Delleman syndrome: anesthetic implications

An infant with oculocerebrocutaneous (Delleman) syndrome (1), only 26 cases of which have been reported (2), presented with focal alopecia of scalp, periorbital skin appendages, hypertrophy of the skin (Fig. 1A), left-sided orbital cyst, lid coloboma, cleft palate (Fig. 1B), neonatal seizures, cerebral hemiatrophy, multiple intracranial cystic spaces, and enlarged lateral ventricles. The anomalies often require multiple anesthetics for examination of the eye, drainage of the orbital cyst, repair of lid coloboma, enucleation of the eye, excision of skin tags, and repair of cleft palate. Although this infant's perioperative course was uneventful, he had significant preoperative problems, such as neonatal seizures and an episode of aspiration pneumonia. Because the Delleman syndrome is rare, this case is presented to illustrate possible anesthetic implications of the disease.     

The aging process. Physiologic changes and pharmacologic implications

Age-related physiologic changes are important to consider when making diagnostic and therapeutic decisions. Such changes begin in the fifth decade and continue at varying rates depending on the organ system involved. Physicians need to be aware of the ramifications of the aging process, especially with regard to decreased functional reserve and changes in drug actions. The concept of homeostenosis implies that a functional elderly person may maintain health into old age but become increasingly vulnerable to stress and illness because of a lack of physiologic reserve. Thoughtful clinical application of this concept improves purely medical outcomes and surely enhances patients' quality of life in their later years.     

Inhalatory anesthetic (halothane) associated changes in the immune response in mice

The extent of surgery, the patient's age, health status and other factors may contribute to alteration of the immune system during anesthesia and surgery. In addition, inhalatory anesthetics may cause acute and chronic toxicity because of the production of intermediate and end metabolic compounds. The present work was undertaken to evaluate, both in vivo and in vitro, if repeated doses of halothane were able to affect the immune response in a murine model developed at our laboratory. Weekly doses of halothane were administered to mice subjected to no surgery and three days after the last anesthetic-exposure, several immunologic parameters were assessed. Results on the in vivo response to sheep red blood cells showed that halothane treatment increased the amount of specific antibody secreting B-cells, without affecting the delayed type hypersensitivity reaction to the same antigen. In vitro studies on spleen cell composition showed that halothane re-exposure diminished the number of CD4+, CD8+ and B-cells. Such changes were not translated into alterations on the mitogen-driven lymphoproliferation, as well as macrophage phagocytic and lytic functions. Our results indicate that halothane re-exposure is able to modulate the immune response affecting both the number of antibody secreting cells involved in a specific in vivo response, and the splenic lymphoid cell composition. Since such halothane-induced immune alterations might bias the results of a wide range of physiological research, even those involving other systems, a careful selection of the anesthetic agent and methods by which the compound is administered is advisable.     

Common variable immunodeficiency associated with autoimmune thrombocytopenia: anesthetic management

A 44-year-old man diagnosed of common variable immunodeficiency associated with thrombopenia due to autoimmunity required anesthesia for anal fissure repair and hemorrhoidectomy. Hemostatic complications developed after surgery, with extreme thrombopenia (1,000 platelets/pl) and analytical changes that necessitated administration of six units of platelets from apheresis, as well as immunoglobulins, antifibrinolytic agents (e-aminocaproic acid) and granulocytic colony stimulating factors. Anesthesia for such patients is reviewed, with emphasis on careful management of the airways, preparation of sufficient material for surgery (rapid transfusion equipment, large caliber intravenous catheters, sterile material) and orientation of anesthetic technique toward general anesthesia through a laryngeal mask.     

Adaptive changes in lipid composition of skeletal sarcoplasmic reticulum membranes associated with aging

We have undertaken a detailed examination of changes associated with aging in lipid composition and corresponding physical properties of hindlimb skeletal sarcoplasmic reticulum (SR) membranes isolated from young (5 months), middle-aged (16 months), and old (28 months) Fischer strain 344 rats. Silica gel HPLC chromatography was used to separate phospholipid headgroup species. Subsequent reversed-phase HPLC was used to resolve fatty acid chain compositions of phosphatidylcholine, phosphatidylethanolamine, and phosphatidylinositol species. For all three phospholipid pools, significant age-related variations are observed in the abundance of multiple molecular species, particularly those having polyunsaturated fatty acid chains. Using mass spectrometry (fast atom bombardment and tandem techniques) to distinguish ester- from ether-linked phosphatidylethanolamine species, we demonstrate that overall plasmenylethanolamine content is substantially increased with age, from 48 mol% to 62 mol%. A substantial increase is also observed in the single molecular species 18:0-20:4 phosphatidylinositol suggesting implications for signalling pathways. In addition, associated with senescence we find a significant increase in the rigidifying lipid, cholesterol. Despite these changes in lipid composition of different aged animals, the average bilayer fluidity examined at several bilayer depths with stearic acid spin labels, is not altered. Neither do we find differences in the rotational mobility of maleimide spin-labeled Ca(2+)-ATPase, as determined from saturation-transfer electron paramagnetic resonance, which is sensitive to both the fluidity of lipids directly associated with the Ca(2+)-ATPase and to its association with proteins.     

Conjunctival changes associated with glaucoma therapy: implications for the external disease consultant and the treatment of glaucoma

PURPOSE: Enhance recognition by the external disease specialist of the conjunctival changes associated with glaucoma therapy and the reported association with glaucoma filtration surgery. METHODS: Literature search with emphasis on the cellular and subcellular changes induced by antiglaucoma medications, the definition and diagnosis of drug-induced cicatricial conjunctivitis (DICC), and the implications for future glaucoma therapy or surgery. RESULTS: Significant conjunctival and subconjunctival changes occur associated with the use of antiglaucoma medications that affect the success of glaucoma filtration surgery. The extreme form of change is the DICC, which is clinically and pathologically identical to ocular cicatricial pemphigoid. The autoantigen in the basement membrane probably differs in these two disease processes. CONCLUSIONS: There is a movement toward an earlier approach to glaucoma filtration surgery, in large part based on the literature reviewed here. The external disease specialist needs to be cognizant of these conjunctival changes to best consult on patients receiving antiglaucoma medications.     

Cardiovascular malformations associated with choanal atresia

In this study, cardiovascular malformations were present in 11 of 63 (17.5%) patients with choanal atresia. The most frequently encountered cardiac lesions were ventricular septal defect and patent ductus arteriosus, while cyanotic heart disease was uncommon.     

Accelerated aging of dermal fibroblast-like cells from the senescence-accelerated mouse (SAM): acceleration of changes in DNA ploidy associated with in vitro cellular aging

Accelerated changes in the DNA ploidy associated with in vitro aging were examined in fibroblast-like cells isolated from the dorsal dermis of newborn SAMP11 (accelerated senescence-prone, short-lived) mice, and were compared to changes observed in cell lines from SAMR1 (accelerated senescence-resistant, long-lived) mice. Flow cytometric analysis of the DNA content in confluent cells and chromosome analysis in mitoses revealed that the diploid cells were being replaced with tetraploid cells until a growth crisis; thereafter, hypotetraploid cells became predominant, accompanied by immortalization. The number of mitoses decreased as the crisis ensued, then increased. Although these changes were observed in the cell lines from both strains of mice, the changes occurred more rapidly and at earlier population doublings in the cell lines from the SAMP11 mice. These results suggest that the cell lines from SAMP11 mice might have higher susceptibility to factors that cause polyploidization, including oxidative stress.     

Estrogen, the ovary, and neutotransmitters: factors associated with aging

Our studies in the C57BL/6J mouse have been designed to examine the interactions of aging and the ovary, and their mutual effects on neuroendocrine function. In the pituitary, ovarian status and not age determines responsiveness to gonadotropin hormone releasing hormone (GnRH), but estrogen (E2) is an important mediator in CNS changes, and removal of the ovary (OVX) is deleterious to the neuroendocrine hypothalamus. OVX for just six days in young animals results in synaptic loss between noradrenergic terminals and gonadotropin hormone releasing hormone (GnRH) neurons. Long-term OVX, hypothesized to protect against neuroendocrine aging, fails to guard against any studied age-related changes. Some age-related changes occur as early as midlife. Although neuron number remains constant at middle age, opiatergic neurons undergo significant functional changes by producing opiate antagonist peptides. This change appears to be caused by alterations in the prohormone convertases, which cleave propeptide to peptide. Altered peptides may trigger the loss of reproductive capacity. The midlife shift in opiate peptide production is a component of natural developmental processes that begin in the neonate and continue through old age. In the cholinergic system, E2 mediates numbers of cholinergic receptors, cholinergic neurons, and cholinergic-modulated memory systems in both young and old animals. Regardless of age, ovarian steroids, if present at physiologic levels, are beneficial to the neuroendocrine CNS, and long-term deprivation from ovarian-produced factors is deleterious in the systems we have examined. Our studies have shown that deprivation from ovarian steroid hormones in the female appears to be a major factor in the health of the CNS and in events associated with aging.     

Telomerase and the aging cell: implications for human health

Recent research has shown that inserting a gene for the protein component of telomerase into senescent human cells reextends their telomeres to lengths typical of young cells, and the cells then display all the other identifiable characteristics of young, healthy cells. This advance not only suggests that telomeres are the central timing mechanism for cellular aging, but also demonstrates that such a mechanism can be reset, extending the replicative life span of such cells and resulting in markers of gene expression typical of "younger" (ie, early passage) cells without the hallmarks of malignant transformation. It is now possible to explore the fundamental cellular mechanisms underlying human aging, clarifying the role played by replicative senescence. By implication, we may soon be able to determine the extent to which the major causes of death and disability in aging populations in developed countries-cancer, atherosclerosis, osteoarthritis, macular degeneration, and Alzheimer dementia--are attributable to such fundamental mechanisms. If they are amenable to prevention or treatment by alteration of cellular senescence, the clinical implications have few historic precedents.     

The aging population: implications for the burden of neurologic disease

Two cDNA clones encoding ribonuclease F1 (EC 3.1.27.3) have been isolated using a probe prepared by polymerase chain reaction with primers designed on the basis of amino acid sequence of the enzyme. They derived probably from the same gene and contained 393-base pair open reading frame encoding 131 amino acid residues (Mr 13,606) including a putative 25-residue signal peptide. The sequences of 43-base pair 5'-untranslated region and 125-base pair 3'-untranslated region including a poly(A) tail of 25 nucleotides were also elucidated. Homology analyses showed that cDNA for ribonuclease F1 has 65% homology to that for ribonuclease T1 in the coding region. At the preprotein level, they share 53% homology.     

Cardiovascular abnormalities associated with human and rodent obesity

Obesity is a major risk factor for cardiovascular disease. However, a direct link between these two states is difficult to establish, since obesity frequently occurs with other disease states such as diabetes, hypertension and atherosclerosis. Clinical studies have clearly shown that uncorrected obesity is associated with cardiac hypertrophy and compromised ventricular function. A number of rodent models of obesity have been studied in terms of cardiovascular adaptations. Cardiac function of the obese Zucker rat appears to be normal at a younger age. Only after several months is depression in cardiac function discernable. These animals are mildly hypertensive, but do not exhibit the characteristic increase in cardiac output associated with human obesity. A unique characteristic of JCR:LA-cp rat is that they develop atherosclerotic and myocardial lesions. Hearts from these animals will maintain normal function when perfused with physiological levels of calcium. At higher calcium concentrations, however, mechanical function becomes impaired. Dietary-induced obese rats exhibit many of the hemodynamic alterations associated with human obesity, but there is no evidence to-date that these animals will develop severe cardiac depression. Short-term weight reduction apparently has beneficial cardiovascular effects, but weight cycling may be harmful. Given the widespread occurrence of obesity, further studies are warranted to characterize the cardiac manifestations of this condition.     

Mitochondrial DNA deletions associated with aging and presbyacusis

BACKGROUND: The membrane hypothesis of aging proposes an association between reactive oxygen metabolites and aging processes. Reactive oxygen metabolites are a normal by-product of oxidative phosphorylation and are also formed under conditions of ischemia, hypoperfusion, and as a result of environmental contaminants. Among the many detrimental activities of reactive oxygen metabolites, also known as free oxygen radicals, is direct damage to mitochondrial DNA. Progressive accumulation of mitochondrial DNA damage renders cells unable to conduct oxidative phosphorylation reactions effectively, thereby leading to a bioenergetically deficient cell. Over time, mitochondrial DNA damage accumulates and leads to cellular dysfunction with subsequent organ failure, aging, and ultimately, death. This sequence forms the basis of the membrane hypothesis of aging. OBJECTIVE: To determine if the membrane hypothesis of aging may be involved in the development of presbyacusis. DESIGN: Fischer rats from 4 age groups were tested for auditory sensitivity using the auditory brainstem response. Brain, stria vascularis, and auditory nerve tissues were harvested and mitochondrial DNA was amplified to identify the highly conserved cytochrome b and ND1-16S ribosomal RNA segment of the NADH genes, as well as a 4834-base pair (bp) deletion associated with aging. SUBJECTS: Fischer rats (n=28) from 4 age groups were used: young (2-4 months [n=9]), mid-young (9-11 months [n=5]), mid-old (18-20 months [n=5]), and old (30-34 months [n=9]). RESULTS: The results demonstrate a progressive reduction in auditory sensitivity with age. The mitochondrial DNA studies identify a significant increase in the presence of the 4834-bp deletion in the aged subjects compared with the young. CONCLUSIONS: These findings raise the possibility that the 4834-bp deletion may be associated with presbyacusis, as well as with aging.     

Cardiovascular toxicity of nicotine: implications for nicotine replacement therapy

This review discusses the known cardiovascular effects of smoking and the effects of nicotine without tobacco smoke and interprets the available data on cardiovascular risk during nicotine replacement therapy (NRT). Nicotine gum and patches are now approved for over the counter sale in the United States. Smokers with cardiovascular disease are advised to seek physician counseling before using nicotine products, but information regarding the safety of these products in such patients is not readily available to most physicians. Nicotine may contribute to cardiovascular disease, presumably by hemodynamic consequences of sympathetic neural stimulation and systemic catecholamine release. However, there are many potential cardiovascular toxins in cigarette smoke other than nicotine. The doses of nicotine obtained by regular cigarette smoking generally exceed those delivered by NRTs, and the cardiovascular effects of nicotine are, in general, more intense when delivered rapidly by cigarette smoking than the slower delivery by transdermal nicotine or nicotine gum. Because the dose-cardiovascular response relation for nicotine is flat, the effects of cigarette smoking in conjunction with NRT are similar to those of cigarette smoking alone. Cigarette smoking increases blood coagulability, a major risk factor for acute cardiovascular events, whereas transdermal nicotine does not appear to do so. Clinical trials of NRT in patients with underlying, stable coronary disease suggest that nicotine does not increase cardiovascular risk. At worst, the risks of NRT are no more than those of cigarette smoking. The risks of NRT for smokers, even for those with underlying cardiovascular disease, are small and are substantially outweighed by the potential benefits of smoking cessation.     

Structural changes in the oligosaccharide moiety of human IgG with aging

In order to elucidate the relationship between glycosylation of IgG and aging, oligosaccharide structures of human IgG purified from sera of men and women aged 18 to 73 years were investigated. Oligosaccharides were liberated quantitatively from IgG by hydrazinolysis followed by N-acetylation and were tagged with p-aminobenzoic acid ethyl ester. The oligosaccharide structures were then analyzed by HPLC in conjunction with sequential exoglycosidase digestion. All IgG samples were shown to contain a series of biantennary complex type oligosaccharides which consisted of +/-Galbeta1-4GlcNAcbeta1-2Manalpha1-6(+/-GlcNAcbeta 1-4)(+/-Galbeta1-4GlcNAcbeta1-2Man(alpha)1-3)Man(beta)1-+ ++4GlcNAcbeta1-4(+/- Fucalpha1-6)GlcNAc and their mono- and disialo glycoforms in different ratios. In female IgG samples only, the incidence of non-galactosylated oligosaccharides with non-reducing terminal GlcNAc residues increased with aging (r>0.8), whereas that of digalactosylated oligosaccharides decreased (r<-0.8). A weaker correlation was observed between aging and the incidence of neutral and monosialo oligosaccharides in female IgG (r=0.461 and r= -0.538, respectively) and between aging and the incidence of oligosaccharides with a bisecting GlcNAc in both male and female IgG samples (r=0.566 and r=0.440, respectively). In addition, a significant change with aging in the galactosylation of IgG oligosaccharides was observed in females in their thirties, fifties, and sixties (p<0.02, p<0.01, and p<0.04, respectively). These findings may contribute to our understanding of autoimmune diseases such as rheumatoid arthritis in which glycosylation is involved.     

Structural changes with aging in cortical bone of the human tibia

Structural modifications are considered to play a significant role in the age-related alterations of bone quality and strength. Senescent compact bone is characterized by an increasing heterogeneity of aspects, including high numbers of lowly mineralized osteons as well as the presence of osteons with hypermineralized lamellae or with a notched haversian canal wall, and of double-zone osteons. These latter three types of osteons are different from the structures involved in the haversian remodeling. In the present study, blocks of midshaft tibia from 7 young men (18-39 years), 14 aged men (50-92 years) and 15 aged women (57-96 years) were embedded in methyl methacrylate in order to perform microradiographic and histomorphometric analysis of undecalcified sections. The intracortical porosity was higher in the aged men than in the young ones, as were the numbers of haversian structures and, to a lesser extent, the diameters of the haversian canals. The aged women showed the same tendency, with cortical porosity still higher than in the men. The osteons with hypermineralized lamellae, those with a notched canal and the double-zone osteons appear to constitute large subgroups of the total haversian population, even in the early adult life. Among them, only the osteons with a notched canal wall increased in frequency with age. The 3 types are much more numerous than the structures involved in the typical haversian remodeling. The correlations between their frequencies as well as their significant topographic association corroborates the hypothesis that the hypermineralized lamellae may crumble down because of their excessive brittleness, giving rise to the haversian canals with notched walls. These enlarged canals could be refilled by bone apposition and result in the double-zone osteons. The 3 types of osteons could constitute different steps of one mechanism of bone desintegration and repair occurring very progressively, which might contribute to modify the bone quality and to increase the intracortical porosity.     

Histological and electrophysiological changes of the lower motor neurone with aging

In 499 patients operated on for cataract, the clinical postoperative signs of extraocular inflammation (conjunctival hyperaemia, chemosis, discharge and oedema of the lids), the number of infiltrates around the corneoscleral sutures, and the severity of intraocular inflammation in the anterior chamber (aqueous-flare) were assessed on the fourth postoperative day and correlated with the bacterial conjunctival flora examined both qualitatively and quantitatively on the same day. Patients with potential pathogens (Staphylococcus aureus, gram-negative bacilli and streptococci) on the conjunctiva following operation did not show any increased inflammatory reactions when compared with those without such pathogen. The quantity of bacteria, i.e. number of colonies, did not appear to play a role. The reasons are discussed. The clinical postoperative inflammatory signs were further correlated with the following factors: surgical complications, quality of suturing technique, use of alpha chymotrypsin, systemic disease, sex and age. A positive correlation was found between the severity of extraocular inflammation and retained lens material and hyphaema. Furthermore, extraocular reactions were more severe in males than in females. The incidence of infiltrates around corneoscleral sutures was found to vary with age, i.e. occurred more frequently in patients less than 60 years. No relationship was found between the severity of aqueous-flare and the above mentioned factors.