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1/28. angiotensin ii blockade in hypertensive dialysis patients.

    Five hypertensive haemodialysis patients have been infused with saralisin. The infusion appears to be a simple diagnostic test separating patients into two groups. First, there are those whose blood pressure does not fall with saralasin pre-dialysis, but does fall with weight removal during dialysis; the blood pressure in these patients can be controlled by a reduction in pre-dialysis weight. Second, there are those whose blood pressure does fall with saralasin either pre- or post-dialysis; their arterial pressure does not fall with weight removal, but can be controlled by anti-hypertensive drugs. In two of the patients who responded to saralasin, the mechanism of the high blood pressure appeared to change from volume dependency, partial or complete, with suppressed renin release, to angiotensin dependency, partial or complete, as weight was removed during dialysis. These patients illustrate the importance of the interaction between volume and the level of angiotensin ii in the maintenance of hypertension.
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2/28. Use of a modified dosing weight for heparin therapy in a morbidly obese patient.

    OBJECTIVE: To report a case of successful anticoagulation using a modified dosing weight (DW) for unfractionated heparin (UFH) therapy in a morbidly obese female. CASE SUMMARY: A 54-year-old morbidly obese (182.4 kg, 155 cm) white female presented to the emergency department with tachycardia, shortness of breath, and chest pain, and was diagnosed with a pulmonary embolism. Anticoagulation with UFH was initiated. A modified DW of 120 kg was obtained from the average of the actual body weight (ABW) and ideal body weight ( approximately 50 kg). We selected this modified DW to account for heparin's altered volume of distribution in an obese patient and avoid potentially supratherapeutic activated partial thromboplastin times (aPTTs) using ABW and subtherapeutic aPTTs using DW. Therapy was initiated with a bolus dose of 9600 units (80 units/kg x 120 kg) and continuous infusion rate of 2160 units/h (18 units/kg/h x 120 kg). This infusion rate was maintained throughout the course of heparin therapy and was successful in maintaining therapeutic aPTTs. DISCUSSION: Proper diagnosis and rapid initiation of therapy prevent mortality in patients with PE. Although weight-based heparin nomograms provide standardization through initial bolus and continuous infusion recommendations, many do not address dosing in morbidly obese patients. Several retrospective studies have evaluated actual, dosing, and ideal body weights for heparin therapy in obese patients; however, none has evaluated modified DW. In our patient, successful anticoagulation was objectively confirmed. CONCLUSIONS: Further investigation is necessary to determine the optimal DW for UFH in morbidly obese patients presenting with acute thrombosis.
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3/28. Diabetic lipemia with eruptive xanthomatosis in a lean young female with apolipoprotein e4/4.

    Eruptive xanthomas in adults are usually indicative of chylomicronemia. Although diabetes mellitus is the most common secondary cause of chylomicronemia, which is designated as diabetic lipemia, the clinical characteristics of diabetes with regard to development of xanthomas are not well defined. In this paper, we describe a young female who displayed eruptive xanthomas as an initial manifestation of diabetic lipemia. The patient was a 20-year-old female with a body mass index of 18.9 kg/m2 and Marfanoid appearance. Her past history was unremarkable, except for patent ductus arteriosus and mild mental retardation. She was admitted to our division for eruptive xanthomas on the extremities and marked hyperglycemia (random glucose, 520 mg/dl) and hypertriglyceridemia (6880 mg/dl). She was diagnosed with Type 2 diabetes based on the positive family history of diabetes, residual secretory capacity of insulin, and absence of autoantibodies related to Type 1 diabetes. Based on the increase in the concentrations of both chylomicrons and very low density lipoproteins, type V hyperlipoproteinemia was diagnosed. After the initiation of insulin therapy, both hypertriglyceridemia and eruptive xanthomas subsided, without administering any hypolipidemic agents. Minimal model analysis of a frequently sampled intravenous glucose tolerance test revealed severe insulin resistance, despite the absence of obesity. Post-heparin lipoprotein lipase (LPL) activity was moderately decreased, and common mutations in the LPL gene were not demonstrated by genetic screening. The apolipoprotein E phenotype was E4/4, which is known to be associated with type V hyperlipoproteinemia. Hypoadiponectinemia of 1.7 microg/ml was also revealed, which may, in part, account for the insulin resistance and decreased LPL activity. In conclusion, the clustering of apolipoprotein e4/4 and hypoadiponectinemia, in addition to insulin resistance and poor glycemic control, might have resulted in hypertriglyceridemia with eruptive xanthomatosis in this subject.
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4/28. prader-willi syndrome-associated obesity treated by biliopancreatic diversion with duodenal switch. Case report and literature review.

    BACKGROUND: prader-willi syndrome (PWS) is a congenital chromosomal disorder characterized by compulsive hyperphagia and the early development of obesity. obesity is identified as the main cause of morbidity and mortality in PWS individuals. Thus, body weight reduction is of major importance for a prolonged survival. PATIENT-METHOD: A 20-year-old female patient with PWS was referred to our department for surgical treatment of her obesity. At admission, her body weight was 153 kg, and her body mass index (BMI) was 74.33 kg/m(2). The patient underwent biliopancreatic diversion with duodenal switch, as well as cholecystectomy and appendicectomy. The volume of the gastric remnant was 100 mL, and the lengths of the gastric and common limbs were 250 and 60 cm, respectively. RESULTS: Eighteen months after the operation, the patient lost 63 kg with no considerable changes in her eating habits. Her sleep disturbances and sleep apnea disappeared, and her social life dramatically improved. CONCLUSIONS: biliopancreatic diversion with duodenal switch seems to be a good method for the treatment of PWS-associated obesity because it offers good results in weight loss without the need for revision, good quality of life, and a chance for a prolonged survival.
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5/28. Cyclical edema in a patient with hypothalamic disorders and chronic glomerulonephritis: arginine vasopressin-dependent atrial natriuretic hormone release.

    A 28-year-old woman had hypothalamic disorders (amenorrhea, obesity, psychiatric abnormalities, polydipsia and fever) and chronic glomerulonephritis. She also suffered from general edema associated with cyclical oliguria and polyuria. Her body weight and plasma osmolality increased during the oliguria phase lasting 2 to 8 days and decreased after paroxysmal polyuria accompanied by the natriuresis. These episodes occurred repeatedly, regardless of the treatment with or without diuretics. The release of arginine vasopressin in response to increased plasma osmolality was exaggerated, but changes in plasma volume did not affect arginine vasopressin release. Plasma atrial natriuretic hormone increased in response to a rise in plasma arginine vasopressin and plasma volume during the oliguria phase, thereby resulting in the diuresis and natriuresis. The renin-angiotensin-aldosterone system was secondarily activated by body fluid depletion and diuretics, and this might play an additive role in general swelling. Plasma gonadal hormones did not change to explain the edema. The mechanism of this cyclical edema remains unknown, but it is likely that hypothalamic dysfunction related to psychiatric abnormalities may exaggerate arginine vasopressin release, and enhanced renal sympathetic activity may cause retention of Na and water, and the increase in atrial natriuretic hormone release responding to the plasma volume expansion may bring about the diuresis and natriuresis.
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6/28. Insulin oedema and its clinical significance: metabolic studies in three cases.

    Three patients with insulin-dependent diabetes mellitus are described in whom generalized oedema and weight gain followed the administration of excessive monocomponent insulins, in two cases associated with symptomatic hypoglycaemia. Serial measurements of plasma volume and transcapillary escape rate of albumin (TERA) using 125I-labelled albumin, serum colloid osmotic pressure (COP) using a membrane colloid osmometer, packed cell volume (PCV), and serum proteins, showed that oedema was associated with an increased plasma volume and TERA, while serum albumin and total protein concentration and serum COP were reduced. A reduction in daily insulin dose abolished hypoglycaemia and resulted in weight loss, natriuresis, diuresis, a reduction in plasma volume and TERA, and an increase in serum albumin, total protein, and COP. Strict metabolic control in previously poorly controlled patients may cause insulin-induced increments in plasma volume and albumin escape rate.
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7/28. Insulin secretion in obesity and diabetes: an illustrative case.

    A patient with obesity and diabetes mellitus had insulin secretion studies done during a 3-year cycle of weight loss and regain in the course of which she progressed from frank diabetes to a normal state of carbohydrate tolerance and then back to her original diabetic state. The results suggest that therapeutic weight reduction not only reverses insulin resistance but also restores beta cell sensitivity and enhances beta cell capacity. The eventual re-establishment of a degree of obesity, hyperinsulinemia, and carbohydrate intolerance virtually identical to that originally seen is compatible with a primary disorder involving hypothalamic control of adipose stores and insulin secretion.
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8/28. Familial type V hyperlipoproteinaemia in identical twins homozygous for apoliprotein variant E2: report.

    Hyperchylomicronaemia and elevated very low density lipoproteins were found in relatively obese 47 year old identical twin brothers. Lipoprotein apoprotein studies showed the presence of apoprotein CII, the activator of lipoprotein lipase, and both men were homozygous E2/2. Studies on the ability of the brothers to clear triglyceride rich particles showed some impairment of post heparin lipase activity, and a slower clearance of infused fat emulsion. The values improved after weight loss. There was some evidence of impaired capacity of the patients' high density lipoprotein to activate post heparin lipoprotein lipase.
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9/28. Investigation of a fatal heatstroke.

    On June 30, 1981, a young, apparently healthy, obese white male suffered a fatal heatstroke. This was the beginning of summer in southern ohio, when mid-day temperatures can reach into the 30s degrees C (90s degrees F) and the humidity can climb above 70%. The predisposition of the individual in terms of acclimatization, physical size and dietary intake, along with strong motivation to perform well on a job requiring a heavy workload in a hot environment, pushed him beyond his physiologic capacity. Of those people who attended him, only professional rescue personnel recognized the illness and properly treated the man. The death may have prevented by acclimatization and training as to the hazards, recognition and treatment of heat illness.
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10/28. Predictive value of random sample urine bile acids corrected by creatinine in liver disease.

    bile acids, in a random sample of urine, discriminated normal controls from liver disease, with a probability similar to fasting plasma bile acids (p less than 0.01 and p less than 0.001, depending on the analytical technique). A high degree of correlation between urinary and plasma bile acids (up to r = 0.93) was achieved only when the urine flow was corrected by using a urinary bile acids/creatinine ratio but not with urinary bile acids as simple volume concentration. These findings originated from 10 patients with severe liver disease and 10 with mild liver disease, all biopsy-confirmed, compared with controls. In 24 normal controls and 24 histologically confirmed compensated liver disease, the predictive value of urinary bile acids/creatinine equaled or exceeded fasting plasma bile acids and routine liver tests. In a patient recovering from subacute hepatic necrosis, the urinary bile acids/creatinine closely resembled changes in plasma bile acids and in the routine liver tests. When sulfated urinary bile acids were included, the discrimination between liver disease and controls did not improve. gallbladder contraction induced by parenteral analogs of cholecystokinin did not change urinary bile acids/creatinine, despite a significant increase in the plasma bile acids. Collection of fasting urine is thus not necessary. Urinary bile acids/creatinine in 12 subjects with renal insufficiency and moderate impairment of creatinine clearance was not different from controls. The weight/height index did not affect this urinary test: there was no significant correlation between the two. Available radioimmunoassays for plasma bile acids can be easily adapted for urine.(ABSTRACT TRUNCATED AT 250 WORDS)
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