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Over 625 patients having gastric bypass for the treatment of morbid obesity are currently being followed at the University of Iowa. Many innovations have increased operative exposure, greatly reduced operating time, and improved the effectiveness and safety of the operation. Recent weight figures show that a 55 percent loss of excess weight can be expected. Several comparative studies between gastric and jejunoileal bypass show that gastric bypass, while producing identical weight loss, has few of the many complications such as liver failure, renal and gallstone formation, diarrhea, enteritis, that are commonly associated with jejunoileal bypass. Stomal ulcer occurrence has been only 2 percent. Imporvements in diabetes mellitus and hypertension can be expected with weight loss. Other effects of gastric bypass were determined by use of a questionnaire. It is concluded, by surgeons having experience with both gastric and jejunoileal bypass, that gastric bypass is the treatment of choice for morbid obesity when nonoperative measures fail.
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PMID:Gastric bypass for obesity after ten years experience. 71 64

Massive obesity is associated with serious co-morbidities. After failure of extensive conservative measures, surgical procedures have developed as the only successful method for sustained weight loss. Criteria for operation are: presence of serious diseases associated with morbid obesity; greater than 45 kg above ideal weight or body mass index greater than 40 kg/m2 for usually greater than 5 years; failure of sustained weight loss on extensive conservative regimens; commitment to lifelong follow-up; and acceptable operative risk. Angina pectoris itself is not a contraindication to these operations. Patients who do not quite meet the weight criteria may still be candidates for an obesity operation in certain instances, e.g., debilitating musculoskeletal pains in weight-bearing joints, diabetes, significant hypertension, reflux esophagitis, urinary stress incontinence. Although current operations result in lasting weight loss of greater than 50% of excess weight in the majority of patients, the surgical candidate must understand and accept the principles of the procedures, the potential for serious complications, the dietary necessities, and occasional failures.
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PMID:Morbid obesity: selection of patients for surgery. 150 8

Nephrotic syndrome is defined as proteinuria sufficiently severe to result in hypoalbuminaemia, oedema and hyperlipidaemia. The early modern history of this illness was characterised by the serendipitous development of renal biopsy technique at approximately the same time as the use of corticosteroids for nephrotic syndrome. The coincidence of these events set the stage for evaluating therapeutic response to corticosteroids and cytotoxic agents in relation to renal histology and ultimate clinical outcome. The International Study of Kidney Disease in Children (ISKDC) was initiated in the 1960s as a multicentre study examining these relationships in children. Over the next decade this study, as well as contributions from other investigators, helped define optimum therapy for these children. It was determined that a child with nephrotic syndrome under the age of 6 years, who did not present with hypertension, azotaemia, hypocomplementaemia or signs of systemic illness, had an approximately 85% chance of responding to corticosteroid therapy. If only those children who had minimal change histology on biopsy were considered, 94% responded. The original regimen which is still used today, was 60 mg/m2 bsa/day prednisone administered on a 3 times per day dosage schedule for 4 weeks, followed by an additional 4 weeks of therapy at a dose of 40 mg/m2 bsa given as a single oral dose every other day. Of those who respond roughly one-third will have no relapses, while almost half will have frequent relapses (greater than or equal to 2 in 6 months) and the rest will have infrequent relapses. Patients in relapse are treated as at presentation but are usually converted to the 40 mg/m2 bsa dose when the urine has been free of protein for 3 days, and are then tapered off or maintained on this dose for several weeks, depending on the individual's history of relapses and incidence of side effects from corticosteroids. For those children who are suffering frequent relapses and severe corticosteroid side effects (e.g. growth failure, morbid obesity, aseptic necrosis of bone), cytotoxic agents were identified as providing long term remission. After inducing remission with conventional corticosteroid dosages, cyclophosphamide is administered at a dose of 2 mg/kg/day given as a single dose for 8 weeks. This regimen was shown to lead to approximately 70% of patients being in remission 2 years after completion of this course of therapy. Chlorambucil given at a dose of 0.2 mg/kg/day as a single oral dose has been equally efficacious.(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:Management of nephrotic syndrome in childhood. 171 84

Severe obesity is associated with abnormalities of cardiac structure and function. These include an increased cardiac workload and ventricular hypertrophy. Hypertension in combination with severe obesity seriously burdens the heart because the increased preload and afterload compound cardiac work. Weight reduction induced by gastric operations for severe obesity is associated with resolution of hypertension, reduction in ventricular wall thickness and cardiac chamber size, as well as improved systolic function. Additional data are needed to predict when in the course of development of obese cardiomyopathy the changes in contractile function become irreversible. Additionally, the impact of coronary artery disease on the progression of obese cardiomyopathy and the effects of surgical weight reduction on cardiac structure and function need to be further clarified. Studies of the association between obesity, its treatment, and modification of cardiovascular risk are a major focus of preventive cardiology today.
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PMID:Heart disease and hypertension in severe obesity: the benefits of weight reduction. 173 33

Most analyses of risk factors affecting survival after coronary artery bypass graft surgery have not differentiated among factors that influence early and late survival. For this reason, a multiphase model was applied to survival data from 2,967 patients undergoing a first coronary artery bypass graft at the Duke University Medical Center between 1969 and 1984. There were 709 deaths during follow-up to 19.6 years. The data were analyzed using a multivariable survival model that separates the underlying hazard function into as much as three different phases, each incorporating separate risk factors. Two distinct phases were detected. One phase dominated early survival (0-1 year), and the second phase dominated late survival (greater than 1 year). Surgery performed earlier in our experience was associated with elevated risk of dying in both phases but with different magnitudes, whereas lower ejection fraction, greater extent of coronary disease, older age, conduction abnormality, and history of hypertension were associated with elevated risk of dying similarly in both phases (p less than 0.05). Severity of angina symptoms and lower weight were associated with an elevated risk of dying only in the early phase (p less than 0.05; because few of the patients were obese, estimates of the relative risk of morbid obesity could not be estimated), whereas vascular disease, diabetes, and extent of myocardial damage were associated with an elevated risk of dying only in the late phase (p less than 0.05). These data illustrate both the differential influence of risk factors over time and the importance of multiphase models.
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PMID:Determinants of early versus late cardiac death in patients undergoing coronary artery bypass graft surgery. 193 15

Vaginal hysterectomy was performed on 31 patients with stage I endometrial cancer because of medical problems which placed them at high risk for morbidity and mortality from abdominal surgery. These risk factors included morbid obesity (87%), hypertension (58%), diabetes mellitus (35%), and cardiovascular diseases (26%). The perioperative morbidity was minimal, with only four patients (13%) experiencing complications requiring extended hospital stays and no deaths. Adjuvant radiotherapy was administered in 35% of patients with either deep myometrial invasion or unfavorable histology. The 3- and 5-year disease-free survival rates were 100 and 93%, respectively. The only cancer-related death occurred 4.5 years following surgery. Although the authors are not advocating vaginal hysterectomy as standard treatment of endometrial cancer, this approach provides an acceptable alternative to abdominal surgery in the medically compromised patient.
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PMID:Use of vaginal hysterectomy for the management of stage I endometrial cancer in the medically compromised patient. 198 19

1. Childhood obesity has been increasing for the last ten years in Tateyama City. Obesity in boys between the ages of 11 to 13 years was especially prominent. 2. Childhood obesity hardly improved especially in middle and morbid obesity. Eighty-five percent of light obesity in children lead to adult obesity. 3. Complications such as hypertension, serum lipid disorder and fatty liver were also observed in childhood obesity. Considering that Tateyama City is a typical Japanese country city, the above results could be representative of Japanese childhood obesity. Recent increases in childhood obesity might be due to the westernized dietary habit.
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PMID:Incidence of childhood obesity over the last 10 years in Japan. 228 54

Morbid obesity is a major health problem in this country and throughout the world. In addition to its social stigma (in the western world), obesity exacerbates several disease states such as diabetes, hypertension, cardiac disease and restrictive lung disease. When effective medical treatment of obesity becomes available, it will depend in part upon understanding the physiologic factors that control satiety. This review summarizes the information available on brain and gut control mechanisms of satiety. Brain nuclei located in the lateral hypothalamus, ventromedial hypothalamus, and other paraventricular areas are the sites of action for potent neuropeptides, such as cholecystokinin (CCK) and neuropeptide Y, that appear to regulate feeding. Exogenous CCK has been used clinically to decrease meal size in obese patients. The sites of the satiety cascade that are most often manipulated are the gastric and intestinal phases. Physiologic gastric distension is a potent inhibitor of feeding, whereas the intermeal interval may be regulated by intestinal signals released by food in the gut. Jejunal-ileal bypass has fallen from favor and has been replaced by gastric restrictive procedures that create a small proximal gastric pouch that empties into the small bowel (gastric bypass) or the distal stomach (gastroplasty). These operations rely partially on their ability to produce gastric distension in the proximal gastric pouch at an early stage during a meal. Thus, failure results if the pouch compensates by distending or if the stoma widens with subsequent loss of slow emptying. Improved medical and surgical treatment will be designed to intervene at specific sites of the satiety cascade as knowledge of the physiologic control mechanisms of satiety increases.
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PMID:Physiologic approaches to the control of obesity. 229 39

Gastric restrictive surgery has evolved over the past decade as the treatment of choice for morbid obesity. We reviewed our experience with 289 patients who underwent gastric surgery for morbid obesity. Comorbid diseases included respiratory insufficiency in 19 percent of the patients, hypertension in 36 percent, diabetes in 15 percent, arthritis in 30 percent, and heart disease in 6 percent. Operative mortality was 0. The follow-up rate was 93 percent. Overall mortality was 1 percent, with no death directly attributed to the operative procedure. Weight loss was studied over the 6-year study period. Four to 6 years postoperatively, overall weight loss was 50 to 64 percent of excess weight. The treatment failure rate 12 to 18 months postoperatively was 5 percent. The experience with gastric restrictive surgery in 12 centers involving 5,178 patients was reviewed and compared with our results. Overall operative and late mortality rates were quite similar to observed death rates for nonobese men and women between 25 and 64 years of age. These data suggest that gastric surgery for morbid obesity results in a significant reduction in health risk.
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PMID:Gastric restrictive operations for morbid obesity. 291 Jan 20

During a 12-year period, when more than 106,000 women were delivered, 28 women with peripartum heart failure of obscure etiology that initially was diagnosed as peripartum cardiomyopathy were studied. None had obvious underlying cardiac disease or iatrogenic fluid overload, and in all an assiduous search for underlying cardiovascular disease was launched. In 21 of these 28 women, heart failure was attributed to chronic underlying disease (chronic hypertension in 14, forme fruste mitral stenosis in four, and morbid obesity in one) or viral myocarditis. Importantly, these women also had multiple compounding cardiovascular factors--preeclampsia, cesarean section, anemia, and infection--which, when superimposed on those of pregnancy, acted in concert to cause heart failure. In seven women, the cause for cardiomegaly and global hypokinesis was not found, and peripartum cardiomyopathy was diagnosed. Compared with women with explicable causes of peripartum heart failure, these women did poorly: six had persistent cardiomegaly and heart failure, and four of these died within four months to eight years. From these observations, the authors conclude that idiopathic peripartum cardiomyopathy is uncommon, and that in most women with peripartum heart failure of obscure etiology, underlying chronic disease will be identified. Heart failure in these women ensues when the cardiovascular demands of normal pregnancy are amplified further by common pregnancy complications superimposed upon these underlying conditions that cause compensated ventricular hypertrophy.
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PMID:Peripartum heart failure: idiopathic cardiomyopathy or compounding cardiovascular events? 293 58


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