Gastroesophageal reflux in morbidly obese patients treated with gastric banding or vertical banded gastroplasty.

OBJECTIVE: To compare gastric banding (GB) and vertical banded gastroplasty (VBG) with respect to postsurgical gastroesophageal reflux (GER) and to investigate the role of preexisting hiatus hernia. SUMMARY BACKGROUND DATA: GB and VBG have for a long time been used in the treatment of morbidly obese patients. The introduction of laparoscopic techniques has renewed the interest in these operations. The long-term results after GB have, however, been poor. VBG was suggested to have antireflux properties because it involves repositioning and retaining the gastroesophageal junction within the abdomen and constructing an elongated intraabdominal tube. METHODS: Forty-three morbidly obese patients accepted for GB or VBG were evaluated for GER before and at regular intervals after surgery. All patients were questioned about adverse symptoms and need for antireflux medication. Both before and after surgery, 24-hour pH measurement and upper gastrointestinal endoscopies were performed. RESULTS: The prevalence of heartburn and acid regurgitation among patients treated with GB increased from 14% and 13% to 63% and 69%, respectively. Heartburn and acid regurgitation were present before surgery in 32% and 23% of patients treated with VBG, percentages unchanged by the procedure. The 24-hour reflux time increased significantly from 6.4% to 30.9% in patients treated with GB but was essentially unchanged in patients treated with VBG. The prevalence of esophagitis after GB and VBG was 75% and 20%. Acid inhibitors were needed in 81% of patients after GB and 29% of patients after VBG. CONCLUSIONS: The prevalence of GER was unchanged by VBG, but VBG did not demonstrate antireflux properties. The incidence of GER increased markedly after GB.

Anorexia/bulimia nervosa: the development of anorexia nervosa and of mental symptoms. Treatment and the outcome of the disease.

Since 1958 we have conducted a prospective study of anorexia/bulimia nervosa (A/BN) covering a total of 550 patients. This paper presents a new idea of the development of A/BN. For a variety of reasons, a predisposition for developing A/BN is triggered by a minor and non-specific loss of weight. The development of mental symptoms with pathological thoughts and behaviour, and disturbances in the satiety and hunger centres suggest a cerebral dysfunction. Educating patients in pathophysiology enables them to use their intelligence, logical thinking and strong will to evaluate the importance of an adequate supply of nutrients. To date, two studies of the outcome of the disease have been carried out producing similar results: 86% fair results (12% spontaneous recovery), 13% chronic cases and 1% have died.

Vitamin D metabolism in normal and hypoparathyroid pregnancy and lactation. Case report.

Plasma concentrations of vitamin D metabolites in 17 non-pregnant women, 22 pregnant women at delivery, and in eight lactating women 3 and 16 days after delivery, were compared with those in a postpartum hypoparathyroid patient treated with 1 alpha-hydroxyvitamin D (1 alpha-OHD). The mean concentration of 1,25-dihydroxyvitamin D [1,25-(OH)2 D] was 203 (SD 61) pmol/l in the pregnant, and 86 (SD 27) pmol/l in the non-pregnant women (P less than 0.0005). The levels 3 and 16 days after delivery were similar [57 (11) compared with 62 (19) pmol/l], and lower than the non-pregnant value (P less than 0.01). The 25-hydroxyvitamin D (25-OHD) concentration remained unchanged between the 3rd and 16th days after delivery, whereas the 24,25-dihydroxyvitamin D [24,25-(OH)2D] level increased from 2.7 (SD 1.8) to 3.7 (SD 2.3) nmol/l (P less than 0.025). The patient temporarily required an increased supplement of l alpha-OHD during pregnancy, but a dose which was appropriate before pregnancy resulted in marked hypercalcaemia and a rise of 1,25-(OH)2D concentration within 16 days of delivery despite lactation. The results suggest that the metabolic need for the active vitamin D metabolite 1,25-(OH)2D is increased during pregnancy and rapidly reduced during early lactation in healthy and hypoparathyroid women.

ACTH suppression after oral administration of cortisone in Addisonian and adrenalectomized patients.

Plasma cortisol and the corresponding ACTH concentrations were determined before, and for 6 h following a single oral dose of 25 mg cortisone acetate in 7 patients with Addison's disease, 6 patients adrenalectomized for Cushing's disease and 1 patient adrenalectomized for congenital adrenal hyperplasia. The basal plasma cortisol concentrations 12 h after an evening dose of cortisone acetate 12.5 mg were below 100 nmol/l, and the corresponding ACTH concentrations were markedly elevated in all patients. Great interindividual variations were found in cortisol peak concentrations (Cmax) and the time to peak values, but without significant differences between the two patient groups. The maximal ACTH suppression occurred within 60-330 min after the cortisol Cmax, and was not significantly different in the two groups. The suppressed plasma ACTH concentrations were considerably above normal in 3 of the patients with Addison's disease and in 4 of the 6 patients adrenalectomized for Cushing's disease, including 2 patients with Nelson's syndrome. A similar degree of impaired ACTH suppression in patients with Addison's disease as in adrenalectomized patients suggests the occurrence of a secondary hypothalamic-pituitary dysfunction with ACTH hypersecretion in Addison's disease. The adequacy of the commonly used adrenocortical replacement therapy and its possible relation to the impaired ACTH suppression is discussed.

A prospective study of 133 patients with anorexia nervosa treatment and outcome.

One hundred and thirty-three patients with anorexia nervosa have been treated in a prospective study from 1958 to 1976. The doctor and the patient alone formed the therapeutic team, the doctor playing the role as an instructor in the pathophysiology of hunger without discussing social or psychological problems. At follow-up 58% of the patients were grouped as 'good', and 28% as 'intermediate', figures which are in accordance with those obtained from other authors. Fourteen per cent of the patients were grouped as 'poor'. None of the patients died. That therapists with different attitudes to treatment may obtain fairly similar results strengthens our view of a strong tendency to spontaneous recovery in anorexia nervosa. The outlook for patients with a short history of anorexia nervosa seems good.

Stimulation of the hexose monophosphate shunt activity in human polymorphonuclear leukocytes.

The glucose metabolism in human polymorphonuclear (PMN) leukocytes was stimulated by latex particles, zymosan particles, gamma-G globulin and formylmet-leu-phe (FMLP) peptide. Maximum stimulation occurred when zymosan particles in amounts above 0.25 mg/ml per 4 X 10(6) leukocytes were used. Latex particles, gamma-G globulin and FMLP stimulated the glucose oxydation less than zymosan particles. The glucose oxydation increase in proportion to the amount of latex particles and gamma-G globulin in the measured range, while the dose response curve using FMLP shows maximum activity at a consentration of the peptide of 5 X 10(-5)M per 4 X 10(6) leukocytes. It is likely that FMLP and gamma-G globulin act on the glucose metabolism via cell surface receptors. The synthetic polystyrene particles (latex) do not occupy these receptors, but stimulate the hexose monophosphate (HMP) shunt activity of the PMN via intracellular mechanisms. Opsonized zymosan particles seem to act on the leukocyte glucose metabolism via cell surface receptors as well as via intracellular mechanisms.

The effect of IgG, F(ab)2 and serum on the glucose metabolism in human leucocytes.

The glucose metabolism in human leucocytes was strongly stimulated by IgG, independent of whether phagocytosis occurred or not. The percentage increase was highest in the pentose phosphate pathway. Maximum stimulation of the glucose oxidation occurred with an IgG concentration of 1-4 g/l. The insignificant effect of F(ab)2 fragments indicated that the Fc piece is necessary for the stimulation by IgG. In nonphagocytosing leucocytes, serum stimulated the lactate production more and the CO2 production less than indicated by the IgG content of the serum. During phagocytosis or with high IgG concentrations, serum increased the glucose oxidation to a greater extent that did IgG alone. These results indicate that IgG is one of the components in serum most important for the stimulation of glucose oxidation in leucocytes. Serum factors counteracting the stimulation of glucose oxidation by IgG in nonphagocytosing leucocytes may have a regulating effect in vivo.

A pituitary tumour with possible ACTH and TSH hypersecretion in a patient with Addison's disease and primary hypothyroidism.

A patient with Addison's disease, who was inadequately substituted with corticosteroids for twenty-five years, developed a pituitary tumour. The diagnosis of autoimmune thryroiditis with asymptomatic hypothyroidism was also made. ACTH and TSH plasma values were abnormally elevated. The ACTH secretion was suppressed by cortisone administered perorally. It seems possible that the pituitary enlargement is due to prolonged insufficient adrenocortical replacement therapy. The differential diagnosis and possible pathogenetic factors are discussed.

The effect of serum from obese and normal weight men on glucose metabolism in leucocytes.

The influence of pooled serum from either obese or normal weight males on glucose metabolism in human leucocytes has been studied. Leucocytes from normal weight males were incubated with 10-90% pooled serum and either [U-14C], or [1-14C]glucose. Compared to serum from the normal weight males, serum from the obese group had a more stimulating effect on the 14CO2 and [14C]lactate production from [U-14C]glucose and on the 14CO2 production from [1-14C]glucose. The two serum pools had the same stimulating effect on the Embden-Meyerhof pathway as indicated by the formation of [14C]lactate from [1-14C]glucose. Calculations revealed that the activity in the pentose phosphate pathway was stimulated more by serum from obese, than from normal weight males. It is a possibility that increased stimulation of the pentose phosphate pathway may contribute to the development of overweight.

Thyrotoxic hypercalcemia treated with corticosteroids.

A 42-year-old man presenting with symptomatic hypercalcemia was successfully treated with corticosteroids. Initially he was thought to suffer from Addison's disease. A thyrotoxic state was, however, disclosed during the treatment. Evidence suggests that the hypercalcemia was caused by thyrotoxicosis. The effects of thyroid and adrenocortical hormones on calcium metabolism are discussed. Corticosteroids seem valuable in differentiating thyrotoxic hypercalcemia from coincidental hyperparathyroidism.

Transsphenoidal meningocele with hypothalamic insufficiency.

A 16-year-old girl with transsphenoidal meningocele and signs of hypothalamic insufficiency is presented. Hormonal disturbances have been reported in only three similar cases in the literature. The radiological criteria for the diagnosis are discussed with emphasis on the differential diagnosis of a persistent cranipharyngeal canal. Based on the present case and studies of the pertinent literature we propose that all patients exhibiting signs of dysraphism of the base of the skull should be thoroughly investigated for hormonal disturbances. Children with cleft palate should be examined for possible concomitant dysraphism of the skull.

Cardiac performance in patients with anorexia nervosa.

The heart function in 15 female patients with anorexia nervosa was examined by means of systolic time intervals. In 3 patients, pulmonary wedge pressure and cardiac output were measured. The findings indicate impaired myocardial contractility in patients with anorexia nervosa.