Herodotos Ellinas

Intestinal and hepatic apolipoprotein B gene expression in abetalipoproteinemia

A 20-year-old woman with abetalipoproteinemia underwent orthotopic liver transplantation for cirrhosis, affording access to her liver and small intestine for study. Before transplantation, her plasma apolipoprotein B concentration was less than 1 mg/dL according to enzyme-linked immunosorbent assay, whereas after transplantation her plasma apolipoprotein B concentration was 76 mg/dL (all apolipoprotein B-100). Apolipoprotein B content was reduced in her intestine and liver compared with normal and cirrhotic controls. Cultured hepatocytes from the patients explanted liver secreted a 1.006 g/mL less than or equal to d less than or equal to 1.063 g/mL lipoprotein rich in apolipoprotein E and a 1.063 g/mL less than or equal to d less than or equal to 1.21 g/mL lipoprotein containing apolipoproteins E and A-I with no immunodetectable apolipoprotein B in the culture medium. Normal hepatocytes secreted very low-density lipoprotein and low-density lipoprotein containing apolipoprotein B-100. Abetalipoproteinemic intestinal apolipoprotein B messenger RNA concentration was 4-5-fold higher than control values. However, the patients liver apolipoprotein B messenger RNA level was one fifth that of control normal and cirrhotic liver. Analysis of the patients intestinal and hepatic apolipoprotein B messenger RNA for posttranscriptional stop-codon insertion revealed normally edited transcripts. These results suggest that apolipoprotein B is synthesized as the product of a normally edited messenger RNA transcript, but not secreted, in abetalipoproteinemia.

Case scenario: nerve injury after knee arthroplasty and sciatic nerve block.

T OTAL knee arthroplasty is one of the most common lower extremity surgeries performed in the United States for progressive pain caused by severe arthritis. Anesthetic management for postoperative pain includes intermittent intravenous opioids and patient-controlled analgesia as well as peripheral nerve blockade. Although peripheral nerve blocks have allowed for a reduction of opioid systemic side effects, perioperative nerve injury can be a distressing complication. Anestheticor surgical-related etiologies should be investigated, and patient-specific risk factors such as preexisting neuropathy, diabetes mellitus, extremes of body habitus, male gender, and advanced age taken into consideration.

Ganglion impar block for management of chronic coccydynia in an adolescent

to insert the epidural catheter contributed at least in part to the genesis of the problems encountered. (i) Maximal back flexion was used to identify the epidural space and insert the catheter: this is not only unnecessary to insert an epidural needle between vertebrae but also carries a risk of catheter kinking (and occlusion) in its pathway between the skin and the epidural space when the patient is supine. It also increases the risk of difficulty in removing the catheter. (ii) The skin to epidural space distance of 7 cm (patient’s body mass index: 35) increased further the risk of catheter kinking once the supine position (and so the lumbar lordosis) was resumed. In our own practice, we avoid using maximal back flexion to identify the epidural space: moderate flexion is sufficient, and we had, for years, the opportunity to confirm this with our extensive use of C-arm fluoroscopy for epidural injections in adult chronic pain patients. In case of anatomic anormalities (scoliosis, obesity), either fluoroscopy or ultrasound (2) can be used to identify the best intervertebral pathway. Moreover, we always check catheter patency after the dressing when the patient is still on its side but with no back flexion to detect catheter, connexion or filter occlusion in time. We hope these technical considerations will be helpful to the reader. F R A N C I S V E Y C K E M A N S J E A N-L O U I S S C H O L T E S Anesthesiology Cliniques universitaires St Luc, Avenue Hippocrate 10-1821, B 1200 Brussels, Belgium, (email: francis.veyckemans@uclouvain.be)

Combined Nd:YAG laser and bleomycin sclerotherapy under the same anesthesia for cervicofacial venous malformations: A safe and effective treatment option

INTRODUCTION Extensive cervicofacial venous malformations (VM) pose significant challenges to a patients quality of life (altered breathing, dysphagia, dysarthria). Treatment options include: 1) Surgical debulking; 2) Sclerotherapy; 3) laser therapy; or 4) Combined modalities. Recent studies have demonstrated the importance of multimodality and multidisciplinary management of these patients. However, no studies have described combined single anesthetic laser and sclerotherapy treatment. We sought to demonstrate the safety and efficacy of combined Nd:YAG laser and sclerotherapy under the same anesthetic administration. METHODS Retrospective review of 8 patients (Age 6 mo -74 yrs, x͂ 31) with extensive cervicofacial VM with significant airway involvement. Patients were treated with combined suspension laryngoscopy with Nd:YAG laser of airway VM followed by image guided direct puncture sclerotherapy using bleomycin in the airway VM and sodium tetradecyl sulfate (STS) foam in the cervicofacial VM during the same anesthetic encounter. RESULTS All 8 patients had extensive cervicofacial VMs that were symptomatic with snoring or orthopnea. Four of the patients had previously been treated at outside institutions with residual disease or significant complications. All patients remained intubated post procedure (Avg. 1.07 days) and tolerated extubation without re-intubation or any major complications. The average length of hospital stay was 3.2 days, of which 1.9 days were spent in the ICU. Patients reported symptomatic improvement or had decreased VM disease on MRI follow up. CONCLUSION Combined Nd:YAG laser therapy and sclerotherapy allows treatment of both superficial and deep components of VMs in a safe and efficient manner. In addition, suspension laryngoscopy provides improved visualization and access for the interventional radiologist in difficult to reach areas for sclerotherapy.