Post-bariatric contour deformity correction: an endeavour to establish objective criteria nationally.

BACKGROUND A marked increase in bariatric surgery has led to higher numbers of patients with contour deformities after massive weight loss seeking plastic surgical correction. Insurance coverage for these post-bariatric interventions is highly subjective and a common set of objective criteria has not yet been established. AIM The aim was to evaluate the factors influencing insurance coverage for post-bariatric surgery, focusing on finding objective, reproducible criteria. METHODS This was a retrospective single centre chart review of all post-bariatric patients with redundant skin requesting body contouring surgery from 2013 to 2018. Demographic, bariatric and surgical, as well as insurance information were collected. A logistic regression model was used to identify predictors of successful insurance coverage. RESULTS 116 Patients were included in the study. Insurance approval for post-bariatric body contouring surgery was obtained for only 47 patients (41%). Mentioning the term "medical indication" in the application letter was associated with a 15.2 times higher rate of receiving a positive answer (p <0.001), whereas mentioning "mental suffering" was associated with 82.3% lower chance of getting a positive response (p <0.001). A high body mass index (BMI) (p <0.009) before the bariatric operation as well as a high BMI reduction (p <0.021) were associated with a higher approval rate by insurance companies . An additional application letter to the insurance company (p <0.024) as well as mentioning mechanical restriction (p <0.022) were associated with a positive response from the insurance companies. CONCLUSIONS We were able to establish certain objective predictive criteria for insurance coverage of post-bariatric surgery. However, it appears that the decisions of insurance companies for this condition are still rather randomly taken. Therefore, the establishment of objective criteria for insurance coverage may allow fairer treatment for this growing patient population

Regional modeling of climate change impacts on smallholder agriculture and ecosystems in Central America

Climate change will have serious repercussions for agriculture, ecosystems, and farmer livelihoods in Central America. Smallholder farmers are particularly vulnerable due to their reliance on agriculture and ecosystem services for their livelihoods. There is an urgent need to develop national and local adaptation responses to reduce these impacts, yet evidence from historical climate change is fragmentary. Modeling efforts help bridge this gap. Here, we review the past decade of research on agricultural and ecological climate change impact models for Central America. The results of this review provide insights into the expected impacts of climate change and suggest policy actions that can help minimize these impacts. Modeling indicates future climate-driven changes, often declines, in suitability for Central American crops. Declines in suitability for coffee, a central crop in the regional economy, are noteworthy. Ecosystem models suggest that climate-driven changes are likely at low- and high-elevation montane forest transitions. Modeling of vulnerability suggests that smallholders in many parts of the region have one or more vulnerability factors that put them at risk. Initial adaptation policies can be guided by these existing modeling results. At the same time, improved modeling is being developed that will allow policy action specifically targeted to vulnerable groups, crops, and locations. We suggest that more robust modeling of ecological responses to climate change, improved representation of the region in climate models, and simulation of climate influences on crop yields and diseases (especially coffee leaf rust) are key priorities for future research.International Development Research Centre/[AC3]/IDRC/CanadaUniversidad de Costa Rica/[805-B6-143]/UCR/Costa RicaUniversidad de Costa Rica/[805-B4-227]/UCR/Costa RicaUniversidad de Costa Rica/[805-B3-600]/UCR/Costa RicaMinisterio de Ciencia, Tecnología y Telecomunicaciones/[]/MICIT/Costa RicaUCR::Vicerrectoría de Investigación::Unidades de Investigación::Ciencias Básicas::Centro de Investigaciones Geofísicas (CIGEFI