A Comprehensive Approach to the Recognition, Diagnosis, and Severity-Based Treatment of Focal Hyperhidrosis: Recommendations of the Canadian Hyperhidrosis Advisory Committee

BACKGROUND: Hyperhidrosis can have profound effects on a patient's quality of life. Current treatment guidelines ignore disease severity. OBJECTIVE: The objective was to establish clinical guidelines for the recognition, diagnosis, and treatment of primary focal hyperhidrosis. METHODS AND MATERIALS: A working group of eight nationally recognized experts was convened to develop the consensus statement using an evidence-based approach. RECOMMENDATIONS: An algorithm was designed to consider both disease severity and location. The Hyperhidrosis Disease Severity Scale (HDSS) provides a qualitative measure that allows tailoring of treatment. Mild axillary, palmar, and plantar hyperhidrosis (HDSS score of 2) should initially be treated with topical aluminum chloride (AC). If the patient fails to respond to AC therapy, botulinum toxin A (BTX-A; axillae, palms, soles) and iontophoresis (palms, soles) should be the second-line therapy. In severe cases of axillary, palmar, and plantar hyperhidrosis (HDSS score of 3 or 4), both BTX-A and topical AC are first-line therapy. Iontophoresis is also first-line therapy for palmar and plantar hyperhidrosis. Craniofacial hyperhidrosis should be treated with oral medications, BTX-A, or topical AC as first-line therapy. Local surgery (axillary) and endoscopic thoracic sympathectomy (palms and soles) should only be considered after failure of all other treatment options. CONCLUSIONS: These guidelines offer a rapid method to assess disease severity and to treat primary focal hyperhidrosis according to severity.     

Long-Term Pulmonary Complications after Laparoscopic Adjustable Gastric Banding

Early pulmonary complications following laparoscopic adjustable gastric banding (LAGB) have been rare, while long-term pulmonary complications have not been reported. Herein, we report two patients who presented 2 and 3 years after LAGB with unexpected pulmonary complications. The first patient had aspiration pneumonia secondary to stomal obstruction and esophageal reflux. The second patient had left lobar pneumonia, in which the connecting catheter appeared as a linear structure within the consolidation. This may be due to migration of the connecting catheter through the diaphragm, piercing lung parenchyma. Both complications presented as asthma-like symptoms. Diagnosis could have been missed if not evaluated properly. A high index of suspicion and long-term follow-up are important for diagnosing such complications after LAGB.     

Pilot study of Sandostatin (octreotide) therapy of refractory HIV-associated diarrhea

Seventeen AIDS patients were enrolled in a prospective open-label dose-finding study of octreotide (Sandostatin) therapy for refractory diarrhea. Five were nonevaluable due to progression of AIDS symptomatology, and one was excluded because of lack of confirmation of HIV infection. Five of 11 evaluable patients responded to therapy (45%); two each at 50 g and 100 g, and one at 250 g thrice daily doses. A sixth patient demonstrated a moderate reduction in stool volume at 250 g thrice daily, which, although deemed clinically relevant, did not meet the criteria for response. On discontinuation of therapy, diarrhea recurred in all patients within 1–12 days, and responded to reinitiation of octreotide in those five patients who resumed treatment. Only one of the three patients with concurrent cryptosporidial infection responded to treatment. The drug was well tolerated, with mild symptomatology in three patients. Long-term treatment at a stable dose was effective in three of five treated patients for periods for seven months in one (moderate responder) and one year in two. One patient required dose increases to control symptoms, but after one year of treatment developed severe nausea following injections, which required dose cessation. One patient had partial control of his diarrhea for only three months despite two dose increases. These data suggest that octreotide may be of useful therapeutic value in HIV-associated diarrhea and that further studies are indicated.This study was supported by Sandoz Canada Inc.     

The RPH Clasp Assembly: A Simple Alternative to Traditional Designs

One of the popular designs for the distal extension partial removable dental prosthesis is the RPI clasp assembly. A modification of the RPI clasp assembly is introduced. It incorporates a mesial rest (R), proximal plate (P), and a horizontal retentive arm (H—RPH). This clasp assembly provides benefits of the RPI clasp and can be used in clinical situations where the RPI clasp is contraindicated.     

Chronic ulcerative colitis,colonic adenocarcinoma and hypoglycemia

Summary This report documents the association of metastatic colonic adenocarcinoma and hypoglycemia occurring in a 40-year-old female with long-standing ulcerative colitis. Although there was extensive replacement of liver parenchyma by metastases, minimal impairment of liver-cell function and the sequence of clinical events indicated that the hypoglycemia was primarily due to the widespread neoplasm and not to hepatic insufficiency. Tumor analysis by the radioimmunoassay method failed to identify the presence of insulin. To our knowledge, this is the first report of the association of chronic ulcerative colitis, colonic adenocarcinoma and hypoglycemia.The authors wish to thank Dr. D. H. Law for his helpful comments and criticism and Mrs. Mildred Hale for her secretarial assistance.     

Home or Nursing Home: Making the Right Choices

Review of: Salamon MJ, Rosenthal G. Home or Nursing Home: Making the Right Choices, Second Ed. New York: Springer Publishing Company Inc., 2004, pp 110.
Purpose: To provide a useful resource for clinicians and the public regarding placement of an individual in long‐term care (LTC). Background: Making the decision to enter a skilled nursing facility or making that choice for a loved one who no longer has the capacity to make that decision for him or herself is fraught with many conflicting feelings. It signifies a loss of independence and begins a new chapter in life: one often incorrectly felt to be the final step before death. For a spouse or next of kin making that decision, guilt often figures heavily into the process, affecting all of those involved. Dr. Salamon is a Fellow of the American Psychological Association and the Gerontological Society of America. He has published extensively and has served on the board of psychologists in LTC. Ms. Rosenthal is an author of four nonfiction books and writes for a variety of national publications. This edition is an update from the first edition published in 1990. Contents: The book contains 110 pages, is divided into nine chapters, and includes a number of case reports. Its brief chapters are all related to the geriatric population and their needs as they relate to LTC placement. Chapter 1 addresses demographic, physiological, and social changes. Life satisfaction as it relates to health care is explored in Chapter 2. Chapter 3 provides an overview of healthcare environments including one and a half pages on assisted living and two and a half pages on skilled nursing homes. Homecare issues, including its effect on family caregivers, are discussed in Chapter 4. Chapter 5 focuses on life satisfaction based on Dr. Salamon's 1987 research. Reactions to LTC placement is addressed in Chapter 6, and Chapter 7 is a quiz designed to be taken by a family member to determine the appropriateness of that person to provide home care. Chapter 8 offers guidelines for selecting a nursing home, and Chapter 9 lists resources and associations.