Marco A. Callejas

Excitability recovery curve of the sympathetic skin response in healthy volunteers and patients with palmar hyperhidrosis.

OBJECTIVES Patients with primary palmar hyperhidrosis (PPH) might exhibit hyperexcitability of the reflex circuits involved in sweating. We hypothesized that this hyperexcitability could become evident in the study of the excitability recovery curve of the sympathetic sudomotor skin response (SSR). METHODS In 10 patients with PPH and 10 healthy volunteers used as control subjects, we recorded the SSR in the palm of the right hand to pairs of median nerve electrical shocks separated by inter-stimuli intervals (ISIs) ranging from 0.5 to 3.5 s. The amplitude of the SSR generated by the second stimulus (SSR2) was expressed as a percentage of that generated by the first (SSR1), and compared between control subjects and patients for each ISI. RESULTS None of the control subjects showed a recovery of the SSR for ISIs of 1.5 s or less. On the contrary, patients showed a statistically significant enhancement of the SSR excitability recovery curve, with onset of recovery at 1.5 s in 5 patients. Two patients showed a double peak response to single electrical stimulation and were not considered in the calculation of the SSR recovery curve. Mean excitability recovery percentages were larger in patients than in control subjects at ISIs of 2, 2.5 and 3 s. CONCLUSIONS The enhancement of the SSR recovery curve in patients with PPH suggests hyperexcitability of the somatosympathetic polisynaptic pathway involved in sweating. This could partly underlie the pathophysiology of PPH.

Mediastinoscopy as an Emergency Diagnostic Procedure in Superior Vena Cava Syndrome

Seven men and one woman (aged 20-70 years) with superior vena cava syndrome underwent diagnostic mediastinoscopy to elucidate the cause, which other, lesser procedures had not identified. Intraoperative frozen-section studies of the biopsy specimens revealed small-cell carcinoma (4 cases), large-cell carcinoma (1), squamous-cell carcinoma (1), large-cell lymphoma (1) and Hodgkins lymphoma (1). Radiotherapy or chemotherapy was initiated within the following 24 hours in six cases. One of the tumors intraoperatively diagnosed as small-cell carcinoma was subsequently reclassified as lymphocytic lymphoma. Complicating hemorrhage from the right carotid artery required median sternotomy in one case and wound infection occurred in another. There was no mediastinoscopy-related mortality. Mediastinoscopy is useful and reliable in the diagnostic emergency posed by the superior vena cava syndrome.

A medical alternative to the treatment of compensatory sweating.

ABSTRACT:  Compensatory sweating after sympathectomy does not have a satisfactory, free‐of‐secondary‐effects treatment. Glycopyrrolate has been successfully used to treat other types of hyperhidrosis. Compensatory sweating after sympathectomy could respond to the topical application of glycopyrrolate. Ten patients were selected with compensatory sweating after sympathectomy. One milliliter of a 2% water solution of topical glycopyrrolate was applied once a day over the affected area and massaged for 30 seconds. Treatment was maintained for 6 weeks. The results were rated using a scale from 1 to 10 of satisfaction at the end of the study. Eight of the 10 treated patients dramatically improved with the topical application of glycopyrrolate. Two patients quit the treatment due to secondary effects (accommodative failure and dry mouth). The results of the study demonstrated that local application of glycopyrrolate might be the treatment of choice for compensatory hyperhidrosis.

Abnormal modulation of electrodermal activity by thermoalgesic stimuli in patients with primary palmar hyperhidrosis

Background The authors examined the effects of thermal stimulation on electrodermal activity (EDA) in patients with primary palmar hyperhidrosis (PPH). The authors hypothesised that temperature changes may induce abnormal sudomotor reactions because of simultaneous activation of sudomotor centres through thermal and emotional pathways, and compared patients before and after thoracoscopic sympathectomy. Methods The authors studied 18 PPH patients and 20 controls. Patients reported subjective evaluation of their symptoms using a visual analogue scale for palmar sweating and for body sweating (bs-VAS). The authors applied focal thermal stimulation to quantify sensory perception and measure ongoing changes in EDA recorded from the palm of the hands. Results Before sympathectomy, patients had lower sensory perception thresholds and higher EDA levels than controls. Increased EDA occurred along the whole test, with no significant modulation by changes in thermal stimulation. Sensory perception normalised after sympathectomy, but thermal modulation of EDA remained abnormal whenever sudomotor activity was present after surgery. There was a significant positive correlation between EDA levels before treatment and the bs-VAS (from r=0.45 to r=0.57). Conclusions Patients with PPH show perceptual abnormalities and exaggerated sudomotor reactions to thermoalgesic stimulation, consistent with central sensitisation of sympathetic circuits. The reduced sympathetic outflow after thoracoscopic sympathectomy induced normalisation of sensory perception, but it did not modify the abnormal control of efferent sudomotor activity.

Resultados del tratamiento videotoracoscópico del blushing

BACKGROUND Involuntary craniofacial erythema, or blushing, due to autonomic dysfunction can be a cause of psychological distress. Although anecdotal reports have suggested that pharmacologic treatments or cognitive behavioral therapy can be used to treat the condition, no rigorous analyses of their efficacy have been reported. OBJECTIVES To assess the efficacy of video-assisted thoracoscopic sympathectomy and to study phobic anxiety and other personality traits in a series of patients with involuntary facial blushing. MATERIALS AND METHODS We carried out a retrospective observational study of patients treated with bilateral video-assisted thoracoscopic sympathectomy for blushing over a 7-year period (2001-2008). All the patients were treated by a dermatologist, a psychologist, and a thoracic surgeon and were informed of the predicted outcomes. RESULTS A total of 204 patients with a mean age of 34 years (range, 15-67 years) were included; the numbers of males and females were similar. Only 10% had unpredicted outcomes; in such cases, either the procedure was insufficiently effective or postoperative reflex sweating developed (and was considered serious in 2%). There were no deaths and only 1 case of transient Horner syndrome. Video-assisted thoracotomy was required for pleural symphysis in 1 patient; 5 patients developed pneumothorax, but only 1 of them required pleural drainage. CONCLUSIONS Video-assisted sympathectomy is a safe, effective and definitive treatment for disabling blushing. Anxiety that is detected before surgery is a reaction to blushing rather than a cause of it.

Enrojecimiento facial súbito incontrolable: tratamiento mediante simpatectomía torácica por videotoracoscopia

Se realiza un estudio clinico en 94 pacientes afectados de blushing a los que se les realizo una simpatectomia toracica endoscopica bilateral. Todos los pacientes fueron visitados por un equipo multidisciplinario (dermatologo, psicologo y cirujano toracico) e informados detalladamente de los efectos secundarios y las expectativas de la intervencion. Los resultados a corto y medio plazo han sido excelentes: un 90,4% mostro un alto indice de satisfaccion; en el resto, el efecto fue solo parcial en un 7,5%, y un 2,1% de los pacientes considero la intervencion insatisfactoria; el aumento de la sudacion en otras areas del cuerpo se produjo en el 75,5% de los pacientes, pero solo en el 3,2% fue grave.

Experiencia en el tratamiento quirúrgico de los tumores primarios malignos de la pared torácica

Resumen Analizamos de manera retrospectiva a 33 pacientes afectados de tumores malignos primarios de la pared toracica, intervenidos quirurgicamente entre enero de 1985 y enero de 2002. Valoramos los resultados de la tecnica quirurgica utilizada, la recurrencia tumoral y la supervivencia de los pacientes. En todos los casos se realizo una reseccion en bloque de la lesion con pretension radical. Se efectuaron 39 resecciones de pared toracica. El numero de arcos costales resecados oscilo entre dos y cinco (media, 2,6). En 27 casos fue necesario reconstruir la pared toracica con protesis de material sintetico, y en cinco de ellos se llevo a cabo, ademas, una mioplastia (cuatro injertos pediculados de musculo dorsal ancho y uno de musculo pectoral mayor). En 6 casos se realizo, ademas, una esternectomia parcial. El seguimiento medio de los pacientes fue de 45,6 meses (rango 3-140 meses). Once pacientes fallecieron a causa del tumor. Los 14 pacientes intervenidos de condrosarcoma tuvieron un seguimiento medio algo inferior (41,5 meses); diez de estos enfermos se hallan actualmente libres de enfermedad y dos han fallecido a consecuencia de la progresion tumoral. La supervivencia actuarial (Kaplan-Meier) a los 5 anos de los pacientes con condrosarcoma (n = 14) fue del 75 ± 21%. El resto de pacientes, exceptuando las fibromatosis agresivas (tumor desmoide) y el paracordoma (n = 14), tuvieron una supervivencia actuarial a los 5 anos del 26 ± 10%.