Evaluation of plantar hyperhidrosis in patients undergoing video-assisted thoracoscopic sympathectomy

Background Sympathectomy is the treatment of choice for primary hyperhidrosis. One curious occurrence that is difficult to explain from an anatomophysiological point of view in cases of video-assisted thoracoscopic sympathectomy (VATS) for the treatment of palmar hyperhidrosis (PH) is the observed improvement in plantar hyperhidrosis (PLH). Nevertheless, current reports on VATS rarely describe the effect on PLH or just give superficial data. The aim of this study was to prospectively investigate, how surgery affects PLH in patients with PH and PLH over one-year period. Methods From May 2003 to January 2004, 70 consecutive patients with combined PH and PLH underwent VATS at the T2, T3, or T4 ganglion level (47 women and 23 men, with mean age of 23 years). Results Immediately after the operation, all the patients said they were free from PH episodes, except for two patients (2.8%) who suffered from continued PH. Compensatory hyperhidrosis (CH) of various degrees was observed in 58 (90.6%) patients after one year. Only 13 (20.3%) suffered from severe CH. There was a great initial improvement in PLH in 50% of the cases, followed by progressive regression, such that only 23.4% still presented that improvement after one year. The number of cases without overall improvement increased progressively (from 17.1% to 37.5%) and the numbers with slight improvement remained stable (32.9–39.1%). Of the 24 patients with no improvement after one year, 6 patients graded plantar sweating worse. Conclusion Patients with PH and PLH who undergo VATS to treat their PH present a good initial improvement in PLH that reduces to a lower level of improvement after the one-year period.     

Neuroblastoma of the Anterior Mediastinum in an 80-Year-Old Woman

A 7-cm anterior mediastinal tumor in an 80-year-old woman was found by light and electron microscopy to be a neuroblastoma. Immunoreactivity for neuron-specific enolase, synaptophysin, and chromogranin supported the diagnosis. Neuroblastoma is an uncommon tumor in adults and we are not aware of a previous report of such a tumor in a patient of this age.     

Single breath-holding scans of the abdomen using FISP and FLASH at 1.5 T

Single breath-holding gradient echo techniques fast imaging with steady-state free precession (FISP) and fast low angle shot (FLASH) images were evaluated in the study of the abdomen in 16 patients (13 liver, two kidney, and one pancreas examinations). Gradient echo images were compared retrospectively with conventional spin echo images for image quality (depiction of pathology and representation of anatomic detail), and contrast characteristics were evaluated. All lesions were shown on gradient echo images, and in three of 16 cases gradient echo images were more diagnostic than spin echo images. On both FISP and FLASH images, most hepatic metastases were hyperintense relative to normal liver. The predicted flip angles for maximal contrast for the liver were modeled from signal intensity equations for FISP and FLASH and yielded predicted flip angles of approximately 40-55 degrees for FISP and 15-25 degrees for FLASH. Peak signal-to-noise ratio in liver of normal volunteers occurred at approximately 30 degrees for both FISP and FLASH. Single breath-holding gradient echo images are useful in the evaluation of abdominal structures and this study provides a framework for future work.     

Decisions near the end of life.

Designing behavior change programs and evaluating their effects on patient care has been a persistent challenge in research on continuing medical education. The challenge becomes even more complex when we aim to change behaviors that are interactive and highly influenced by the formal and informal institutional context. The authors describe an interdisciplinary continuing education program in bioethics that is designed to effect just such behaviors. The program aims to help hospital and long-term care facilities improve their ability to resolve the ethical dilemmas inherent in terminal care decisions. Targeted to interdisciplinary groups of physicians, nurses, social workers, pastoral counselors, and administrators, Decisions Near the End of Life will provide strategies and tools for examining institutional policies and team practices as well as more traditional information, education, and skill building. The authors describe the program's rationale and design, and raise questions about the potential for developing interdisciplinary, action-oriented CME on other topics.     

The effect of omitting botulinum toxin from the lower eyelid in blepharospasm treatment

We randomly selected 26 patients with essential blepharospasm to receive either botulinum toxin or saline injection in their lower eyelids to evaluate the necessity of lower eyelid injection to relieve blepharospasm. As diplopia may occur from botulinum toxin injections for blepharospasm, most commonly from injection of the lower eyelid, and surgical relief of blepharospasm is often achieved by excision of only the upper eyelid protractors, omission of toxin from the lower eyelid seemed both desirable and possible. All patients received botulinum toxin in the upper eyelids, above the eyebrows, across the glabella, and near the lateral canthus. Thirteen of 15 patients who received saline in their lower eyelids had relief of spasm, with the same spasm-free interval as those who received toxin. We recommend avoiding injection of toxin in the medial two thirds of the lower eyelid in order to diminish the likelihood of diplopia from inferior oblique muscle paresis.     

Intrathecal baclofen for intractable spinal spasticity--a double-blind cross-over comparison with placebo in 6 patients.

A group of six subjects with intractable spinal spasticity completed a double-blind cross-over paradigm in which they received two intrathecal bolus injections of baclofen solution five hours apart on two different days and two intrathecal bolus injections of placebo saline five hours apart on two other days. Each subject was repeatedly tested with a battery of clinical and physiological tests. In contrast to the placebo injections, the group responded to the baclofen injections with subjective and objective, clinically significant improvement in parameters of spasticity in their lower limbs, including muscle tone, frequency of spasms, hyperreflexia and passive range of joint motion. Furthermore, this improvement was maintained following thirty consecutive days of intrathecal bolus injections of baclofen at a fixed dose.