Abstract-Obesity is associated with comorbidities that may lead to disability and death. During the past 20 years, the number of individuals with a body mass index Ͼ30, 40, and 50 kg/m 2 , respectively, has doubled, quadrupled, and quintupled in the United States. The risk of developing comorbid conditions rises with increasing body mass index. Possible cardiac symptoms such as exertional dyspnea and lower-extremity edema occur commonly and are nonspecific in obesity. The physical examination and electrocardiogram often underestimate cardiac dysfunction in obese patients. The risk of an adverse perioperative cardiac event in obese patients is related to the nature and severity of their underlying heart disease, associated comorbidities, and the type of surgery. Severe obesity has not been associated with increased mortality in patients undergoing cardiac surgery but has been associated with an increased length of hospital stay and with a greater likelihood of renal failure and prolonged assisted ventilation. Comorbidities that influence the preoperative cardiac risk assessment of severely obese patients include the presence of atherosclerotic cardiovascular disease, heart failure, systemic hypertension, pulmonary hypertension related to sleep apnea and hypoventilation, cardiac arrhythmias (primarily atrial fibrillation), and deep vein thrombosis. When preoperatively evaluating risk for surgery, the clinician should consider age, gender, cardiorespiratory fitness, electrolyte disorders, and heart failure as independent predictors for surgical morbidity and mortality. An obesity surgery mortality score for gastric bypass has also been proposed. Given the high prevalence of severely obese patients, this scientific advisory was developed to provide cardiologists, surgeons, anesthesiologists, and other healthcare professionals with recommendations for the preoperative cardiovascular evaluation, intraoperative and perioperative management, and postoperative cardiovascular care of this increasingly prevalent patient population. (Circulation. 2009;120:86-95.)

Three milking frequency treatments were compared: twice daily milking; thrice daily milking until milk dropped below 24 kg; thrice daily milking until milk dropped below 31 kg. Three time milking was at least 45 days but no more than 150 days. Cows (12 to 14 per group) were managed alike except for milking frequency. In early lactation, increased milking had little effect. With time the superiority in yields increased such that cows on three times for 150 days were outproducing two time cows by 20%. Cumulative milk yields were greater for the thrice groups than for the twice group by 5% at 56 days, 11 and 8% at 154 days, 11 and 9% at 182 days, and 10% at 280 days. Fat percentage, adjusted for previous lactation fat percentage, averaged .2 to .3% lower for the cows milked three times until 24 kig but only .1% lower for cows milked thrice until 31 kg. Increased yield was primarily from prolonged peak yield and less subsequent decline. Switching from three to two milkings decreased yield 6 to 8% in the 1st wk. However, three time milking had a positive carryover, apparently due to higher starting yield at the point at which they were switched.

Vacuum, b-phase duration, and liner compression are 3 milking machine factors that affect peak milk flow rate; however, extreme values of these factors can also have negative effects on teat tissue health. The main and interactive effects of vacuum, b-phase duration, and liner compression on peak milk flow rate were studied by independently controlling these causal variables over a wide range of settings, using a central composite experimental design (42 to 53 kPa of system vacuum, 220 to 800 ms of b-phase, and residual vacuum for massage of 16 to 30 kPa; corresponding to a liner compression of 8 to 14 kPa). The results of this study indicated that increasing the vacuum and b-phase duration always increased peak milk flow rate (no relative maximum was reached); however, the rate of increase of flow rate decreased as the vacuum and b-phase were increased. Increasing the liner compression also increased peak flow rates, with an increasing effect at greater vacuum. The interaction between vacuum and liner compression and the lack of interaction between b-phase and liner compression indicate that for a corresponding increase in peak milk flow rate, increasing the b-phase produced less teat-end tissue congestion than increasing the vacuum. The effect of milking vacuum on peak milk flow rate was smaller than that reported in previous studies, probably because of the independent adjustment of milking vacuum and liner compression used in this study. The effect of b-phase duration on peak milk flow was also smaller in this study than in previous studies, probably because of the independent adjustment of b-phase and d-phase durations used in this study.

The primary objective of this experiment was to assess the effect of mouthpiece chamber vacuum on teat-end congestion. The secondary objective was to assess the interactive effects of mouthpiece chamber vacuum with teat-end vacuum and pulsation setting on teat-end congestion. The influence of system vacuum, pulsation settings, mouthpiece chamber vacuum, and teat-end vacuum on teat-end congestion were tested in a 2×2 factorial design. The low-risk conditions for teat-end congestion (TEL) were 40 kPa system vacuum (Vs) and 400-ms pulsation b-phase. The high-risk conditions for teat-end congestion (TEH) were 49 kPa Vs and 700-ms b-phase. The low-risk condition for teat-barrel congestion (TBL) was created by venting the liner mouthpiece chamber to atmosphere. In the high-risk condition for teat-barrel congestion (TBH) the mouthpiece chamber was connected to short milk tube vacuum. Eight cows (32 quarters) were used in the experiment conducted during 0400 h milkings. All cows received all treatments over the entire experimental period. Teatcups were removed after 150 s for all treatments to standardize the exposure period. Calculated teat canal cross-sectional area (CA) was used to assess congestion of teat tissue. The main effect of the teat-end treatment was a reduction in CA of 9.9% between TEL and TEH conditions, for both levels of teat-barrel congestion risk. The main effect of the teat-barrel treatment was remarkably similar, with a decrease of 9.7% in CA between TBL and TBH conditions for both levels of teat-end congestion risk. No interaction between treatments was detected, hence the main effects are additive. The most aggressive of the 4 treatment combinations (TEH plus TBH) had a CA estimate 20% smaller than for the most gentle treatment combination (TEL plus TBL). The conditions designed to impair circulation in the teat barrel also had a deleterious effect on circulation at the teat end. This experiment highlights the importance of elevated mouthpiece chamber vacuum on teat-end congestion and resultant decreases in CA.

The objective of this study was to quantify the effect of d-phase (rest phase) duration of pulsation on the teat canal cross-sectional area during the period of peak milk flow from bovine teats. A secondary objective was to test if the effect of d-phase duration on teat canal cross-sectional area was influenced by milking system vacuum level, milking phase (b-phase) duration, and liner overpressure. During the d-phase of the pulsation cycle, liner compression facilitates venous flow and removal of fluids accumulated in teat-end tissues. It was hypothesized that a short-duration d-phase would result in congestion of teat-end tissue and a corresponding reduction in the cross-sectional area of the teat canal. A quarter milking device, designed and built at the Milking Research and Instruction Laboratory at the University of Wisconsin-Madison, was used to implement an experiment to test this hypothesis. Pulsator rate and ratios were adjusted to achieve 7 levels of d-phase duration: 50, 100, 150, 175, 200, 250, and 300ms. These 7 d-phase durations were applied during one milking session and were repeated for 2 vacuum levels (40 and 50kPa), 2 milking phase durations (575 and 775ms), and 2 levels of liner overpressure (9.8 and 18kPa). We observed a significant reduction in the estimated cross-sectional area of the teat canal with d-phase durations of 50 and 100ms when compared with d-phase durations of 150, 175, 225, 250, and 300ms. No significant difference was found in the estimated cross-sectional area of the teat canal for d-phase durations from 150 to 300ms. No significant interaction was observed between the effect of d-phase and b-phase durations, vacuum level, or liner overpressure.