), \(1\)]\):"],
        InputField[Dynamic[x1],
         FieldHint -> "Type  \!\(\*SubscriptBox[\(x\), \(1\)]\)",
         FieldSize -> 7, FieldHintStyle -> {Red}],
        Spacer[20], Style["   \!\(\*SubscriptBox[\(x\), \(2\)]\):"],
        InputField[Dynamic[x2],
         FieldHint -> "Type  \!\(\*SubscriptBox[\(x\), \(2\)]\)",
         FieldSize -> 7, FieldHintStyle -> {Red}],
        (* Begin button "Memorize scale X" *)
        Spacer[30],
        Button["Memorize scale",
         X1 = Min[Transpose[myRound /@ Union[pts]][[1]]];
         X2 = Max[Transpose[myRound /@ Union[pts]][[1]]];
         \[CapitalDelta]X = X2 - X1;
         ](* End of button "Memorize scale X" *)
              }],
      (* End of the block of InputFields and button *)
      Spacer[20],
      (* Begin button "Make the list of the curve's points" *)
      Button[
       Style["Pick up the locators coordinates and calculate the distance \
between them" , Bold],
       g[{a_, b_}] := {(x1*X2 - x2*X1)/\[CapitalDelta]X +
          a/\[CapitalDelta]X*Abs[x2 - x1], (x1*X2 - x2*X1)/\[CapitalDelta]X +
          b/\[CapitalDelta]X*Abs[x2 - x1]};
       Clear[poinTs, diStance];
       poinTs = Map[myRound, Map[g, pts]];
       diStance = poinTs // Differences // Norm
                   ],(* End of button "Make the list..." *)
      Row[{Style["Locators coordinates:      ", 14, Blue, Bold],
        InputField[Dynamic[poinTs]]}],
      Spacer[10],
      Row[{Style["The inter-locator distance: ", 14, Blue, Bold],
        InputField[Dynamic[diStance]]}]

      }, Alignment -> Center](*
    End of column with all the content of the manipulate *)
    ],(* End of the DynamicModule *)

   (* The massive of sliders  begins *)
   Column[{Row[{Control[{whiteLocatorRing, {True, False}}], Spacer[50]}],
     Row[{Spacer[32.35], Control[{{size, 450}, 300, 800}], Spacer[38.5`],
       Control[{{opacity, 0.5}, 0, 1}]}],
     Row[{Spacer[10.], Control[{{thickness, 1}, 0.5, 5}], Spacer[13.65],
       Control[{{lineThickness, 1}, 0, 10}] }],
     Row[{Spacer[22.8], Control[{color, Red}], Spacer[59.3],
       Control[{{radius, 0.5}, 0, 3}]}]
     }, Alignment -> Center],(* The massive of sliders ends *)

   (* Definitions of sliders *)
   ControlType -> {Checkbox, Slider, Slider, Slider, Slider, ColorSlider,
     Slider},
   ControlPlacement -> Top, SaveDefinitions -> True
   ];

The example of what you should see on the screen is shown in the picture below:


text:
Larger work-related events of up to 1,000 people can be held from Jan 3 with some restrictions
People wearing masks attend a seminar. (File photo: iStock)
SINGAPORE: Businesses in Singapore can hold larger work-related events for 51 to 1,000 people from Jan 3, subject to conditions such as having participants who are seated or standing in fixed positions.
There must be no mask-off activities at the event, such as the consumption of food and beverage, said the Ministry of Manpower (MOM) and the Ministry of Trade and Industry (MTI) on Saturday (Jan 1).
This comes after the COVID-19 multi-ministry task force announced last month that it would raise the cap for events where participants are masked and seated.
Under the current rules, work-related events are capped at 50 people. Any meals are to be "incidental" and not the main feature of the event.
From Jan 3, larger events are allowed - but with no consumption of food and drinks.
Participants must be "predominantly static", meaning that they are "seated or standing in a fixed position", said the authorities.
They are required to keep a distance of at least 1m from each other and be in zones of up to 100 people each, with 2m between zones.
In addition, they have to be either be fully vaccinated, have recovered from COVID-19 within the past 180 days, or be medically ineligible for vaccines under the national vaccination programme.
Organisers of such events must notify authorities online before the event and submit documents including an event itinerary and floor plan.
Work-from-home no longer the default from Jan 1, up to 50% of workers allowed back in the office
Unvaccinated people to be barred from returning to workplaces, even with negative test result
According to the online submission form, work-related events include meetings, conferences or seminars, award ceremonies, annual general meetings, training, townhalls, corporate retreats and tender briefings to vendors.
"This change will give businesses more flexibility to organise work-related events," said MOM and MTI.
They added that authorities will perform spot checks for such work-related events and take enforcement action against businesses that flout the rules.
Work-related events for 50 or fewer participants can continue to be held without notifying or seeking approval from authorities.
MICE events for up to 1,000 people, where more interactions between participants are expected, will continue to require approval from MTI before proceeding, said the authorities.
Source: CNA/dv(gs)
MOM MTI COVID-19


text:
ORS-News2Use-Fall-2021

ORS News2Use - Fall 2021 - Photography Requests, 'Contactless' NIH Library, Amenities Update, and More
The ORS News2Use newsletter is published quarterly by the Office of Research Services (ORS), providing pertinent information and updates about ORS services to the NIH community. To view the entire newsletter, select: https://news2use.ors.nih.gov/.
Photography Requests at NIH.
Do you need a passport photo? What about an official portrait or a headshot for your organization's webpage? Are you hosting an event and need photography support? All requests for photos are handled through NIH Photography in the Events Management Branch Multimedia Section. https://go.usa.gov/xeXdN.
Contactless Pickup Now Available at the NIH Library.
Contactless pickup service is now available for print/physical materials. Requested items that are available online will still be delivered electronically. https://go.usa.gov/xeXdR.
NIH Amenities Update.
What changes can you expect to see the next time you visit Masur Auditorium? Want to stay fit during the holiday season? Get these updates and more on staff amenities. https://go.usa.gov/xeXdQ.
I AM ORS Fall 2021.
The Office of Research Services (ORS) is comprised of a diverse portfolio of services that support the NIH mission. In this section - I AM ORS, we showcase the exceptional employees behind these vital programs. https://go.usa.gov/xeXdy.
Radiation Safety Lab Numbering Explained.
If you're an Authorized User and you've ever been confused about the list of labs assigned to you on your monthly DRS report, this explanation should help. https://go.usa.gov/xeXdV.
2021 USPS Holiday Season Price Increase.
This year the U.S. Postal Service will institute a temporary price increase for their retail parcel products for the 2021 peak holiday season. Price increases went into effect on October 3, 2021 and will remain in place until December 26, 2021. https://go.usa.gov/xeXdv.
Annual Training Inspires Employee Courage, Renewal and Wellness.
While this accomplishment is commendable and a source of pride among Division of International Services (DIS) staff, it is understandable that after such an abrupt period of change in all areas of life, there would be a certain level of fatigue. In recognition of the efforts that the DIS staff has made, and in keeping with the larger theme of "Self-Care and Wellness" adopted by the NIH, DIS reinstated its annual training for staff on October 27 with a theme of Courage, Renewal and Wellness. https://go.usa.gov/xeXdw.
NRC Inspection Completed NIH Awaiting Final Report.
Radiation Safety staff and stakeholders attending the exit briefing were pleased to hear the inspectors share phrases like "excellent and strong safety culture" and "robust safety discussions" and "pro-active and preventative culture of safety." https://go.usa.gov/xeXdG.
Learn How the NIH Library Can Help You in This Quick Video.
Did you know that the NIH Library has an extensive training program for NIH staff? Or we provide remote access to bioinformatics and data science tools? https://go.usa.gov/xeXd7.
Federal Relay Transitions November 2021.
Effective November 15, 2021, the GSA FedRelay contract with Sprint expires, and the Federal Communication Commission (FCC) Telecommunications Relay Service (TRS) program will begin to fund five of the seven services. https://go.usa.gov/xeXds.
Trash Talking - Important Reasons Not to Leave Food in Wastebaskets and Other Integrated Pest Management Tips.
The smell of food on items such as wrappings, yogurt containers, beverage cans and napkins, becomes even stronger over time and attracts pests including mice, ants, flies and cockroaches to the workspace. https://go.usa.gov/xeXdH.
Holiday Decorating Guidance.
The NIH Fire Marshal wishes everyone a safe and enjoyable winter holiday season. To that end, we are disseminating the following information to help us all celebrate safely here at the NIH. Much of this is equally appropriate for your home. https://go.usa.gov/xeXd6.
For questions or comments about this issue or to request story topics: ORSNews2Use@mail.nih.gov.
For questions or comments about ORS services in general: ORSInfo@mail.nih.gov or 301-594–6677.


text:
Little Orchestra
Pink Martini seeks to meld world influences with the beauty of old-school American culture
8 p.m., Friday, Sept. 25
$36 to $53; all ages
Of his 12-piece band Pink Martini, Thomas M. Lauderdale likes to say, "If the United Nations had a band in 1962, we would be that band."
Since 1994, the Portland, Ore.-based Pink Martini has traded in the sort of lush, beautiful jazz and pop that typified movie musicals and pop standards of the 1930s, '40s and '50s, but with a contemporary edge and a robust embrace of global music.
Growing from four to the current dozen players, Pink Martini is now referred to as a "little orchestra," with strings, horns, harp and pan-cultural percussion. Lauderdale—the founder, pianist and artistic director—met and became fast friends with China Forbes while they were students at Harvard, and the classically trained vocalist joined the group as its sultry lead singer.
The music of Pink Martini can be likened to an "urban music travelogue," Lauderdale has said. Along with English-language songs and pop interpretations of classical material, the group's music draws from the cultures and languages of countries all over Europe, Asia, South America and the Middle East.
Forbes ably handles the foreign lyrics, too. "There have been only a handful of American pop singers who have sung in different languages, and China is in that tradition," Lauderdale said last week while the band was in Los Angeles.
The official Pink Martini press material points out that the band was formed to play political fundraisers for progressive causes. But Lauderdale was more specific.
"The band actually was formed to play one political fundraiser in particular: There was a movement back then in Oregon to illegalize homosexuality; it was called Proposition 13, and I was working hard to oppose that. I had the idea to bring the Del Rubio Triplets to Oregon to play a 'No on 13' event."
Wearing miniskirts, bouffant hairdos and go-go boots, the Del Rubio Triplets were real triplets (born in 1921) who played peppy covers of modern-rock songs in the 1980s and '90s. Two of them have since passed away.
"So Pink Martini was really formed to be the backing band for the Del Rubio Triplets," Lauderdale said, proudly, adding that Proposition 13 was narrowly defeated.
Before the formation of Pink Martini, Lauderdale was considering a career in politics, but the band gave him a new means of pursuing a similar goal.
Desert Detour: Keith Robinson Band Digs Beneath Roots Music on 'Homecoming'
"After that campaign, we found ourselves playing benefits for affordable housing, public broadcasting, libraries, all sorts of causes," he said.
Although Lauderdale doesn't mind Pink Martini being called an activist band, direct political references stay out of the music, he said.
"We don't sing songs about the political causes we support or anything like that. The spirit of the band is more ambassadorial. Especially during the Bush years, I think, being an American band singing songs in Arabic, Greek, Turkish, Italian, German and other languages was very important. I think Pink Martini represents a broader, more adventurous view of America."
Also important to Pink Martini are values that can be found in the music and culture of earlier eras in American society, Lauderdale said.
"The thing is, I think in America until 1964, there was a certain kind of American commitment to beauty and beautiful things. I think beauty was a goal of art and music and the culture, even advertising. I have old bound issues of Life and Look and even Playboy, and there is so much space and richness in the ads."
So what does Lauderdale think happened to pop culture?
"This is only my theory, but after the death of John F. Kennedy, it all turned dark and plastic and disposable. The goal of beauty began to slowly die. That was paired with the combination of changing politics in our country, and Vietnam and probably drugs, as well as an increase in selfishness and the idea of community."
The lyrics of many Pink Martini songs feature tangible, deep-felt emotions in the same way pop standards and movie music did in the first half of the 20th century. This is in many ways a response to the irony and sarcasm so popular now.
"I totally believe in romance and that heightened sense of love that China sings about. And people come up to me, certain friends who are otherwise really smart, and they tell me, 'I just love how your music is so ironic.' There is nothing ironic about it! I don't know what to tell them," he laughed.
Pink Martini has seen the release of three albums, the most recent being 2007's Hey Eugene!
This year, a live DVD (Discover the World: Live in Concert) has been made available for buyers, released by the band's independent label, Heinz Records, named for Lauderdale's late dog. A new Pink Martini disc, Splendor in the Grass, is scheduled to hit stores Oct. 27.
Produced by Lauderdale, Forbes and longtime collaborator Alex Marashian, Splendor in the Grass features way-cool guest stars such as the 90-year-old ranchera singer Chavela Vargas (a onetime lover of Frida Kahlo); actor-singer Emilio Delgado (aka Luis on Sesame Street); National Public Radio correspondent Ari Shapiro (making his singing debut); and guitarist Courtney Taylor-Taylor of the Dandy Warhols.
Pink Martini has played in Tucson before, and Lauderdale remembers well the last time—a gig at the Rialto Theatre, the venue to which the band will return.
"There was this little coffeehouse down the street, and I drank a dangerous amount of caffeine there, and the whole day turned out to be delightfully surreal. I had such a good time that day, and I think the audience did, too, but I am not so sure the rest of the band did, because I was probably a little manic during the show."
Gene Armstrong
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Allrounder is a modern website PSD template which is based on fixed width and layout. It is a responsive template having a mixed column and uses a Dark Grey, Green, Light Green and White color design with HTML, and CSS file.
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text:
Альден () — громада в Німеччині, розташована в землі Нижня Саксонія. Входить до складу району Гайдекрайс. Центр об'єднання громад Альден.

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text:
Troy Historical Society
60 W WATTLES RDTROY, MI 48098 United States
http://www.troyhistoricvillage.org
We learn from the past to understand the present and build a better future.
The Troy Historical Society is a nonprofit organization with more than 40 years of success in preserving and presenting the history of our region. On July 1, 2011 the Troy Historical Society assumed responsibility for operation of the Troy Historic Village, where history lives. The Troy Historic Village includes ten historic buildings, surrounding a village green that is enhanced by gardens and mature trees. A tent and gazebo on the green provide areas for outdoor concerts, storytelling and reading aloud. There is ample space for picnics and traditional activities and games. Our historic buildings host concerts, lectures, discussions and meetings, as well as exhibits of arts and artifacts.
The Troy Historic Village is a destination for students, children, families and adults who live in or visit southeast Michigan.
Would you recommend Troy Historical Society?


Ben Esakoff and James Vivian purchased their home on Esakoff's 30th altogether and anamnesis continuing in the aback garden post-auction in atheism that the home was now theirs. Four years later, and the brace are still avidity themselves on their acceptable fortune.
Vivian comes from a ancestors with a affection for attention and adulatory Melbourne's architectural ancestry (his mum, Kristin Stegely, is an activist in ancestry protection), and this adulation of congenital history carries through to his own property. The home was originally congenital in 1893, and retains abounding of its aboriginal features.
This aggregate is partly accomplished through the couple's all-encompassing accumulating of abreast Australian and all-embracing art. The admired accumulating was "born out of the charge to ample some abandoned spaces" and acquired into a new passion. They both chase a gut-response action to purchasing, breadth they alone aggregate pieces that they "have a actinic allure to and cannot alive without".
In a agnate appearance to the change of their art collection, Esakoff and Vivian's decorating appearance developed alone already they confused in. Vivian says: "Before we purchased the home, neither Ben or I would say we absolutely had a claimed style." As they affiliated a adapted space, there was no charge for structural changes, and the home has instead offered a beginning canvas on which to analyze their developing aesthetic.
As it is a almost baby home, the brace needs every amplitude to be anatomic and beautiful, with "no allowance for bombastic zones". Esakoff and Vivian began by introducing ample appliance items from Jardan, and again gluttonous afflatus from their favourite food in Melbourne, including Hub, Space, Loom and Euroluce.
The couple's own affably adult artful has been acclaim massaged by the advice of acquaintance Zoe Murphy, who assisted with the administration and decorating. "There were a few $.25 and pieces that were out of our caster house, and we accepted addition casting their eye over the space," Vivian says.
Murphy additionally aggregate Vivian and Esakoff's adulation of colour, which has been carefully splashed throughout the home.
While Esakoff suggests that the best aspect of the home is its adjacency to the MCG (he's a one-eyed Demons fan), it is bright that for both he and Vivian, this home is absolutely cherished. Four years afterwards affective in, they are still captivated to airing in the aperture anniversary day afterwards work. "We're acutely advantageous and we apperceive it," they say.
It's accessible to feel a little apprenticed on the accountable of art. There are no adamantine and fast rules back it comes to announcement art, but actuality are a few guidelines.