Is sympathectomy at T4 level better than at T3 level for treating palmar hyperhidrosis?

PURPOSE: We compared the results from a video-assisted thoracoscopic sympathectomy (VTS) at the T4 denervation level with those from a VTS at the T3 level for the treatment of palmar hyperhydrosis (PH). METHODS: Seventy patients with PH were prospectively followed for VTS at the T3 or T4 denervation levels for 6 months. The end points of this study were: absence of PH, compensatory hyperhydrosis (CH), and quality-of-life assessment. RESULTS: Sixty-seven patients reported a complete resolution of PH after surgery. One failure occurred in the T3 group and 2 in the T4 group. When anhydrosis was obtained, we noticed totally dry hands in 26 patients in the T3 group and 6 patients in the T4 group. The other 27 patients in the T4 group and 8 in the T3 group maintained a small level of sweating and were also considered to be therapeutic successes. At 6 months, 25 patients in the T4 group had some degree of CH (71.42%) and all patients in the T3 group (100%), though the T4 group had a lower degree of severity of CH at the 6-month follow-up (P < 0.05). After the operation, quality of life was improved similarly in both groups. CONCLUSIONS: VTS at either the T3 or T4 level provides an effective treatment for PH. VTS at the T4 level is associated with a less severe form of CH. Despite the occurrence of CH, patients' quality of life is significantly improved following VTS at the T3 or T4 levels. For this reason, the T4 resection can now be used as a treatment for PH.     

Palmar hyperhidrosis—which is the best level of denervation using video-assisted thoracoscopic sympathectomy: T2 or T3 ganglion?

PURPOSE: This study compares early results of video-assisted thoracoscopic sympathectomy (VTS) at the thoracic T2 versus T3 ganglion denervation levels for the treatment of palmar hyperhidrosis (PH). METHODS: Sixty patients with PH were prospectively randomized for VTS at the thoracic T2 or T3 ganglion denervation levels. The patients underwent postoperative evaluation on three occasions: before surgery, and 1 and 6 months after the operation. Endpoints included the absence of PH, the presence, location, and severity of compensatory hyperhidrosis (CH), and a quality-of-life assessment. RESULTS: Fifty-nine of 60 patients reported complete resolution of PH after surgery. One failure occurred in the T3 group. CH was observed in 26 patients (86.66%) in the T2 group and in 27 patients (90%) in the T3 group at 1 month. At 6 months, 30 of 30 patients in the T2 group and 29 of 30 in the T3 group experienced CH, although in the T3 group, CH was less severe at both 1 and 6 months (P < .05). Quality of life was very poor in both groups before surgery. One month after operation, quality of life was improved similarly in both groups. This improvement was maintained at 6 months in both groups. CONCLUSION: PH is well treated by VTS at either the T2 or T3 levels. Denervation at the T3 level appears associated with less severe CH in the early postoperative period. Quality of life improved significantly in both groups.     

Compensatory sweating after thoracoscopic sympathectomy for primary focal hyperhidrosis in children: Are there patient‐related risk factors?

IntroductionCompensatory sweating (CS) is a common complication after thoracoscopic sympathectomy (TS) and is mainly associated with surgical technique. Our aim was to identify potential risk-factors for CS following TS for primary focal hyperhidrosis in children.MethodsA retrospective, single-center review of all bilateral TS was performed between 2017 and 2019. Hyperhidrosis disease severity scale was used for pre-operative severity assessment. Post-operative evaluations were performed after three and six months.ResultsMore than the 36-month period, 41 patients were submitted to T2–T4 TS, and 25 were females (60.9%). Median age at surgery was 15.5 years. CS was identified at the 3rd month in 17 (41%) children with most in the dorsolumbar region (56%). By the 6th month, there was a significant reduction in CS (41 to 32%, p = 0.02). The probability of resolution of CS by 6 months is about 50% in both the dorsolumbar and abdominal regions. Neither age, gender, body mass index, family history, or concomitant illnesses seemed to influence CS (p > 0.05). Axillary hyperhidrosis appears to be associated with the development of dorsolumbar CS (p = 0.037).ConclusionThoracoscopic sympathectomy for PFH is a safe and effective procedure, but compensatory sweating can be a common and debilitating side effect. Age, gender, and body mass index do not appear to influence CS. Axillary hyperhidrosis may be related to the development of dorsolumbar CS.Level of evidenceIII.     

Comparison between ketamine and fentanyl–droperidol for rectal premedication in children: a randomized placebo controlled trial

Purpose  

A common concern of anesthesiologists is the management of children involved in stressful scenarios, and premedication is considered, in most situations, as useful to reduce the stress responses. This randomized placebo-controlled study was designed to evaluate two premedicants, ketamine versus a combination of fentanyl–droperidol, rectally administered, in pediatric surgical outpatients.     

Factors affecting long-term satisfaction after thoracic sympathectomy for palmar and plantar hyperhidrosis. Is the sudomotor reflex the only villain?

The main objective of this study was to determine if there are variations in the level of improvement of the palmar and plantar hyperhidrotic symptoms, as well as the incidence and intensity of the sudomotor reflex, throughout the seasons of the year, after thoracic sympathectomy for hyperhidrosis. The study also looks for the real impact of these variables in the long-term satisfaction. A cohort of 75 patients was followed through distinct seasons. A multivariate analysis was performed to identify possible variables responsible for dissatisfaction. Both the palmar (P=0.002) and plantar (P<0.001) symptoms and the presence and the intensity of the sudomotor reflex varies significantly throughout the seasons of the year. The sudomotor reflex was the main factor associated with low satisfaction in our patients in the summer (P=0.025) and winter (P<0.001) but in spring the lack of improvement in the hyperhidrosis in the foot was the unique factor related to dissatisfaction (P<0.001). The sudomotor reflex is the main negative factor in the summer and in the winter, independent of its intensity. However, at least in spring, the lack of removal of the plantar symptoms had a negative impact on satisfaction.     

Intradiscal oxygen-ozone chemonucleolysis versus microdiscectomy for lumbar disc herniation radiculopathy: a non–inferiority randomized control trial

BACKGROUND CONTEXTLow back pain with or without radicular leg pain is an extremely common health condition significantly impacting patient's activities and quality of life. When conservative management fails, epidural injections providing only temporary relief, are frequently utilized. Intradiscal oxygen-ozone may offer an alternative to epidural injections and further reduce the need for microdiscectomy.PURPOSETo compare the non–inferiority treatment status and clinical outcomes of intradiscal oxygen-ozone with microdiscectomy in patients with refractory radicular leg pain due to single-level contained lumbar disc herniations.STUDY DESIGN / SETTINGMulticenter pilot prospective non–inferiority blocked randomized control trial conducted in three European hospital spine centers.PATIENT SAMPLEForty-nine patients (mean 40 years of age, 17 females/32 males) with a single-level contained lumbar disc herniation, radicular leg pain for more than six weeks, and resistant to medical management were randomized, 25 to intradiscal oxygen-ozone and 24 to microdiscectomy. 88% (43 of 49) received their assigned treatment and constituted the AS-Treated (AT) population.OUTCOME MEASURESPrimary outcome was overall 6-month improvement over baseline in leg pain. Other validated clinical outcomes, including back numerical rating pain scores (NRS), Roland Morris Disability Index (RMDI) and EQ-5D, were collected at baseline, 1 week, 1-, 3-, and 6-months. Procedural technical outcomes were recorded and adverse events were evaluated at all follow-up intervals.METHODSOxygen-ozone treatment performed as outpatient day surgeries, included a one-time intradiscal injection delivered at a concentration of 35±3 μg/cc of oxygen-ozone by a calibrated delivery system. Discectomies performed as open microdiscectomy inpatient surgeries, were without spinal instrumentation, and not as subtotal microdiscectomies. Primary analyses with a non–inferiority margin of -1.94-point difference in 6-month cumulative weighted mean leg pain NRS scores were conducted using As-Treated (AT) and Intent-to-Treat (ITT) populations. In post hoc analyses, differences between treatment groups in improvement over baseline were compared at each follow-up visit, using baseline leg pain as a covariate.RESULTSIn the primary analysis, the overall 6-month difference between treatment groups in leg pain improvement using the AT population was -0.31 (SE, 0.84) points in favor of microdiscectomy and using the ITT population, the difference was 0.32 (SE, 0.88) points in favor of oxygen-ozone. The difference between oxygen-ozone and microdiscectomy did not exceed the non–inferiority 95% confidence lower limit of treatment difference in either the AT (95% lower limit, -1.72) or ITT (95% lower limit, -1.13) populations. Both treatments resulted in rapid and statistically significant improvements over baseline in leg pain, back pain, RMDI, and EQ-5D that persisted in follow-up. Between group differences were not significant for any outcomes. During 6-month follow-up, 71% (17 of 24) of patients receiving oxygen-ozone, avoided microdiscectomy. The mean procedure time for oxygen-ozone was significantly faster than microdiscectomy by 58 minutes (p<.0010) and the mean discharge time from procedure was significantly shorter for the oxygen-ozone procedure (4.3±2.9 hours vs. 44.2±29.9 hours, p<.001). No major adverse events occurred in either treatment group.CONCLUSIONSIntradiscal oxygen-ozone chemonucleolysis for single-level lumbar disc herniations unresponsive to medical management, met the non–inferiority criteria to microdiscectomy on 6-month mean leg pain improvement. Both treatment groups achieved similar rapid significant clinical improvements that persisted and overall, 71% undergoing intradiscal oxygen-ozone were able to avoid surgery.     

Anatomical redistribution of sweating after T2–T3 thoracoscopic sympathicolysis: a study of 210 patients

Background The cutaneous influence areas of the different sympathetic ganglia have not been fully established to date. The aim of this study was to define the cutaneous influence area of sympathetic ganglia T2–T3. Methods A total of 210 patients with primary hyperhidrosis (PH) underwent 420 thoracoscopic sympathicolysis procedures of ganglia T2–T3 in a prospective study. All completed a preoperative questionnaire and a second questionnaire 12 months after the operation. The questionnaires evaluated perspiration in the different body areas. Only the zones of anhidrosis were considered in delimiting the cutaneous expression of sympathetic ganglia T2–T3. Results Redistribution of perspiration as reported by the patients comprised significant reduction in the palms, axillas, and soles, and an increase in the abdomen, back, and gluteal and popliteal regions. Regarding the incidence of anhidrosis by anatomical location, statistically significant changes were recorded in the head, hands, axillas, and soles (p < 0.001). Conclusions Bilateral upper thoracic sympathicolysis is followed by redistribution of body perspiration, with a clear decrease in the zones regulated by mental or emotional stimuli, and an increase in the areas regulated by environmental stimuli, though we are unable to establish the etiology of this redistribution.     

Optimizing treatment strategies in myeloma cast nephropathy: rationale for a randomized prospective trial

Renal failure is a frequent complication of multiple myeloma (MM) that strongly affects patient survival. Although a variety of renal diseases may be observed in MM, myeloma cast nephropathy (MCN), a tubulo-interstitial disorder related to precipitation of a monoclonal light chain (LC) within tubular distal lumens, is the main cause of severe and persistent renal failure. To date, the respective frequency and initial evolution of renal disorders associated with monoclonal LC in MM remain poorly defined. Treatment of MCN relies on urgent symptomatic measures and rapid introduction of chemotherapy to reduce the production of monoclonal LC. The introduction of novel chemotherapy regimens based on the association of bortezomib with dexamethasone is likely to have improved the prognosis of MM patients with renal failure. In addition, the combination of novel agents with efficient removal of circulating LC through high cut-off hemodialysis membrane may further increase renal response rate. However, the impact on patient and renal outcomes of these potential therapeutic advances has not been evaluated in prospective studies. The randomized trials EuLITE in the UK and Germany and MYRE in France should help to answer these issues. MYRE is a randomized controlled phase III trial (NCT01208818) that aims to better define the epidemiology and typology of inaugural renal failure in MM and to optimize therapy of MCN patients with and without dialysis-dependent renal failure.     

Nortriptyline for treating enuresis in ADHD—a randomized double-blind controlled clinical trial

Background

Treating enuresis in children with attention deficit hyperactivity disorder (ADHD) has not been previously reported. This study aims to investigate the efficacy, tolerability, and adverse effects of nortriptyline for treating enuresis in children with ADHD.

Methods

Forty-three children aged from 5 to 14?years old were randomized into two groups. The treatment group received methylphenidate plus nortriptyline, while the placebo group received methylphenidate plus placebo. Nortriptyline and placebo were administered for 30?days and methylphenidate was administered for 45?days. The major outcome measure was parent-reported frequency of enuresis for 2?weeks prior to the intervention, during the intervention, and for 2?weeks after stopping the adjuvant therapy. Adverse effects were also checked.

Results

While nortriptyline statistically decreased the incidence of nocturnal enuresis during the intervention, the number of enuresis events did not significantly change in the placebo group. In addition, enuresis was not different from the baseline frequency of enuresis after stopping nortriptyline or placebo administration. Both nortriptyline and placebo were tolerated well.

Conclusions

Administration of nortriptyline for treating enuresis in ADHD has not been investigated before. Nortriptyline is statistically superior to placebo. However, enuresis will relapse after stopping nortriptyline in children with ADHD who continue taking methylphenidate.     

Evaluation of pain in bilateral total knee replacement with and without tourniquet; a?prospective randomized control trial

Aim

Thigh pain following tourniquet application is a common complaint in early post operative period following total knee arthroplasty.

Method

Post operative Thigh pain was evaluated in 30 consecutive simultaneous bilateral total knee arthroplasty patients between July 2013 and January 2014. Patient thigh pain was evaluated with the VAS score. The scale was applied on first, second, third day & second and six weeks after surgery.

Result

There were statistically significant difference in VAS score in non-tourniquet group on first, second, third post operative day. We did not find statistically significant difference at Second and Six weeks post operatively.

Conclusion

This Randomized trial demonstrates that non-tourniquet use in TKA has less early postoperative pain and leads to better recovery.     

Is there a role for antimuscarinics in renal colic? A randomized controlled trial

PURPOSE: We determined whether the addition of hyoscine butylbromide (Buscopan) reduces the amount of opioid analgesia required and the need for ongoing opioid analgesia in acute renal colic. MATERIALS AND METHODS: Patients with a clinical diagnosis of acute renal colic were prospectively randomized to receive Buscopan or placebo in addition to morphine and intravenous fluids, with or without indomethacin. Observations and pain scores were recorded 15 every minutes during the first hour then hourly thereafter. Morphine was administered in 2.5 mg increments until pain relief was achieved. Recordings were ceased at 4 hours or on discharge from the emergency department, whichever occurred first. The diagnosis of renal colic was confirmed by computerized tomography. The dose of morphine (mg/kg) and the proportion of patients who required further morphine were compared between the 2 groups. RESULTS: Of the 192 patients randomized, data were available for 178 on an intent to treat basis. A total of 85 patients received Buscopan while 93 received placebo in addition to standard therapy. Patients in the Buscopan group required a median of 0.12 mg/kg of morphine while those in the placebo group received a median of 0.11 mg/kg, and this difference was not significant (p =0.4). There was also no significant difference in the proportion of patients who required additional morphine, 33% in the Buscopan group and 38% in the placebo group (p =0.5). Subgroup analysis of the 138 patients with a confirmed stone also showed no difference between the groups. CONCLUSIONS: There is no evidence that Buscopan reduces opioid requirements or the need for ongoing opioid analgesia in acute renal colic.