Randomized trial - oxybutynin for treatment of persistent plantar hyperhidrosis in women after sympathectomy

OBJECTIVE:

Hyperhidrosis is a common disease, and thoracoscopic sympathectomy improves its symptoms in up to 95% of cases. Unfortunately, after surgery, plantar hyperhidrosis may remain in 50% of patients, and compensatory sweating may be observed in 70%. This clinical scenario remains a challenge. Our objective was to evaluate the effectiveness of oxybutynin in the treatment of persistent plantar hyperhidrosis and compensatory sweating and its effects on quality of life in women after thoracoscopic sympathectomy.

METHOD:

We conducted a prospective, randomized study to compare the effects of oxybutynin at 10 mg daily and placebo in women with persistent plantar hyperhidrosis. The assessment was performed using a quality-of-life questionnaire for hyperhidrosis and sweating measurement with a device for quantifying transepidermal water loss. Clinicaltrials.gov: NCT01328015.

RESULTS:

Sixteen patients were included in each group (placebo and oxybutynin). There were no significant differences between the groups prior to treatment. After oxybutynin treatment, there was a decrease in symptoms and clinical improvement based on the quality-of-life questionnaire (before treatment, 40.4 vs. after treatment, 17.5; p = 0.001). The placebo group showed modest improvement (p = 0.09). The outcomes of the transepidermal water loss measurements in the placebo group showed no differences (p = 0.95), whereas the oxybutynin group revealed a significant decrease (p = 0.001). The most common side effect was dry mouth (100% in the oxybutynin group vs. 43.8% in the placebo group; p = 0.001).

CONCLUSION:

Oxybutynin was effective in the treatment of persistent plantar hyperhidrosis, resulting in a better quality of life in women who had undergone thoracoscopic sympathectomy.     

Compensatory sweating after restricting or lowering the level of sympathectomy: a systematic review and meta-analysis

OBJECTIVE:

To compare compensatory sweating after lowering or restricting the level of sympathectomy.

METHOD:

A systematic review and meta-analysis were conducted of all randomized controlled trials published in English that compared compensatory sweating after lowering or restricting the level of sympathectomy. The Cochrane collaboration tool was used to assess the risk of bias, and the Mantel-Haenszel odds ratio method was used for the meta-analysis.

RESULTS:

A total of 11 randomized controlled trials were included, including a total of 1079 patients. Five of the randomized controlled trials studied restricting the level of sympathectomy, and the remaining six studied lowering the level of sympathectomy.

CONCLUSIONS:

The compiled randomized controlled trial results published so far in the literature do not support the claims that lowering or restricting the level of sympathetic ablation results in less compensatory sweating.     

The changes of skin temperature on hands and feet during and after T3 sympathicotomy for palmar hyperhidrosis

Unilateral thoracic sympathectomy in patients with palmar hyperhidrosis causes a skin temperature drop in the contralateral hand. A cross-inhibitory effect by the post-ganglionic neurons innervating hands is postulated as a mechanism of contralateral vasoconstriction. The purpose of our study was to evaluate whether this cross-inhibitory effect also occurs in the feet. Twenty patients scheduled for thoracoscopic sympathicotomy due to palmar hyperhidosis were studied. Right T3 sympathicotomy was performed first, followed by left T3 sympathicotomy. The thenar skin temperatures of both hands and feet were continuously monitored using a thermometer and recorded before induction of anesthesia, during the operation, 4 hr after and 1 week later. Following right T3 sympathicotomy, the skin temperature of the ipsilateral hand gradually increased, however the skin temperature of the contralateral hand gradually decreased. Immediately after bilateral sympathicotomy, the skin temperature differences between hands and feet increased, but these differences decreased 1 week later. Our results show that cross-inhibitory control may exist in feet as well as in the contralateral hand. Thus, the release of cross-inhibitory control following T3 sympathicotomy results in vasoconstriction and decrease of skin temperature on the contralateral hand and feet. One week later, however, the temperature balance on hands and feet recovers.     

Treatment of uncommon sites of focal primary hyperhidrosis: experience with pharmacological therapy using oxybutynin

OBJECTIVES:

Primary hyperhidrosis usually affects the hands, armpits, feet and cranio-facial region. Sweating in other areas is common in secondary hyperhidrosis (after surgery or in specific clinical conditions). Oxybutynin has provided good results and is an alternative for treating hyperhidrosis at common sites. Our aim was to evaluate the efficacy of oxybutynin as a treatment for primary sweating at uncommon sites (e.g., the back and groin).

METHODS:

This retrospective study analyzed 20 patients (10 females) who received oxybutynin for primary focal hyperhidrosis at uncommon sites. The subjects were evaluated to determine quality of life before beginning oxybutynin and six weeks afterward and they were assigned grades (on a scale from 0 to 10) to measure their improvement at each site of excessive sweating after six weeks and at the last consult.

RESULTS:

The median follow-up time with oxybutynin was 385 days (133-1526 days). The most common sites were the back (n = 7) and groin (n = 5). After six weeks, the quality of life improved in 85% of the subjects. Dry mouth was very common and was reported by 16 patients, 12 of whom reported moderate/severe dry mouth. Five patients stopped treatment (two: unbearable dry mouth, two: excessive somnolence and one: palpitations). At the last visit, 80% of patients presented with moderate/great improvement at the main sites of sweating.

CONCLUSION:

After six weeks, more than 80% of the patients presented with improvements in their overall quality of life and at the most important site of sweating. Side effects were common (80% reported at least one side effect) and caused 25% of the patients to discontinue treatment. Oxybutynin is effective for treating bothersome hyperhidrosis, even at atypical locations and most patients cope well with the side effects.     

Degeneration patterns of postganglionic fibers following sympathectomy

Summary In cats the time course of degeneration following lumbal sympathectomy was studied in the ramus communicans griseus (reg) and in the nerves to the triceps surae muscle using light and electron microscopic methods.The left lumbar sympathetic trunk including its rami communicantes was removed from L2 to S1 using a lateral approach. The animals were sacrificed between 2 and 48 days after the sympathectomy. Tissue samples were taken (a) one cm proximal to the entrance of the rcg into the spinal nerve, and (b) one cm proximal to the entrance of the nerve into the muscle belly.In the reg signs of degeneration can already be recognized in the myelinated as well as in the unmyelinated axons 48h after sympathectomy. The degenerative processes in the axons reach their peak activity at about 4 days p.o. They end a weck later. Signs of the reactions of the Schwann cells and of the endoneural cells can first be seen 2 days p.o. They are most pronounced around the 8th day p.o., and last at least up to the third week. Thereafter the cicatrization processes settled to a rather steady state (total observation period 7 weeks).In the muscle nerves the first signs of an axonal degeneration of the sympathetic fibers can be recognized 4 days after surgery. The signs of axonal degeneration are most striking about 8 days p.o. They have more or less disappeared another week later. The reactions of the Schwann cells also start on the fourth day but outlast the degenerative processes by some 8 days. Thus the degenerative and reactive processes in the reg precede those in the muscle nerves by 2 days early after surgery and by 6 days 3 weeks later. Seven weeks after surgery, fragments of folded basement lamella and Remak bundles with condensed cytoplasm and numerous flat processes are persisting signs of the degeneration.In addition to the differences in time course between the proximal and the distal site of observation, it was also noted that both the axonal degeneration and the reactions of the Schwann cells are more pronounced in the rcg than in the muscle nerve. For example there was abundant mitotic activity in the central endoneural and Schwann cells whereas we could not detect such activity in the periphery.It is concluded that the time course of degeneration and the intensity of the degenerative and reactive processes is, to a considerable extent, determined by the distance between the site of nerve section and the site from which the specimen is taken. Many of the conflicting data in the literature can be explained by this finding.     

化学阻断交感神经对脾脏形态学的影响及其抗氧化机制的研究

目的研究使用六羟多巴胺(6-OHDA)化学性阻断交感神经对小鼠脾脏形态原的影响及其抗氧化机制。方法应用组织学、免疫组织化学、MTT等方法研究了化学性阻断交感神经对小鼠脾脏组织结构、脾淋巴细胞体内和体外增殖以及抗氧化酶活性的变化。结果 6-OHDA组的脾脏平均重量下降,动脉周围淋巴鞘面积和脾小体直径均分别低于对照组12.62%和20.21%。脾小体和边缘区以及动脉周围淋鞘细胞的PCNA的阳性率分别比对照组降低了82.23%、30.37%和33.16%,但在红髓内差异不显著。用ConA诱发体外T淋巴细胞增殖,实验组的刺激指数均低于对照组,尤其在6、15μg/ml时差异极显著;用LPS诱导脾脏B细胞增殖的结果可见实验组的刺激指数在15μg/ml和25μg/ml分别低于对照组9.39%和12.31%。6-OHDA组SOD、GSH-Px和T-AOC均低于对照组,而MDA含量高于对照组49.94%。结论阻断交感神经造成脾脏组织的氧化损伤,表现为脾脏重量下降,动脉周围淋巴鞘的面积和脾小体直径减少以及脾淋巴细胞增殖水平降低。     

Influence of sympathectomy on body weight of rats given chow or supermarket diets

Rats that were neonatally sympathectomized with guanethidine (GUA) and given access to a four-component supermarket diet (SD) when either adolescent or adult gained weight at the same rate as controls. Adrenodemedullation (MDL) of adults, either alone or in combination with GUA treatment, also failed to influence the development of dietary obesity. Neonatal sympathectomy induced small changes in caloric consumption and diet preferences. These results question the notion that the sympathetic nervous system (SNS) is an essential contributor to the control of body weight and the development of dietary obesity.     

Specific subtypes of nicotinic cholinergic receptors involved in sympathetic and parasympathetic cardiovascular responses

Various subtypes of nicotinic cholinergic receptors are expressed in autonomic ganglia. The distinct functional roles of these receptors in autonomic ganglionic transmission to different target organs remain to be elucidated. In this study, we tested the sympathetic and parasympathetic cardiovascular responses to nicotinic agonist and antagonists in urethane-anesthetized mice. Intravenous injection with a nicotinic agonist, 1,1-dimethyl-4-phenylpiperazinium iodide, induced a brief but pronounced decrease in heart rate, followed by significant increases in heart rate and arterial blood pressure. The bradycardic response was blocked by atropine whereas the pressor response was blocked by prazosine, confirming those responses were parasympathetic and sympathetic activities, respectively. The sympathetic response was blocked by methyllycaconitine citrate, a selective α7 nicotinic cholinergic receptor (nAchR) antagonist. The parasympathetic response was blocked by a selective α4β2 nAchR antagonist, dihydro-β-erythroidine hydrobromide. Moreover, injection with a selective α4β2 nAchR agonist, RJR2403 oxalate, induced a pronounced parasympathetic response with a smaller sympathetic response. Collectively, these data show that activations of α4β2 nAchRs elicits a parasympathetic cardiovascular response and activation of α7 nAchRs elicits a sympathetic cardiovascular response. These data suggest that specific subtypes of nicotinic receptors at the level of the ganglia may play distinct roles in mediating sympathetic or parasympathetic activation.     

Effects of guanethidine sympathectomy on feeding, drinking, weight gain and amphetamine anorexia in the rat

Adult female rats that underwent sympathectomy induced by guanethidine treatment (10, 20 or 40 mg/kg) exhibited markedly increased water intake, but did not display significant alterations of either food intake, body weight, or the Lee Index of obesity. Guanethidine treatment did not attenuate amphetamine anorexia as evidenced by comparable dose-dependent reductions in food intake to d-amphetamine sulfate (0.25, 0.50, 1.0, and 2.0 mg/kg) in sympathectomized and control rats. These data are not consistent with the hypothesis that amphetamine anorexia is partially mediated via enhanced BAT thermogenesis.     

Influence of thoracic sympathectomy on cardiac induced oscillations in tissue blood volume

The photoplethysmographic (PPG) signal, which measures cardiac-induced changes in tissue blood volume by light transmission measurements, shows spontaneous fluctuations. In this study, PPG was simultaneously measured in the right and left index fingers of 16 patients undergoing thoracic sympathectomy, and, from each PPG pulse, the amplitude of the pulse (AM) and its maximum (BL) were determined. The parameter AM/BL is proportional to the cardiac-induced blood volume increase, which depends on the arterial wall compliance. AM/BL increased after the thoracic sympathectomy treatment (for male patients, from 2.60±1.49% to 4.81±1.21%), as sympathetic denervation decreases arterial tonus in skin. The very low-frequency (VLF) fluctuations of BL or AM showed high correlation (0.90±0.11 and 0.92±0.07, respectively) between the right and left hands before the thoracic sympathectomy, and a significant decrease in the right-left correlation coefficient (to 0.54±0.22 and 0.76±0.20, respectively) after the operation. The standard deviation of the BL or AM VLF fluctuations also reduced after the treatment, indicating sympathetic mediation of the VLF PPG fluctuations. The study also shows that the analysis of the PPG signal and the VLF fluctuations of the PPG parameters enable the assessment of the change in sympathetic nervous system activity after thoracic sympathectomy.     

Effect of guanethidine sympathectomy on intake and body weight of intact and LHA-lesioned rats

The present study investigated the role of direct sympathetic nervous system innervation of the viscera in the reduced body weight levels maintained by animals bearing lesions of the lateral hypothalamic area (LHA). Adult, male rats with, and without, electrolytic lesions of the (LHA) were treated with guanethidine sulphate (25 mg/kg IP daily for 6 weeks) to produce destruction of the peripheral sympathetic nervous system. LHA-lesioned rats displayed the expected reduced body weight compared to intact rats. Sympathectomy in lesioned rats resulted in an identical pattern of effects to that seen in intact rats. Transitory reductions in intake were effected and weight was significantly depressed by one week of guanethidine treatment. However, weight had recovered to control levels in both intact and lesioned drug-treated groups by the end of the experiment. The reduced body weight level maintained by LHA-lesioned rats was not altered by guanethidine sympathectomy. The major conclusions are (1) the reduced body weights maintained following LHA lesions are not dependent upon an intact sympathetic nervous innervation of visceral organs, and (2) peripheral sympathectomy in intact adult rats has no chronic effects on either body weight or food and water intake.     

Growth of sympathetic postganglionic axons after partial chemical destruction with guanethidine

Partial sympathectomy of neonatal rats was produced by treatment with guanethidine. The number of neurons of the superior cervical ganglion decreased to 15% of control values and remained constant throughout the subsequent observation period of 4 months. The volume of the remaining neuronal perikarya increased faster than that of control animals during the observation period, and the density of adrenergic innervation of the iris and the noradrenaline content of the heart were found to partially recover after the initial decrease produced by the guanethidine treatment, reaching 33% and 30% of control values, respectively, after 4 months. The noradrenaline content of the duct of the vas deferens was greatly reduced by guanethidine treatment, but almost recovered after 4 months. The frequency of sympathetic preganglionic impulses was elevated throughout the 4 months observation period, and it is suggested that this increase is responsible for the compensatory changes in cell volume, terminal density and terminal noradrenaline content of the remaining neurons.     

Morphological aspects of rabbit masseter muscle after cervical sympathectomy

The objective of this paper was to study the effect of sympathetic innervation on morphological and histochemical aspects of skeletal muscle tissue. Rabbit masseter muscle was studied using histochemical and immunohistochemical methods for periods of up to 18 months post-sympathectomy. The morphological and enzymatic characteristics of control masseter muscles were similar on both the left and right sides. The main features were muscle fibres with a mosaic pattern and a predominance of type IIa fibres, followed by type I. Type IIb fibres showed very low frequency. Sympathectomized animals showed varying degrees of metabolic and morphological alterations, especially 18 months after sympathectomy. The first five groups showed a higher frequency of type I fibres, whilst the oldest group showed a higher frequency of type IIb fibres. In the oldest group, a significant variation in fibre diameter was observed. Many fibres showed small diameter, atrophy, hypertrophy, splitting, and necrosis. Areas with fibrosis were observed. Thus cervical sympathectomy induced morphological alterations in the masseter muscles. These alterations were, in part, similar to both denervation and myopathy. These findings indicate that sympathetic innervation contributes to the maintenance of the morphological and metabolic features of masseter muscle fibres.     

超声测量跖筋膜的数字化评价

目的　通过数字化分析评价超声测量跖筋膜的准确度。 方法　选取2014年5月至2016年5月内蒙古医科大学附属医院50名健康成人志愿者,男25名,女25名;年龄为18～51岁,平均(31.6±3.5)岁,身高155~181 cm,平均(172.3±7.6) cm;体重49~90 kg,平均(78.3 ±3.6) kg,分别行双足CT断层、MRI断层与超声检查,记录超声图像上的跖筋膜厚度,将CT、MRI原始图像数据以dicom格式导入Materialise Mimics Innovation Suite 16.0软件,进行数字化分析、测量,比较三者的相关性。 结果　超声、CT、MRI三者之间的测量在同性别之间差异无统计学意义（P＞0.05）。同一性别的左、右两侧差异无统计学意义（P＞0.05）,而同一侧在男、女性别之间差异有统计学意义,三种检查结果跖筋膜平均厚度男性大于女性,（P＜0.05）。 结论　超声检查能够为跖筋膜厚度的测量提供相对简便的方法而且准确度较高。     

Rubinstein-Taybi syndrome: Objective evaluation of craniofacial structure

Rubinstein-Taybi syndrome (RTS) is a rare multiple congenital anomaly syndrome comprising mental and growth retardation, broad thumbs and great toes, and an unusual face. The classical facial appearance is well-established, striking and easy to recognize. It includes downslant of the palpebral fissures, epicanthic folds, ptosis, strabismus, highly arched palate, simple ears and a small mouth. The nose is distinctive with a beaked appearance, broad fleshy bridge, deviated septum and short low columella. Previous studies have documented considerable change in this facial phenotype with time. In this study, we evaluated 31 individuals with RTS from Great Britain and The Netherlands. They range in age from 1 to 39 years. Detailed craniofacial measurements were obtained on each subject and composite pattern profiles were compiled. There was remarkable concordance of patterns at all ages from infancy to adulthood. Microcephaly was present consistently. The head was relatively round with head width equal to head length. There was narrowness at the skull base with relative broadening of the minimal frontal diameter and lower facial width. The mouth was small and ears were broad and short. Eyes were wide-spaced in comparison to upper facial width and head circumference. The child under 4 years demonstrated some differences. Width and depth of the upper face exceeded that of the lower face, where as with increasing age, mandibular dimensions were closer to normal than their maxillary counterparts. Despite these differences, the similarity of the profiles of all age groups seems to belie the phenotypic changes that can be appreciated subjectively. This suggests that major components of the change in appearance are those which have not been assessed in this study, such as palpebral fissure slant, deviation of the nasal bridge, presence of epicanthal folds or ptosis; or for which norms are not available, for example, beaking of the nose, and low nasal septum. Am. J. Med. Genet. 71:414–419, 1997. © 1997 Wiley-Liss, Inc.     

腹腔镜模拟训练效果的客观评价

目的目前国内尚无结合腹腔镜模拟训练者的手眼运动特征对其训练效果进行客观评价的研究。本文主要利用Micron Tracker双目视觉导航仪和眼动仪,通过分析训练者的手眼运动特征对腹腔镜模拟手术的训练效果进行评价。方法利用Micron Tracker双目视觉导航仪采集并记录器械尖端运动的三维坐标,计算器械运动的总路径长度;利用眼动仪采集并记录训练者的操作时间和眼动信息,并计算出注视率、眼跳率和眼跳幅度,来评价腹腔镜手术训练效果。结果随着操作次数的增加,训练者的熟悉程度增加。第30次训练操作与第1次训练操作相比较:操作时间减小了58.18%,呈现减小趋势,并趋于稳定;右手器械总路径长度减少了63.95%,左手器械总路径长度减少了56.28%,左手器械总路径长度小于右手器械总路径长度,且均呈减少趋势并趋于稳定;眼跳率减小了20.81%,呈现减小的趋势;眼跳幅度增大了28.39%,呈现增大趋势;而眼动注视率和注视持续时间平均值并没有显著性变化(P0.05)。结论基于手眼运动特征的参数(操作时间、左右手总路径长度、眼跳率和眼跳幅度等)可以作为腹腔镜手术技能培训效果的客观评价指标。     

Spectral evaluation of aging effects on blood pressure and heart rate variations in healthy subjects

The background to heart rate variability (HRV) and blood pressure variability (BPV), and their determinants and physiological correlates, remain obscure. The impact of age must be taken into account if HRV and BPV are used for predictive purposes in clinical settings. Healthy subjects show wide inter-individual variation in their heart rate behaviour and the factors affecting heart rate dynamics are not well known. This paper has undertaken to evaluate heart rate variability (HRV) and baroreflex sensitivity (BRS) in a random sample of subjects without evidence of heart disease, and to estimate the relation of HRV and BPV behaviour to age. The aim of this study was to analyse the effects of ageing on HRV and BPV for simultaneous recordings of electrocardiograph (ECG) and blood pressure (BP) signals at rest in healthy subjects. We studied eight young (21 – 34 years old) and eight elderly (68 – 85 years old) rigorously screened subjects from the Fantasia Database to make the reproducibility and comparability of the results more extensive. Time- and frequency-domain analysis of HRV and BPV was performed on 5-minute ectopic-free recordings. BRS on the heart was estimated by frequency-domain analysis of spontaneous variability of systolic blood pressure (SBP) and RR interval. It has been observed that compared to young the elderly subjects have (i) diminished HRV; (ii) a shift in the power spectral density and median frequency to low frequency side for HRV and to higher frequency side for BPV; and (iii) increased low-frequency alpha index and decreased high-frequency alpha index of BRS with overall alpha index augmented. The results convey that normal ageing in the absence of disease is associated with lesser parasympathetic regulation of heart rate. Thus it is concluded that the age is an important factor to be considered for prognosis and diagnosis by HRV and BPV. For reliable clinical applications, more research needs to be done on a broad spectrum of subjects. In addition, these observations will prove to be useful for dynamic modelling of cardiovascular regulation for testing the authentication of new techniques for analysis purposes.     

涤纶布修补胸壁肿瘤切除后巨大胸壁缺损46例

背景：涤纶布作为一种临床常用耗材,取材简单,价格低廉,具有较高的坚韧度及延展性,可作为一种良好的修复材料使用。 目的：观察涤纶布用于巨大胸壁修补的实际疗效。 方法：选择46例胸壁肿瘤患者,其中男29例,女17例,年龄39-73岁。将46例患者随机均分为观察组与对照组,观察组患者切除胸壁肿瘤后采用涤纶布修补巨大胸壁缺损,对照组采用自体带蒂侧胸壁筋膜皮瓣修补巨大胸壁缺损,记录两组患者临床疗效及患者满意度。 结果与结论：术后全组病例均能胜任日常工作,无死亡及严重并发症发生,其中2例术后发生局部积液,经切口引流后好转,所有患者胸廓外观良好,呼吸运动时重建处无不适感。随访6-24个月,复查X射线片复查显示重建胸廓良好,未见移植松动、异物排斥反应、胸壁畸形等,无复发及严重并发症。观察组临床疗效及患者满意度优于对照组(P < 0.05)。结果表明涤纶布用于巨大胸壁修补的治疗,具有疗效显著、安全可靠的特点。中国组织工程研究杂志出版内容重点：生物材料;骨生物材料; 口腔生物材料; 纳米材料; 缓释材料; 材料相容性;组织工程      

Autonomic nervous control of the heart rate response to dynamic incremental exercise: evaluation of the Rosenblueth-Simeone model

Summary To evaluate the validity of the Rosenblueth-Simeone model for the heart rate response to incremental dynamic exercise, 11 healthy men performed maximal exercise tests on a cycle ergometer after administration of placebo, propranolol, atropine or both propranolol and atropine. The model showed that the influence of sympathetic activity on heart rate increased at intensities up to those which resulted in a heart rate 70% maximal heart rate on placebo, and levelled off at higher intensities, while there was a progressive withdrawal of the parasympathetic activity. The ratio between heart rate predicted by the model and the recorded heart rate following placebo treatment tended to be less than 1.0 at lower exercise intensities, and approached the unit at intensities above those which resulted in a heart rate higher than 70% of maximal heart rate on placebo. There was a strong correlation (r=0.94,P<0.01) between the heart rate on placebo and the heart rate estimated by the model. Nevertheless, there was some scattering of the data around the identity line, with a standard error of the estimate for the regression line of 11 beats · min^–1. Thus, during incremental exercise, the influence of sympathetic activity on heart rate does not become progressively more important at higher exercise intensities. The application of the Rosenblueth-Simeone model shows limitations during incremental exercise, particularly at low exercise intensities.