Decreased S-nitrosylation of tissue transglutaminase contributes to age-related increases in vascular stiffness

RATIONALE

Although an age-related decrease in NO bioavailability contributes to vascular stiffness, the underlying molecular mechanisms remain incompletely understood. We hypothesize that NO constrains the activity of the matrix crosslinking enzyme tissue transglutaminase (TG2) via S-nitrosylation in young vessels, a process that is reversed in aging.

OBJECTIVE

We sought to determine whether endothelium-dependent NO regulates TG2 activity by S-nitrosylation and whether this contributes to age-related vascular stiffness.

METHODS AND RESULTS

We first demonstrate that NO suppresses activity and increases S-nitrosylation of TG2 in cellular models. Next, we show that nitric oxide synthase (NOS) inhibition leads to increased surface and extracellular matrix-associated TG2. We then demonstrate that endothelium-derived bioactive NO primarily mediates its effects through TG2, using TG2(-/-) mice chronically treated with the NOS inhibitor l-N(G)-nitroarginine methyl ester (L-NAME). We confirm that TG2 activity is modulated by endothelium-derived bioactive NO in young rat aorta. In aging rat aorta, although TG2 expression remains unaltered, its activity increases and S-nitrosylation decreases. Furthermore, TG2 inhibition decreases vascular stiffness in aging rats. Finally, TG2 activity and matrix crosslinks are augmented with age in human aorta, whereas abundance remains unchanged.

CONCLUSIONS

Decreased S-nitrosylation of TG2 and increased TG activity lead to enhanced matrix crosslinking and contribute to vascular stiffening in aging. TG2 appears to be the member of the transglutaminase family primarily contributing to this phenotype. Inhibition of TG2 could thus represent a therapeutic target for age-associated vascular stiffness and isolated systolic hypertension.

Glomerular protein levels of matrix metalloproteinase-1 and tissue inhibitor of metalloproteinase-1 are lower in diabetic subjects

Matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) regulate extracellular matrix turnover throughout the body, including in renal glomeruli. We investigated protein levels of multiple MMPs (MMP-1, MMP-2, MMP-3, and MMP-9) and TIMP-1 in glomeruli and investigated whether disease phenotypes were associated with levels of these proteins. Renal cortex was collected from 100 adult autopsy subjects arrayed across 17 tissue microarrays. Immunohistochemical staining intensity for each MMP and TIMP-1 was determined using quantitative color deconvolution techniques. We observed significantly decreased glomerular MMP-1 and TIMP-1 staining in subjects with diabetes, hypertension, and an estimated glomerular filtration rate <30 ml/min/1.73 m(2) in univariate analyses. MMP-1 staining, but not TIMP-1 staining, was inversely correlated with increased glomerular fibrosis (r = -0.40). In multivariable analysis, diabetes was robustly associated with decreased staining intensity. This study indicates that in human subjects, the long-term sequelae of diseases such as diabetes that cause chronic renal failure result in decreased TIMP-1 and MMP-1 proteins in renal glomeruli. This manuscript contains online supplemental material at http://www.jhc.org. Please visit this article online to view these materials.

Use of human vascular tissue microarrays for measurement of advanced glycation endproducts

Advanced glycation endproducts (AGEs) are present in the vasculature and are associated with vascular disease. We determined levels of AGEs in eight distinct adult vascular tissues using tissue microarray (TMA) technology and associated these levels with clinical characteristics. Medium-to-large caliber blood vessels were harvested from 100 adult autopsies to create 17 TMAs. AGE levels were evaluated by IHC using a polyclonal anti-AGE antibody on over 700 unique blood vessels. Slides were digitally scanned, and quantitative analysis was performed using a color deconvolution image analysis technique. Medial AGE staining was strongly correlated between all eight blood vessels. In the media, AGE staining levels were significantly higher at older ages (p=0.009), in white subjects (p<0.001) and with longer postmortem interval (PMI; p<0.0001). These associations remained significant after simultaneous adjustment for age, race/ethnicity, PMI, and diabetes status. Diabetes was associated with elevated AGE levels but only after adjustment for confounding by clinical variables including race/ethnicity, hypertension, and kidney function. This extensive vascular study shows that AGE accumulation in the macrovasculature is a global process affecting atherosclerosis-prone and -resistant vessels. It also suggests ethnicity has a previously undescribed role in vascular tissue AGE levels. This manuscript contains online supplemental material at http://www.jhc.org. Please visit this article online to view these materials.

Tissue inhibitor of matrix metalloproteinase-3 levels in the extracellular matrix of lung, kidney, and eye increase with age

Tissue inhibitor of matrix metalloproteinase-3 (TIMP-3) is an important regulator of matrix metalloproteinase activity in many types of disease, including atherosclerosis, neoplasia, and inflammatory conditions. Among TIMPs, TIMP-3 uniquely binds the extracellular matrix (ECM). We performed IHC staining on 17 tissue microarrays containing >1500 samples to determine the location of ECM TIMP-3 staining in a variety of predominantly vascular tissues. We found a unique pattern of TIMP-3 staining in the ECM of renal arterioles, small pulmonary vessels and parenchyma, and Bruch's membrane in the retina. There was no staining in larger caliber arteries including coronary and internal mammary arteries. TIMP-3 protein accumulation was found to be an age-dependent phenomenon, with staining appearing in all three tissues in early adulthood and becoming more robust among the elderly. These findings may help to explain the late onset of the TIMP-3-associated ocular diseases Sorsby fundus dystrophy and age-related macular degeneration and suggest a similar phenomenon could be at work in other age-related conditions.

Meralgia paresthetica following bariatric surgery

BACKGROUND

Two papers in the literature have described meralgia paresthetica following bariatric surgery. One author ascribed the cause of the condition to pressure from an abdominal retractor. We encountered 11 similar cases in our bariatric surgery practice, but do not use the retractor previously invoked as the cause of the problem. It seems likely that some other factor is involved.

METHODS

Retrospective chart review.

RESULTS

11 patients were identified whose symptoms and clinical findings were consistent with meralgia paresthetica. There were 6 men and 5 women. Symptoms developed immediately following surgery in 8 cases, and resolved spontaneously within 3 months in 6 of these.

CONCLUSIONS

Multiple causes have been described for meralgia paresthetica. It appears to be more common in obese patients. While extrinsic pressure from an abdominal retractor may play a role in some cases, other factors are clearly involved in the cases reported here.

A comparison of body size evaluations of obesity surgery patients and general population adults

OBJECTIVE

To compare post-operative obesity surgery patients and general population adults in their assessments of a wide range of body sizes.

RESEARCH METHODS AND PROCEDURES

Obesity surgery patients (n = 274) and general population adults (n = 326) rated ideal and socially acceptable body sizes in separate arrays of babies, children, young adults, and middle-aged and older adults. Nine line figure drawings ranging from very thin to very obese were rated for each array.

RESULTS

Both groups selected the same ideal body size for all arrays except for babies. Both groups rejected obese and very thin body sizes as socially acceptable. However, the obesity surgery patients were more restrictive than general population adults in their ratings of socially acceptable body sizes. Current obesity status did not impact ratings for the patient or general population subjects. In the patient sample, time since surgery did not influence body size evaluations.

DISCUSSION

The study of body size ratings limited only to the "ideal" size may be misleading because it may mask subtle but meaningful differences between groups. The consistent difference in more restrictive ratings of obesity surgery patients compared to general population adults may be due to patients' greater psychological investment in endorsing the societal ideal body size. It may also be due to patients' status as peripheral group members of the normal weight community. The inability of some patients to maintain their post-operative weight loss may be particularly problematic for those who have defined "socially acceptable" body size most narrowly.

Perforated peptic ulcer following gastric bypass for obesity

Peptic ulcer in the excluded segment of a gastric bypass performed in the management of morbid obesity has only rarely been reported in the literature. The purpose of this study is to review our experience with the condition in a series of 4300 patients who underwent gastric-restrictive surgery between 1978 and 1997. Eleven patients presented with acute perforation of a peptic ulcer in the excluded gastric segment. Nine ulcers were duodenal, one was gastric, and one patient had both gastric and duodenal perforations. The time between primary gastric-restrictive surgery and ulcer perforation varied from 20 days to 12 years. All patients presented with upper abdominal pain. The classical radiological sign of perforated peptic ulcer, free air under the diaphragm, did not occur in any patient. Nine patients were initially treated by primary closure of the perforation with subsequent definitive ulcer therapy by vagotomy, pyloroplasty, or gastrectomy. One case, initially treated elsewhere, was managed by placement of a Malecot catheter through the duodenal perforation, gastrostomy, and peritoneal drainage. One recent case remains symptom-free on H2 blockers after simple closure. There was no mortality. Six cases were previously reported in the literature with a 33 per cent mortality rate.

The night eating syndrome in the general population and among postoperative obesity surgery patients

OBJECTIVE

To determine the prevalence of night-eating syndrome in the general population and among a new sample of obesity surgery patients.

METHODS

Night-eating syndrome was defined by presence of morning anorexia, excessive evening eating, evening tension and/or feeling upset, and insomnia. A randomly selected sample of 2,097 adults (survey sample) answered structured interview questions on night-eating syndrome. A self-report form was completed by 111 patients who had received gastric restriction surgery for obesity at a patient reunion (patient sample).

RESULTS

Prevalence of night-eating syndrome in the survey sample was 1.5% (31 of 2,097). Prevalence in the patient sample was 27% (30 of 111). Weights for subjects in each sample, with and without the syndrome, were comparable.

DISCUSSION

Prevalence of night-eating syndrome was higher in the patient sample than in the survey sample. Within each sample, presence of the syndrome was not related to weight. Prevalence in the survey sample was within the range reported for binge-eating disorder. Night-eating syndrome may warrant consideration as a distinct eating disorder.

No association between non-steroidal anti-inflammatory drugs and acute appendicitis in a case-control study

BACKGROUND

A recent case-control study reported an association between non-steroidal anti-inflammatory drug (NSAID) use and acute appendicitis. This association was investigated in a case-control study of patients, aged 30 years and over, admitted as an emergency to hospitals in Tayside between 1989 and 1992, who had appendicectomy for acute appendicitis.

METHODS

A record-linkage database containing records of dispensed prescriptions and hospital admissions was used. A total of 223 patients were identified. The medical records of 161 were checked, of which 138 were valid cases, and information on white cell count and NSAID exposure was recorded. Community and hospital controls were generated.

RESULTS

Some 9.0 per cent of patients were prescribed NSAIDs within 90 days of hospitalization, compared with 7.6 per cent of community controls and 11.5 per cent of hospital controls. The odds ratio was 1.21 (95 per cent confidence interval 0.73-2.01) and 0.75 (0.43-1.32) respectively. There was no significant difference in white cell count between exposed and non-exposed cases. No increased risk of appendicectomy was associated with aspirin use: odds ratio 1.67 (0.52-5.30) and 0.37 (0.12-1.13) using community and hospital controls respectively.

CONCLUSION

Appendicectomy for acute appendicitis is not associated with increased prior use of NSAIDs.

The Influence of Dumping on Weight Loss After Gastric Restrictive Surgery for Morbid Obesity

BACKGROUND: The dumping syndrome that follows Roux-en-Y gastric bypass for morbid obesity is considered to, be the primary mechanism of improved weight loss as compared with the purely restrictive vertical banded gastroplasty. To evaluate the influence of dumping on post-operative weight loss, severity of dumping was determined using Sigstad's clinical diagnostic index. METHODS: One hundred and thirty seven gastric bypass and 19 gastroplasty patients were assessed 18-24 months following surgery. Sigstad's criteria for the dumping syndrome were met by 75.9% of gastric bypass and no gastroplasty patients. Among gastric bypass patients, no relationships were found between severity of dumping and weight loss, as measured by per cent of excess body weight loss or change in body mass index. Weight loss was significantly greater with gastric bypass than gastroplasty patients (72.5 compared to 47.9% of excess body weight loss). All gastroplasty and 24.1% of gastric bypass patients were classified as non-dumpers. The difference in weight loss between surgical procedures was not related to dumping: gastric bypass non-dumpers lost significantly more weight (69.1% excess body weight loss) than gastroplasty patients. CONCLUSIONS: This study fails to demonstrate a significant relationship between dumping severity and weight loss. It is inferred that the superior weight loss of gastric bypass compared to gastroplasty has some other etiology.

The Patient Factor

Long-term results of bariatric surgery are reviewed. The weight criteria for patient acceptance for bariatric surgery and their variation are presented graphically and discussed. Factors affecting patient selection in an attempt to improve outcome results in the small group of patients who currently achieve less weight loss than anticipated are defined. An attempt is made to define pre-operative criteria for selection of pure restrictive versus combined restrictive and malabsorptive procedures. Aspects of motivation, co-morbidity, age and pre-operative weight are discussed and the position statement of the ASBS in regard to laparoscopic bariatric surgery is defined.

Drug Distribution in Obesity and following Bariatric Surgery: A Literature Review

BACKGROUND: The pharmacokinetic variables of drug clearance and volume of distribution are usually corrected for body weight or surface area. Only recently have the relationships which exist between body size, physiologic function and pharmacokinetic variables been evaluated in the obese population. These effects are not widely known, and data on this and the effects of bariatric surgical procedures are scantily documented in the surgical literature. METHODS: Literature review. RESULTS: Drugs with a low or moderate affinity for adipose tissue have a moderate increase in the volume of distribution (Vd), and this correlates with the increase in lean body mass (LBM). Highly lipophilic drugs, with some exceptions, show the expected increase in Vd and prolongation of elimination half-life, indicating a marked distribution into adipose tissue. Drug absorption, in general, is slowed by delayed gastric emptying and is normal when gastric emptying is normal or increased. Most drug absorption occurs in the small intestine where duration of drug/mucosal contact is the most important factor. CONCLUSIONS: Drugs whose distribution is restricted to LBM should utilize a loading dose based on ideal body weight (IBW). For those drugs which distribute freely into adipose tissue, the loading dose should be based on total body weight (TBW). Adjustment of the maintenance dose depends on clearance rates. In a few cases dosage adjustment depends on pharmacodynamic data, since drug clearance does not conform to these recommendations, for reasons which remain to be defined. Following bariatric surgery, in the absence of delayed gastric emptying or uncontrolled diarrhea, drug absorption rates are usually comparable to the non-operated patient.

Body size preferences and desired weight of patients who have received obesity surgery and of comparison adults

Patients who had received obesity surgery (n = 144) and comparison adults (n = 72) selected the most attractive male and female size and the same-sex size they most wanted to look like from an array of 15 outline drawings. Subjects also reported their height, and current and desired weights (transformed into body mass index units [BMI]). There was a remarkable consensus on the sizes considered most attractive: Two male sizes were chosen by 78% of all subjects, and two female sizes by 83%. The hypothesis that adults who had obesity surgery would idealize thin sizes and, therefore, select thinner sizes and lower weights than comparison adults was not supported. Not only did patients and comparison adults select the same desired size, but women patients desired significantly larger BMIs than comparison women. There was a large range of desired BMIs associated with each desired size; the correlation between desired BMI and desired size was significant for women but not for men. It was speculated that subjects' desired size reflected cultural norms while subjects' desired BMI was a function of their current weight. Health professionals working in weight loss and/or physical fitness areas need to help clients understand weight-size relationships so that clients can have both realistic weight and realistic size goals.

Adolescents having obesity surgery: a 6-year follow-up

Thirty-four adolescents aged 11 to 19 at the time of gastric surgery for obesity were interviewed an average of 6 years postoperatively. Patients' preoperative body mass index averaged 47; at follow-up, their body mass index averaged 32. Two thirds of the patients weighed within 9 kg of their lowest postsurgical weight at the time of follow-up; three had had additional obesity surgery. Patients reported excellent psychosocial adjustment, including improved self-esteem, social relationships, and appearance. No patient was unemployed. Patients reported poor compliance with exercise and dietary instructions. More seriously, only four patients reported taking vitamin B12, multivitamin supplements, and calcium as directed. The need for long-term patient commitment and monitoring is discussed.

Metabolic Implications of Obesity, Weight Loss and Energy Expenditure following Gastric Restrictive Surgery

This review examines the energetics and metabolic parameters which influence the effectiveness of gastric restrictive surgery in achieving weight loss in the clinically severely obese patient. Among the subjects discussed are the metabolic determinants and consequences of obesity, energy expenditure and its components, factors other than dietary restriction and weight loss which affect energy expenditure, and the metabolic risk factors for weight gain. The role of exercise is reviewed, including the effects of exercise on energy balance and the thermic effect of food. The value of combining exercise with diet restriction, the effect of caloric restriction on the capacity to exercise and the place of exercise in the obese diabetic are examined. Finally, the metabolic consequences of gastric restrictive surgery, the adaptive response to surgically-induced weight loss and nutritional recommendations following gastric restrictive surgery are reviewed.

Gastric surgery in morbid obesity. Outcome in patients aged 55 years and older

OBJECTIVE

To evaluate long-term outcome of gastric restrictive surgery in morbidly obese patients aged 55 years and older.

DESIGN

Retrospective review with 3- to 13-year postoperative follow-up. Average follow-up 6 years.

SETTING

Private surgical practice with bariatric surgery specialty.

STUDY PARTICIPANTS

Eighty-eight morbidity obese patients, 73 women and 15 men, aged 55 years and older.

INTERVENTION

Between 1977 and 1989, 77 patients had Roux-en-Y gastric bypass, four had vertical banded gastroplasty, and seven had silicone ring vertical gastroplasty.

MAIN OUTCOME MEASURES

Weight loss, change in incidence of comorbidity, and reduction in medication use.

RESULTS

Patients had an average of 57% excess body weight loss, lost 31 kg, and decreased their body mass index by 12 kg/m2. There was a 20% to 48% reduction in the number of patients requiring medication for obesity-related disorders (eg, diabetes mellitus and hypertension). Body mass index of less than 30 kg/m2 was achieved and maintained by 42% of patients.

CONCLUSION

This form of therapy is appropriate for selected patients in the older age groups.

Some Tips on Preparing Slides

The author has drawn up instructions and warnings about slides for authors of abstracts accepted for presentation at the Annual Meeting of the American Society for Bariatric Surgery. These tips were invited for publication here, for wider use (Editor).

Effect of Surgically Induced Weight Loss on Asthma in the Morbidly Obese

Forty morbidly obese asthmatic patients who underwent gastric restrictive surgery more than 2 years earlier were evaluated to determine the influence of weight loss on asthma outcome. Mean percentage excess weight loss in this group was 68% and body mass index (BMI) fell from a mean of 46 to 30. Following surgery, 90% showed improvement in asthma symptoms. Complete remission of asthma occurred in 48% and a further 12.5% became asthma free on reduced medications dosage. Of those taking daily medications for asthma before surgery, 42% were completely off medication following weight loss surgery, and another 18.5% experienced fewer asthma attacks on reduced medication dosage. Of the 22 patients with severe asthma (> 10 attacks per year) on routine daily medications for asthma preoperatively, 8(36%) required no medication after surgery, 7(32%) used medication only on an 'as-needed' basis, and 7(32%) controlled their asthma on reduced medication dosage. Five patients gained weight during the follow-up period. All developed an increased incidence of asthma attacks, which again abated after successfully losing weight following revisional surgery. Coexistent factors of smoking and clinically apparent esophageal reflux were evaluated, but no statistically significant correlation was shown with either smoking or reflux and improvement in asthma. Possible etiologies of the improvement in asthma with weight loss are discussed

Small Bowel Obstruction Following Gastric Bypass

Intestinal obstruction is no more frequent after gastric bypass than after any other similar gastric surgical procedure. However, occurrence of any complication requiring revisional surgery in these hugely obese patients may have serious implications. Bariatric surgeons and physicians who take part in the care of such patients must be aware of the different clinical pictures which accompany the varying levels of obstruction following gastric bypass surgery. Particularly critical is an understanding of closed loop gastroduodenal obstruction, a potentially lethal complication, which can cause rapidly occurring hypovolemic shock and death within a few hours of onset.

Characterization of glucose-6-phosphatase in hepatocytes. Effects of amiloride and pentamidine

The hepatic microsomal glucose-6-phosphatase enzyme is situated inside the lumen of the endoplasmic reticulum and, for normal enzyme activity in vivo, three transport systems are needed for the substrate glucose-6-phosphate and the products phosphate and glucose. Previous studies using isolated microsomes showed that the drugs amiloride and pentamidine do not affect the glucose-6-phosphatase enzyme but can activate the glucose-6-phosphate transport system. Here we demonstrate that, very surprisingly, the addition of pentamidine (and to a lesser extent amiloride) to isolated hepatocytes results in an inhibition of the catalytic subunit of glucose-6-phosphatase.

Successful weight loss following obesity surgery and the perceived liability of morbid obesity

Patients (n = 47) who lost 45 kg (100 lb) or more and who successfully maintained weight loss for at least three years following gastric restrictive surgery for morbid obesity viewed their previous morbidly obese state as having been extremely distressful. In spite of the strong proclivity for people to evaluate their own worst handicap as less disabling than other handicaps, patients said they would prefer to be normal weight with a major handicap (deaf, dyslexic, diabetic, legally blind, very bad acne, heart disease, one leg amputated) than to be morbidly obese. All patients said they would rather be normal weight than a morbidly obese multi-millionaire.

Pulmonary Changes in Obesity: surgical implications. A Literature Review

Obesity affects approximately one-third of the population of the United States. Pulmonary complications are common following upper abdominal surgery, and constitute the most frequent postoperative complication in the obese surgical patient. This literature review addresses the pathophysiology of the pulmonary changes associated with simple obesity and examines intraoperative and postoperative changes which occur in this patient group. Measures used prophylaxis and management of these complications are reviewed.

Revision of Staple Line Failure Following Roux-en-Y Gastric Bypass for Obesity: a follow-up of weight loss

Eighty-one patients with primary Roux-en-Y gastric bypass for obesity underwent revisional surgery for staple-line failure. All patients (100%) were included in the follow-up. Two years later, patients had an excess weight loss of 77%; 91% of the patients had a final weight loss of 50% or more of their excess weight. Weight loss of revision patients was comparable to that reported for patients with primary operations. It was concluded that revision for staple line failure is clearly justified.

Age, Obesity Surgery, and Weight Loss

Some centers consider an age over 50 to be a contraindication for obesity surgery. This study was conducted to examine the relationship between age and one-year postoperative weight of patients receiving gastric restrictive surgery (n = 616) for morbid obesity. Patients were divided into four age groups (18-29, 30-39, 40-49, 50-65 years) matched for preoperative obesity. At one year there were no statistically significant differences in weight loss or postoperative obesity. There were four (0.6%) surgically-related deaths. The mortality of patients aged 50 or older (1.1%) was not significantly higher than that of younger patients (0.6%). It was concluded that older age per se need not be a contraindication for surgery.

Folate Status Following Gastric Bypass Surgery (The Great Folate Mystery)

Several previous investigators have reported an incidence of folic acid deficiency following gastric bypass surgery of up to 38%. Failure to encounter any folic acid deficiencies in our postoperative patients led us to discontinue follow-up folate studies for several years. However, due to repeated references to this deficiency in the literature, we re-instituted folate studies as part of the routine follow-up of our patients. Preoperative serum folate levels were obtained in 1,067 patients and preexisting deficiencies found in 63, an incidence of 6%. Of the 588 folate levels determined 1 to 10 years following gastric bypass, only six were less than 3.0 ng/di, an incidence of 1%. All patients were instructed preoperatively and postoperatively to take multivitamin/mineral supplements after gastric restrictive surgery, and were continually educated on their importance. In a bariatric surgery practice in which patients are instructed, reminded, encouraged and even badgered into taking postoperative vitamin/mineral supplements, folate deficiency should be a rarity. In such circumstances, folate deficiency may well act as a sensitive marker of non-compliance.

Morbidly obese patients' perceptions of social discrimination before and after surgery for obesity

Morbidly obese patients' perceptions of obesity-related prejudice and discrimination were assessed before and 14 months after operation for obesity. Preoperatively, the 57 consecutive patients perceived overwhelming prejudice and discrimination at work, within the family, and in public places. After a weight loss of more than 45.5 kg (100 lb), these patients perceived little or no prejudice or discrimination. We examine factors contributing to the change in patients' perceptions and comment upon patients' perceptions of the negative attitudes held by health professionals toward obese patients.

Eating behavior after gastric bypass surgery for obesity

We studied eating behavior in two non-overlapping cohorts of consecutive patients electing gastric bypass surgery for obesity: 100 patients one year after operation and 60 patients three years afterward. Information was obtained through structured interviews and from office charts. Eating behavior was compared with previously collected data on 232 morbidly obese adults and 174 adults of normal weight. Despite an average weight loss of 100 lb (45 kg), there was little evidence of disturbed eating patterns among gastric bypass patients. Significantly fewer gastric bypass patients than morbidly obese comparison subjects reported frequent hunger, overeating, guilt about eating, or food preoccupation. Gastric bypass patients reported less preoccupation with food than did the normal-weight comparison subjects.

Rupture fo the intestine in patients with hernia

Two cases of perforation of the small intestine associated with minor abdominal trauma and right inguinal hernia are presented along with a review of 104 cases in the literature, The condition is treacherous because this minimal injury can produce catastrophic intraabdominal perforation. The most reliable signs and symptoms are abdominal pain associated with guarding and rigidity. Laboratory data may only show leukocytosis and signs of dehydration. Early operation, using a formal laparotomy, is imperative. Systemic antibiotics are recommended.

Renal hypertension

Continuing interest in the mechanism of hypertension have produced considerable new information on the underlying pathophysiologic processes involved. Elucidation of the role of renal malperfusion, the renin-angiotensin-aldosterone mechanism, and renal medullary antihypertensive substances continues to clarify our understanding of renal hypertension. Current evidence suggests that angiotensin can produce hypertension by a direct effect on peripheral blood vessels in malignant hypertension and in renin-secreting renal tumors and by an intrarenal mechanism influencing intrarenal distribution of blood flow, and, thereby, sodium resorption in chronic renovascular hypertension. The current diagnostic techniques used to determine the presence of renal atery stenosis and its functional significance are reviewed. Arteriographic evidence of renal artery collaterals and a positive differential venous renin ratio are the two parameters whose usefulness and practicality have been best documented in recent years. The results of surgical procedures reported in the world literature show a 50 per cent rate with a further 30 per cent improvement rate in terms of control of hypertension. When functional significance of stenosis is demonstrated before surgical procedures, cure rates of the order of 80 per cent can be achieved. Recent developments of technique of operating room upon less extensive lesions of the renal artery branch extend the possibilities of surgical benefit which should also be considered in the presence of renal failure of renovascular origin.

Calcification of the Adrenal Glands in Young Children: A Report of Three Cases with a Review of the Literature

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