Anesthetic Management for Cesarean Delivery in a Patient with a Gigantic Intracranial Tumor.

A 31-year-old G5P1 patient with unremarkable past medical history at 29 weeks of gestation was diagnosed with a gigantic left frontotemporal brain mass. Initial clinical management as an inpatient achieved an improvement in the symptoms. The patient and surgical team agreed to schedule a cesarean delivery at 32 weeks of gestation if no neurological deterioration was observed. Intraoperative course with general endotracheal anesthesia and bilateral transversus abdominis plane block was uneventful and promoted efficient postoperative pain control. Seven days after delivery, the patient underwent craniotomy for brain tumor resection. This report describes the anesthetic management of a patient with an intracranial tumor during pregnancy.

Identification of optimal reference genes for RT-qPCR in the rat hypothalamus and intestine for the study of obesity.

BACKGROUND: Obesity has a complicated metabolic pathology, and defining the underlying mechanisms of obesity requires integrative studies with molecular end points. Real-time quantitative PCR (RT-qPCR) is a powerful tool that has been widely utilized. However, the importance of using carefully validated reference genes in RT-qPCR seems to have been overlooked in obesity-related research. The objective of this study was to select a set of reference genes with stable expressions to be used for RT-qPCR normalization in rats under fasted vs re-fed and chow vs high-fat diet (HFD) conditions. DESIGN: Male long-Evans rats were treated under four conditions: chow/fasted, chow/re-fed, HFD/fasted and HFD/re-fed. Expression stabilities of 13 candidate reference genes were evaluated in the rat hypothalamus, duodenum, jejunum and ileum using the ReFinder software program. The optimal number of reference genes needed for RT-qPCR analyses was determined using geNorm. RESULTS: Using geNorm analysis, we found that it was sufficient to use the two most stably expressed genes as references in RT-qPCR analyses for each tissue under specific experimental conditions. B2M and RPLP0 in the hypothalamus, RPS18 and HMBS in the duodenum, RPLP2 and RPLP0 in the jejunum and RPS18 and YWHAZ in the ileum were the most suitable pairs for a normalization study when the four aforementioned experimental conditions were considered. CONCLUSIONS: Our study demonstrates that gene expression levels of reference genes commonly used in obesity-related studies, such as ACTB or RPS18, are altered by changes in acute or chronic energy status. These findings underline the importance of using reference genes that are stable in expression across experimental conditions when studying the rat hypothalamus and intestine, because these tissues have an integral role in the regulation of energy homeostasis. It is our hope that this study will raise awareness among obesity researchers on the essential need for reference gene validation in gene expression studies.

Improvements in hippocampal-dependent memory and microglial infiltration with calorie restriction and gastric bypass surgery, but not with vertical sleeve gastrectomy.

BACKGROUND: Much recent evidence suggest that obesity and related comorbidities contribute to cognitive decline, including the development of non age-related dementia and Alzheimer's disease. Obesity is a serious threat to public health, and few treatments offer proven long-term weight loss. In fact, bariatric surgery remains the most effective long-term therapy to reduce weight and alleviate other aspects of the metabolic syndrome (MetS). Unlike the demonstrated benefits of caloric restriction to prevent weight gain, few if any studies have compared various means of weight loss on central nervous system function and hippocampal-dependent cognitive processes. DESIGN AND RESULTS: Our studies comprise the first direct comparisons of caloric restriction to two bariatric surgeries (Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG)) on cognitive function. Weight loss following caloric restriction, RYGB and VSG was associated with generalized improvements in metabolic health and hippocampal-dependent learning, as measured in the radial arm maze and spontaneous alternation tests. However, VSG-treated rats exhibited deficits on spatial learning tasks in the Morris water maze. In addition, whereas VSG animals had elevated hippocampal inflammation, comparable to that of obese controls, RYGB and calorie-restricted (pair-fed, PF) controls exhibited an amelioration of inflammation, as measured by the microglial protein ionized calcium binding adaptor molecule 1 (IBA1). We also assessed whether GHR (ghrelin) replacement would attenuate hippocampal inflammation in VSG, as post-surgical GHR levels are significantly reduced in VSG relative to RYGB and PF rats. However, GHR treatment did not attenuate the hippocampal inflammation. CONCLUSION: Although VSG was comparably effective at reducing body weight and improving glucose regulation as RYGB, VSG did not appear to confer an equal benefit on cognitive function and markers of inflammation.

Deconstructing obesity: the face of fatness before and after the discovery of leptin.

The prevalence and severity of obesity have increased to epidemic proportions around the globe, and over two-thirds of the US population grapples with either being overweight or obese. Obesity and its comorbidities not only subtract from quality of overall life, but also claim a substantial cost to life. In this edition of 'Then and now', two seminal papers by D.L. Coleman, 'The influence of genetic background on the expression of the obese (ob) gene in the mouse' and 'Effects of parabiosis of obese with diabetes and normal mice', which featured in Diabetologia in 1973, are appraised for their merit and foresight regarding the present eruption of research into what has consequently been labelled 'the metabolic syndrome'. These two studies determined that a then-unknown circulating factor was responsible for the obese/diabetic state of the ob/ob mouse by using a parabiosis model. This circulating factor was later dubbed 'leptin'. The present commentary juxtaposes the astute deduction and simple methods used over 35 years ago and modern research methods as we go forth in our effort to successfully treat and prevent obesity, diabetes and their co-morbidities.

Changes in melanocortin expression and inflammatory pathways in fetal offspring of nonhuman primates fed a high-fat diet.

The hypothalamic melanocortin system, which controls appetite and energy expenditure, develops during the third trimester in primates. Thus, maternal nutrition and health may have a profound influence on the development of this system. To study the effects of chronic maternal high-fat diet (HFD) on the development of the melanocortin system in the fetal nonhuman primate, we placed adult female macaques on either a control (CTR) diet or a HFD for up to 4 yr. A subgroup of adult female HFD animals was also switched to CTR diet during the fifth year of the study (diet reversal). Third-trimester fetuses from mothers on HFD showed increases in proopiomelanocortin mRNA expression, whereas agouti-related protein mRNA and peptide levels were decreased in comparison with CTR fetuses. Proinflammatory cytokines, including IL-1beta and IL-1 type 1 receptor, and markers of activated microglia were elevated in the hypothalamus, suggesting an activation of the local inflammatory response. Fetuses of diet-reversal mothers had normal melanocortin levels. These results raise the concern that chronic consumption of a HFD during pregnancy, independent of maternal obesity and diabetes, can lead to widespread activation of proinflammatory cytokines that may alter the development of the melanocortin system. The abnormalities in the fetal POMC system, if maintained into the postnatal period, could impact several systems, including body weight homeostasis, stress responses, and cardiovascular function. Indeed, the HFD offspring develop early-onset excess weight gain. These abnormalities may be prevented by healthful nutrient consumption during pregnancy even in obese and severely insulin-resistant individuals.

Critical determinants of hypothalamic appetitive neuropeptide development and expression: species considerations.

Over the last decade there has been a striking increase in the early onset of metabolic disease, including obesity and diabetes. The regulation of energy homeostasis is complex and involves the intricate integration of peripheral and central systems, including the hypothalamus. This review provides an overview of the development of brain circuitry involved in the regulation of energy homeostasis as well as recent findings related to the impact of both prenatal and postnatal maternal environment on the development of these circuits. There is surprising evidence that both overnutrition and undernutrition impact the development of these circuits in a similar manner as well as having similar consequences of increased obesity and diabetes later in life. There is also a special focus on relevant species differences in the development of hypothalamic circuits. A deeper understanding of the mechanisms involved in the development of brain circuitry is needed to fully understand how the nutritional and/or maternal environments impact the functional circuitry as well as the behavior and physiological outcomes.

Prenatal development of hypothalamic neuropeptide systems in the nonhuman primate.

In the rodent, arcuate nucleus of the hypothalamus (ARH)-derived neuropeptide Y (NPY) and proopiomelanocortin (POMC) neurons have efferent projections throughout the hypothalamus that do not fully mature until the second and third postnatal weeks. Since this process is likely completed by birth in primates we characterized the ontogeny of NPY and melanocortin systems in the fetal Japanese macaque during the late second (G100), early third (G130) and late third trimesters (G170). NPY mRNA was expressed in the ARH, paraventricular nucleus (PVH), and dorsomedial nucleus of the hypothalamus (DMH) as early as G100. ARH-derived NPY projections to the PVH were initiated at G100 but were limited and variable; however, there was a modest increase in density and number by G130. ARH-NPY/agouti-related peptide (AgRP) fiber projections to efferent target sites were completely developed by G170, but the density continued to increase in the postnatal period. In contrast to NPY/AgRP projections, alphaMSH fibers were minimal at G100 and G130 but were moderate at G170. This study also revealed several significant species differences between rodent and the nonhuman primate (NHP). There were few NPY/catecholamine projections to the PVH and ARH prior to birth, while projections were increased in the adult. A substantial proportion of the catecholamine fibers did not coexpress NPY. In addition, cocaine and amphetamine-related transcript (CART) and alpha-melanocyte stimulating hormone (alphaMSH) were not colocalized in fibers or cell bodies. As a consequence of the prenatal development of these neuropeptide systems in the NHP, the maternal environment may critically influence these circuits. Additionally, because differences exist in the neuroanatomy of NPY and melanocortin circuitry the regulation of these systems may be different in primates than in rodents.

Postnatal development of the hypothalamic neuropeptide Y system.

In the adult rat, arcuate-neuropeptide Y/agouti-related protein neurons have efferent projections throughout the hypothalamus and provide a potent orexigenic stimulus. At birth neuropeptide Y fibers are also present throughout the hypothalamus; however, the source of these fibers has been unknown. The present studies determined the postnatal ontogeny of arcuate-neuropeptide Y fibers into the paraventricular nucleus and dorsomedial hypothalamic nucleus, as well as the ontogeny of neuropeptide Y1 receptor expression within these areas. Agouti-related protein messenger RNA and protein expression was present exclusively in cell bodies in the arcuate throughout postnatal development, starting at P2, and was colocalized in the vast majority of arcuate-neuropeptide Y neurons. This exclusive colocalization of agouti-related protein with arcuate-neuropeptide Y neurons makes it an excellent marker for these neurons and their projections. Even though single-label neuropeptide Y fibers were abundant in the dorsomedial hypothalamic nucleus and paraventricular nucleus as early as P2, arcuate-neuropeptide Y/agouti-related protein fibers did not significantly innervate these areas until P5-6 and P10-11, respectively. In contrast, a portion of the neuropeptide Y fibers within the paraventricular nucleus as early as P2 originated from the brainstem, as indicated by their colocalization with dopamine beta hydroxylase. It remains to be determined if local sources of neuropeptide Y-expressing cells within the dorsomedial hypothalamic nucleus and paraventricular nucleus also contribute to the neuropeptide Y-immunoreactive fibers within these regions prior to the development of arcuate-neuropeptide Y/agouti-related protein projections. In addition to the dramatic change in arcuate-neuropeptide Y/agouti-related protein projections, there is also a striking change in Y1 protein expression in the hypothalamus during the first two postnatal weeks. Taken together these data suggest that the early postnatal period, during which there is a dynamic change in the hypothalamic neuropeptide Y system, may constitute a critical period in the development of this important feeding circuit.