| The case of a 21-year-old male taking over-the-counter pseudoephedrine for weight loss who died suddenly during exercise shortly after inoculation with Japanese encephalitis and phenol-inactivated typhoid vaccines is presented. The patient collapsed in mild weather while exercising 75 minutes after his vaccinations. He presented in asystole with a core temperature of 42.2 degrees C (108 degrees F). There was no evidence of urticaria or angioedema. It is likely that the combined pyrogenic effects of the vaccines, pseudoephedrine, exercise, and mild obesity contributed to a failure of the thermoregulatory system. fever is still a common side effect of numerous other vaccines. Military physicians should consider administrative controls on thermogenic activities for a period after inoculations. Additionally, the dangers of ephedrine-containing compounds need to be more widely publicized. ( info) |
2/949. Myocardial infarction in patients with systemic lupus erythematosus with normal findings from coronary arteriography and without coronary vasculitis--case reports. The authors present the cases of two young patients, a man and a woman, who presented with myocardial infarction, in the absence of ischemic heart disease or stenosis of the coronary arteries. The woman was known to have systemic lupus erythematosus (SLE) for the past 3 years (the immunoglobulin m [IgM] anticardiolipins antibodies were positive), without a history of coronary risk factors. Suddenly she presented with acute chest pain on rest that lasted 4 hours and culminated in anterior wall myocardial infarction. She was admitted to the coronary care unit, where no thrombolysis was given. She did not have echocardiographic evidence of Libman-Sacks endocarditis, but myocardial infarction was evident at the electrocardiogram (ECG). The young man had SLE (the IgM anticardiolipins were absent, but he was positive for lupus anticoagulant antibodies), he was hyperlipidemic, was a moderate smoker and moderately obese, and had no history of ischemic heart disease. He suddenly presented with an acute myocardial infarction documented by ECG, enzymes, and gammagraphy. In both patients, coronary angiography findings were normal and myocardial biopsy did not show evidence of arteritis. The relevance of these cases is the rare association of ischemic heart disease in SLE, with normal coronary arteries and without evidence of arteritis or verrucous endocarditis. ( info) |
3/949. obesity and life underwriting. obesity is increasing in the US population and currently affects one-third of adults. The physiology of obesity is complex and predisposition to obesity is influenced by multiple genes and environment. obesity may be measured by body fat percentage, body mass index (BMI), or visceral adiposity. life insurance companies generally use height and weight (build) determinations. The purpose of this paper is to review the life risks and physiology of obesity, and to suggest that the current trend to liberalize traditional build table ratings may not be prudent. A case history will be utilized to demonstrate these points. ( info) |
4/949. Adverse psychologic reactions to ileal bypass surgery. Of 33 patients who underwent ileal bypass surgery for morbid obesity and were followed up with psychiatric interviews and consultation postsurgery, five appear to have had adverse psychologic sequelae related to the procedure. The emotional problems of these five patients were in part related to or precipitated by their drastic weight loss after ileal bypass. In most cases, the patients generally had depressive symptoms and, in dynamic terms, were dependent individuals with lifelong problems in object relations. The coping styles demonstrated, while not rigorously classified as psychiatric illness, appeared to predispose them for certain difficulties even when weight had been lost. Ileal bypass surgery apparently is not psychologically innocuous as previously thought, and psychiatric follow-up of patients is indicated. ( info) |
5/949. Lower dosages of phentermine-fenfluramine given in the afternoon: five cases with significant weight loss. phentermine and fenfluramine are widely used in the treatment of obesity. Despite the fact that primary pulmonary hypertension and mitral valve insufficiency have been associated with fenfluramine use, many of these patients need medication to achieve weight loss. Small degrees of weight loss have been shown to significantly improve obesity-related medical conditions such as hypertension, hypercholesterolemia, and noninsulin-dependent diabetes mellitus. Current practice is to give phentermine and fenfluramine in the morning and afternoon. Doses for phentermine have ranged from 15 to 37.5 mg and for fenfluramine from 20 to 120 mg per day. We report five cases of severely obese women with medical complications who were treated with phentermine 8 mg twice per day (at 1:00 p.m. and 4:00 p.m.) and fenfluramine 20 mg per day (at 4:00 p.m.). Because many obese patients skip breakfast and eat more in the afternoon and evening, medication was dosed in order to cover these high-risk eating periods. overall, these patients lost a mean of 22.4% of their initial weight (range 18.6% to 32.8%) over an average of 8.4 months (range 3.5 to 16 months). These cases suggest that short-term weight loss can be achieved with a low dose of fenfluramine when both medications are given in the afternoon to better target the eating patterns of obese subjects. ( info) |
6/949. pregnancy after treatment with the insulin-sensitizing agent troglitazone in an obese woman with the hyperandrogenic, insulin-resistant acanthosis nigricans syndrome. OBJECTIVE: To report a case of unassisted pregnancy after 5 months of troglitazone treatment in a severely hyperandrogenic, insulin-resistant woman with acanthosis nigricans (hair-AN) previously managed with depot leuprolide acetate (LA) plus oral contraceptive and dexamethasone therapy. DESIGN: Case report. SETTING: Private infertility clinic. PATIENT(S): A 28-year-old African-American woman with excessive obesity (body mass index = 42 kg/m2) and hair-AN syndrome. INTERVENTION(S): Androgen suppression with depot LA plus oral contraceptive and dexamethasone therapy, troglitazone treatment resulting in normalization of fasting insulin and testosterone, spontaneous menses, and an unassisted pregnancy. MAIN OUTCOME MEASURE(S): luteinizing hormone and testosterone concentrations, fasting insulin and glucose levels, insulin-glucose ratios, hCG levels, and ultrasound examinations. RESULT(S): Spontaneous menses followed by an intrauterine pregnancy after 5 months of treatment with troglitazone, an insulin-sensitizing agent, in a woman with severe hair-AN syndrome whose hyperandrogenism previously could be normalized only with depot LA plus oral contraceptive therapy and dexamethasone. CONCLUSION(S): Troglitazone treatment resulted in attenuation of both hyperinsulinemia and hyperandrogenism in an obese woman with hair-AN and resulted in resumption of menses and a spontaneous pregnancy. ( info) |
7/949. Syndromal obesity due to paternal duplication 6(q24.3-q27). The likelihood of a paternally expressing imprinted gene in chromosome region 6(q23-24) has been highlighted by cases of transient neonatal diabetes mellitus (TNDM) in which paternal uniparental disomy (UPD) for chromosome 6 or paternal duplication 6(q23-qter) was detected. We present the case of a 38-year-old man with moderate to severe intellectual delay, short stature, small hands and feet, eye abnormality, small mouth, and obesity (without hyperphagia) beginning in mid-childhood. The perinatal and neonatal histories were normal. The patient had a duplication within 6q. fluorescence in situ hybrisation studies were performed with single and dual hybridisations using a chromosome 6 library probe, short and long arm subregional probes, 6q23-24, 6q25.3-6qter locus-specific probes, and a 6q telomere probe. The hybridisation results defined an inverted duplication of 6q24.3 to 6q27. dna studies with microsatellite markers from 6p and 6q showed regular biparental inheritance of chromosome 6 and confirmed that the duplication was paternal in origin. Our patient appears to be the first one known to have paternal duplication of chromosome area 6(q24-q27) who did not have TNDM as an infant. He has remained nondiabetic, although obesity, without hyperphagia, has been a constant problem since its onset in mid-childhood. ( info) |
| We report on a 27-year-old man with acanthosis nigricans (AN) associated with severe obesity, insulin resistance and hypothyroidism. A very low-calorie diet treatment decreased his weight and then ameliorated the insulin-resistant state. These effects were followed by remarkable improvement of the AN prior to the correction of the hypothyroidism. This confirms that AN may be mainly attributed to insulin resistance rather than hypothyroidism per se. ( info) |
9/949. Systems approach to childhood and adolescent obesity prevention and treatment in a managed care organization. OBJECTIVE: To outline an intervention approach to childhood and adolescent obesity prevention and treatment, that will systematically facilitate effective communication, provide long-term social support and access to resources, that may be accessed proactively or on demand. Furthermore, this approach operates in an environment that involves all critical parties: child/adolescent, family-unit, physician and allied health professionals. SYSTEMS thinking APPROACH: The objective is to bring together all key stakeholders and consider the interrelationships among them as a common process. In a managed care setting, this may be accomplished by optimizing the contributions of care delivery, health promotion and information systems. SETTING: A not-for-profit, community governed Managed Care Organization (MCO) in the midwestern united states. telephone-based, centralized services facilitate a process of access, communication, documentation and intervention implementation. CASE STUDIES:Two case studies are presented as examples of how access is obtained, the intervention is tailored to individual needs, communication is established, documentation is organized and long-term support is facilitated. CONCLUSIONS: A systems thinking approach to obesity prevention and treatment in youth has great potential. In a MCO setting, such an approach may be implemented, since integrated health care delivery systems may allow a common process to be established that can bring together all key stakeholders. ( info) |
10/949. A biopsychosocial model for youth obesity: consideration of an ecosystemic collaboration. Youth obesity is a difficult problem for health care professionals, the patients' themselves, and their families. This complex issue requires new theoretical and clinical models for intervention, which accommodates interdisciplinary collaboration. The family-Collaborative Ecosystemic Model (FEM) is a view of obesity grounded in family systems theory, ecosystems theory and biopsychosocial theory, integrated with Eastern and Western philosophical views of health. The Ecosystemic Biopsychosocial Grid (EBG) is presented as a clinical application to evaluate the clinical picture and organize delivery of interventions. The EBG can be used to assess resources and obstacles in ten domains or levels of patients' daily experience of obesity. Using a strengths perspective, it utilizes the experience of the patient and family, in partnership with the expertise of health care professionals, to meet patient and family-centered goals of health. ( info) |