The Etiology of Primary Hyperhidrosis: A Systematic Review.

PURPOSE: Primary hyperhidrosis is a pathological disorder of unknown etiology, affecting 0.6-5% of the population, and causing severe functional and social handicaps. As the etiology is unknown, it is not possible to treat the root cause. Recently some differences between affected and non-affected people have been reported. The aim of this review is to summarize these new etiological data. METHODS: Search of the literature was performed in the PubMed/Medline Database and pertinent articles were retrieved and reviewed. Additional publications were obtained from the references of these articles. RESULTS: Some anatomical and pathophysiological characteristics (as well as enzymatic, metabolic, and neurological dysfunctions) have been observed in hyperhidrotic subjects; three main possible etiological factors predominate. A familial trait seems to exist, and genetic loci associated with hyperhidrosis have been identified. Histological differences were observed in sympathetic ganglia of hyperhidrotic subjects: the ganglia were larger and contained a higher number of ganglion cells. A higher expression of acetylcholine and alpha-7 neuronal nicotinic receptor subunit in the sympathetic ganglia of patients with hyperhidrosis has been reported. CONCLUSIONS: Despite these accumulated data, the etiology of primary hyperhidrosis remains obscure. Nevertheless, three main lines for future research seem to be delineated: genetics, histological observations, and enzymatic studies.

Thoracic sympathectomy: a review of current indications.

BACKGROUND: Thoracic sympathetic ablation was introduced over a century ago. While some of the early indications have become obsolete, new ones have emerged. Sympathetic ablation is being still performed for some odd indications thus prompting the present study, which reviews the evidence base for current practice. METHODS: The literature was reviewed using the PubMed/Medline Database, and pertinent articles regarding the indications for thoracic sympathectomy were retrieved and evaluated. Old, historical articles were also reviewed as required. RESULTS AND CONCLUSIONS: Currently, thoracic sympathetic ablation is indicated mainly for primary hyperhidrosis, especially affecting the palm, and to a lesser degree, axilla and face, and for facial blushing. Despite modern pharmaceutical, endovascular and surgical treatments, sympathetic ablation has still a place in the treatment of very selected cases of angina, arrhythmias and cardiomyopathy. Thoracic sympathetic ablation is indicated in several painful conditions: the early stages of complex regional pain syndrome, erythromelalgia, and some pancreatic and other painful abdominal pathologies. Although ischaemia was historically the major indication for sympathetic ablation, its use has declined to a few selected cases of thromboangiitis obliterans (Buerger's disease), microemboli, primary Raynaud's phenomenon and Raynaud's phenomenon secondary to collagen diseases, paraneoplastic syndrome, frostbite and vibration syndrome. Thoracic sympathetic ablation for hypertension is obsolete, and direct endovascular renal sympathectomy still requires adequate clinical trials. There are rare publications of sympathetic ablation for primary phobias, but there is no scientific basis to support sympathetic surgery for any psychiatric indication.

Laparoscopic appendectomy: a junior trainee's learning curve.

BACKGROUND: Appendicectomy has traditionally been a training operation for junior surgical trainees. With the increased incidence of laparoscopic appendicectomy, concern has increased about the safety of this far more technically demanding procedure in the hands of junior surgical trainees. The learning curve of a junior surgeon is presented. METHODS: Consecutive patients having laparoscopic appendicectomy were studied. A 3-port Hasson technique was used. Patient demographics, conversion rate and reason for conversion, operation times, number of complicated cases (retrocecal position, dense adhesions, perforated/gangrenous/abscess associated appendicitis), and postoperative complications were recorded. The moving average and cumulative sum (CUSUM) methods were used to delineate the learning curve. RESULTS: Forty patients were studied. Median age was 24 (IQR: 18, 40). Twenty-nine (72.5%) patients were female. Data were not available for 3 patients (6%); the remaining patients form the basis of this study. A statistically significant improvement occurred in operating time between group 2 and group 3, P<0.0001 (95% CI, 21.23 to 47.99). The CUSUM plot demonstrates that the learning curve was surmounted by 20 cases performed. CONCLUSIONS: Laparoscopic appendicectomy is a safe procedure for junior trainees, and the learning curve stabilizes by 20 cases performed.

Deceit and fraud in medical research.

Deceit and fraud in medical research is a serious problem for the credibility of published literature. Although estimating its prevalence is difficult, reported incidences are alarming. The spectrum of the problem ranges from what may seem as rather innocuous gift authorship to wholesale fabrication of data. Potential factors which may have promoted fraud and deceit include financial gain, personal fame, the competitive scientific environment and scientific hubris. Fraud and deceit are difficult to detect and are generally brought to the fore by whistleblowers. Although most cases may be dealt with at an institutional level, regulatory organisations such as the Committee on Publication Ethics (COPE) and Medical Research Ethics Committee (MREC) have been established to monitor and try to remedy the problem.

Specific complications and mortality of endoscopic thoracic sympathectomy.

Endoscopic Thoracic Sympathectomy (ETS) has gained an increasing popularity due to its minimal invasive character. Despite the simplicity of the procedure, non-surgical options should always be considered as the first line of treatment. The complication risk of ETS is low but side effects, primarily compensatory sweating (CS) of mainly the trunk may be severe enough to cause regret of the procedure. The risk/benefit ratio should always be discussed with the patient. Severe palmar hyperhidrosis and facial blushing respond very well to ETS with a high patient satisfaction rate. Facial hyperhidrosis is effectively treated with ETS but is associated with a high risk for severe CS. Axillary hyperhidrosis is best treated by other means than ETS. The use of ETS for pain syndromes, vascular insufficiency and angina pectoris is not well supported by scientific evidence, making mandatory careful patient selection.