Complex fractures of the clivus: diagnosis with CT and clinical outcome in 11 patients

During a 20-month period, fractures of the clivus occurring after craniocerebral trauma were diagnosed with computed tomography (CT) in 11 patients. Five patients had longitudinally oriented fractures; these were fatal in four patients due to either vertebral-basilar artery occlusion, brain stem trauma, or both. Six other patients had transversely oriented fractures that extended through the carotid canal and petrous temporal bone. While less frequently contributing directly to mortality, transverse fractures were also associated with cerebrospinal fluid leaks (two patients) and a cavernous sinus-carotid fistula (one patient). They were not as frequently associated with Horner syndrome or cranial nerve deficits as suggested in the current literature. This retrospective evaluation reveals two distinct injury patterns that demonstrate a difference in related morbidity and mortality.     

Q fever (Coxiella burnetii) causing an infected thoracoabdominal aortic aneurysm

We report a patient, which we believe is the first, with a thoracoabdominal aortic aneurysm, Crawford type IV, caused by Q fever (Coxiella burnetii). Treatment consisted of antibiotic therapy started preoperatively and continued postoperatively and an open repair, including resection of the infected aneurysm, replacement with a rifampin-soaked polyester graft, and an omental wrap covering the grafts. After 13 months of follow-up, the patient had no signs of infection, and results of laboratory findings were normal.     

Pruritus in liver disease. Pathogenesis and treatment

Pruritus is a severe symptom in patients with cholestatic hepatobiliary disease; it can greatly reduce the quality of life. Cholestatic itching often peaks in the evening and early night. It mainly occurs on the palms of the hands and soles of the feet but can also occur more generalised. The pathogenesis of cholestatic pruritus has not yet been completely clarified. Possible contributors are bile salts, histamine, progesterone metabolites and opioids. A relationship between these elements and the intensity of the itch has not, however, been demonstrated. Autotaxin, an enzyme that produces lysophosphatidic acid, has recently been identified as a possible pruritogen caused by cholestasis. Treatment is aimed at eliminating pruritogens with bile acid sequestrants (cholestyramine), managing the metabolism of pruritogens (rifampicin), and influencing the perception of itch by the central nervous system with μ-opioid antagonists or SSRIs. In cases of unbearable, treatment-resistant itching, consideration may be given to experimental therapies such as UV light therapy or nasobiliary drainage.     

Endothelial glycocalyx thickness and platelet-vessel wall interactions during atherogenesis

The endothelial glycocalyx (EG), the luminal cover of endothelial cells, is considered to be atheroprotective. During atherogenesis, platelets adhere to the vessel wall, possibly triggered by simultaneous EG modulation. It was the objective of this study to investigate both EG thickness and platelet-vessel wall interactions during atherogenesis in the same experimental model. Intravital fluorescence microscopy was used to study platelet-vessel wall interactions in vivo in common carotid arteries and bifurcations of C57bl6/J (B6) and apolipoprotein E knock-out (ApoE-/-) mice (age 7 - 31 weeks). At the same locations, EG thickness was determined ex vivo using two-photon laser scanning microscopy. In ApoE-/- bifurcations the overall median level of adhesion was 48 platelets/mm2 (interquartile range: 16 - 80), which was significantly higher than in B6 bifurcations (0 (0 - 16), p = 0.001). This difference appeared to result from a significant age-dependent increase in ApoE-/- mice, while no such change was observed in B6 mice. At the same time, the EG in ApoE-/- bifurcations was significantly thinner than in B6 bifurcations (2.2 vs. 2.5 μm, respectively; p < 0.05). This resulted from the fact that in B6 bifurcations EG thickness increased with age (from 2.4 μm in young mice to 3.0 μm in aged ones), while in bifurcations of ApoE-/- mice this growth appeared to be absent (2.2 μm at all ages). During atherogenesis, platelet adhesion to the wall of the carotid artery bifurcation increases significantly. At the same location, EG growth with age is hampered. Therefore, glycocalyx-reinforcing strategies could possibly ameliorate atherosclerosis.     

Pathophysiology and current management of pruritus in liver disease

Pruritus is frequently reported by patients with cholestatic hepatobiliary diseases such as primary biliary cirrhosis, primary sclerosing cholangitis, intrahepatic cholestasis of pregnancy and hereditary cholestatic syndromes, but may accompany almost any other liver disease. Increased concentrations of bile salts, histamine, progesterone metabolites or endogenous opioids have been controversially discussed as potential pruritogens in cholestasis in the past. Most recently, novel insights unravelled lysophosphatidic acid (LPA), a potent neuronal activator, as a potential pruritogen in pruritus of cholestasis. Nevertheless, the pathogenesis of pruritus in cholestasis is still not clearly defined and current antipruritic treatment strategies provide relief only in a part of the affected patients. Based on recent experimental and clinical findings, this review outlines the actual insight in pathogenesis of pruritus in cholestasis and summarizes evidence-based and experimental therapeutic interventions for cholestatic patients suffering from itch.     

n-3 fatty acids, ventricular arrhythmia-related events, and fatal myocardial infarction in postmyocardial infarction patients with diabetes

OBJECTIVE

We carried out a secondary analysis in high-risk patients with a previous myocardial infarction (MI) and diabetes in the Alpha Omega Trial. We tested the hypothesis that in these patients an increased intake of the n-3 fatty acids eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and α-linolenic acid (ALA) will reduce the incidence of ventricular arrhythmias and fatal MI.

RESEARCH DESIGN AND METHODS

A subgroup of 1,014 post-MI patients with diabetes aged 60–80 years was randomly allocated to receive one of four trial margarines, three with an additional amount of n-3 fatty acids and one placebo for 40 months. The end points were ventricular arrhythmia–related events and fatal MI. The data were analyzed according to the intention-to-treat principle, using multivariable Cox proportional hazards models.

RESULTS

The patients consumed on average 18.6 g of margarine per day, which resulted in an additional intake of 223 mg EPA plus 149 mg DHA and/or 1.9 g ALA in the active treatment groups. During follow-up, 29 patients developed a ventricular arrhythmia–related events and 27 had a fatal MI. Compared with placebo patients, the EPA-DHA plus ALA group experienced less ventricular arrhythmia–related events (hazard ratio 0.16; 95% CI 0.04–0.69). These n-3 fatty acids also reduced the combined end-point ventricular arrhythmia–related events and fatal MI (0.28; 0.11–0.71).

CONCLUSIONS

Our results suggest that low-dose supplementation of n-3 fatty acids exerts a protective effect against ventricular arrhythmia–related events in post-MI patients with diabetes.There is strong evidence from prospective cohort studies and randomized trials that >250 mg/day of the fish fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) will reduce fatal coronary heart disease (CHD) by as much as 36% (1). There is also evidence, although less conclusive, that EPA-DHA reduces sudden death (2,3). Prospective cohort studies have provided evidence that the plant food–derived n-3 fatty acid α-linolenic acid (ALA) may reduce fatal CHD (4). Animal experiments showed that n-3 fatty acids reduce the vulnerability to cardiac arrhythmias (5). The Alpha Omega Trial tested the hypothesis that an additional intake of 0.4 g/day of EPA-DHA or 1.9 g/day of ALA will reduce fatal CHD and ventricular arrhythmia–related events in stable postmyocardial infarction (post-MI) patients (6). However, this hypothesis was not confirmed in the main analysis of the trial (7).A post hoc analysis of the Alpha Omega Trial showed that in post-MI patients with diabetes, EPA-DHA reduced both fatal CHD and ventricular arrhythmia–related events by 49% (7). The reduction in these end points was in accord with that obtained in the Gruppo Italiano per lo Studio della Sopravvivenza nell''Infarto miocardico (GISSI)-Prevenzione trial for fatal coronary and sudden death (8). In the Alpha Omega Trial, an even stronger reduction of 61% of ventricular arrhythmia–related events was observed for ALA. This evokes the question of whether post-MI patients with diabetes are particularly susceptible to protective effects of n-3 fatty acids on fatal CHD and ventricular arrhythmia–related events.In a cohort study of diabetic women, a dose-response relation was observed between fish consumption and CHD mortality (9). Women who consumed fish five or more times per week had a 64% lower risk of CHD mortality compared with those who consumed fish less than once per month. In a trial of heart failure patients with diabetes, a supplement of 0.9 g EPA-DHA per day reduced the composite end point of all-cause mortality or admission to the hospital for cardiovascular reasons significantly with 11% (10). Although evidence of the effect of fish consumption and EPA-DHA supplementation on fatal CHD in patients with diabetes is small, the available data are compatible with the hypothesis that EPA-DHA may protect against fatal CHD.The life expectancy of a 50-year-old patient with diabetes is 6 years shorter than that of a person without diabetes (11). This difference is largely due to an increased risk of macrovascular diseases among diabetic patients. In addition, they have an increased risk of fatal CHD (12) and an increased risk of sudden death (13,14). A previous MI in combination with diabetes especially makes patients prone to fatal CHD and ventricular arrhythmia–related sudden death (12,15). Therefore, post-MI patients with diabetes are a suitable group to test the hypothesis that n-3 fatty acids protect against fatal CHD and ventricular arrhythmia–related events.Overlap in the definitions of ventricular arrhythmia–related events and in fatal CHD was present in the main publication of the results of the Alpha Omega Trial (7). Both end points included fatal cardiac arrest and sudden death. In the present analysis, mutually exclusive definitions will be used; therefore, fatal CHD is limited to fatal MI. In the main publication, the two groups that received EPA-DHA were compared with the two groups that did not receive EPA-DHA. The same strategy was used for ALA. This was done because in the analysis of the primary end-point major cardiovascular events, the cumulative incidence of the four treatment groups did not differ. Here we present the results of an in-depth analysis of the effects of different n-3 fatty acids compared with placebo on ventricular arrhythmia–related events and fatal MI in stable post-MI patients with diabetes.