Laparoscopic-Assisted Percutaneous Endoscopic Gastrostomy Reduces Major Complications in High-Risk Pediatric Patients.

PURPOSE: Percutaneous endoscopic gastrostomy (PEG) is a safe method to feed patients with feeding difficulty. This study aimed to compare the outcomes of conventional PEG and laparoscopic-assisted PEG (L-PEG) placement in high-risk pediatric patients. METHODS: In our tertiary pediatric department, 90 PEG insertions were performed between 2014 and 2019. Children with severe thoracoabdominal deformity (TAD), previous abdominal surgery, ventriculoperitoneal (VP) shunt, and abdominal tumors were considered as high-risk patients. Age, sex, diagnosis, operative time, complications, and mortality were compared among patients who underwent conventional PEG placement (first group) and those who underwent L-PEG placement (second group). RESULTS: We analyzed the outcomes of conventional PEG placement (first group, n=15; patients with severe TAD [n=7], abdominal tumor [n=6], and VP shunts [n=2]) and L-PEG placement (second group, n=10; patients with VP shunts [n=5], previous abdominal surgery [n=4], and severe TAD [n=1]). Regarding minor complications, 1 (6.6%) patient in the first group underwent unplanned PEG removal and 1 (10%) patient in the second group had peristomal granuloma. We observed three major complications: colon perforation (6.6%) in a patient with VP shunt, gastrocolic fistula (6.6%) in a patient with Fallot-tetralogy and severe TAD, and pneumoperitoneum (6.6%) caused by early tube dislodgement in an autistic patient with severe TAD. All the three complications occurred in the first group (20%). No major complications occurred in the second group. CONCLUSION: In high-risk patients, L-PEG may be safer than conventional PEG. Thus, L-PEG is recommended for high-risk patients.

The role of an overinflated endotracheal tube in the diagnosis of tracheal injuries / A túlfújt endotrachealis mandzsetta szerepe a légcsosérülések diagnosztikájában

Tracheobronchial injury is an uncommon, but often life-threatening condition. It is mostly caused by blunt thoracic or neck trauma, difficult or prolonged intubation associated with nasogastric tube insertion. An early diagnosis and treatment can be lifesaver. The diagnosis is often late because of atypical symptoms and unspecific radiological signs, and due to the presence of severe coexistent injuries. Generally, the classic hallmark during physical examination is a progressive, extensive surgical emphysema. Radiological signs are often atypical, which makes the diagnosis more difficult. The most frequent signs found on computed tomography are also unspecific, mostly surgical emphysema, pneumomediastinum or pneumothorax may be noted. We present three patients suffering from airway laceration caused by car accident, difficult intubation, and prolonged utilization of nasogastric and endotracheal tube. All the patients had an overdistended endotracheal balloon herniated outside the extratracheal space along the rupture of the tracheal wall. These external balloons were all detected on radiography. This is a direct and pathognomic sign of airway injury, suggesting complete rupture in the tracheal wall. In our report, we would like to highlight the diagnostic role of an overinflated cuff. Orv Hetil. 2020; 161(25): 1063-1068.

Outcomes of laparoscopic incarcerated inguinal hernia repair in children.

AIM: Laparoscopic inguinal hernia repair (LIHR) is gaining widespread acceptance, but its role in the management of incarcerated cases is not well outlined. This review analyses the outcomes of laparoscopic repair of incarcerated inguinal hernia in children. PATIENTS AND METHODS: Literature was searched on PubMed® using terms 'laparoscopic', 'incarcerated', 'inguinal', 'hernia' and 'children'. Age, sex, side, sac content, operative technique, follow-up period, complication and recurrence rate were analysed. RESULTS: Fifteen articles with 689 paediatric incarcerated inguinal hernias were identified between 1998 and 2018. Median age of patients was 22.4 months (2 weeks-16 years; M:F = 2.2:1). Side was mentioned in n = 576: n = 398 (69.1%) right and n = 178 (30.9%) left. In n = 355 (51.5%) manual reduction and delayed surgery (MRDS), in n = 34 (4.9%) manual reduction in general anaesthesia (MRGA) followed by emergency LHR and in n = 300 (43.5%) intraoperative reduction (IOR) was necessary. Incarcerated contents were documented in n = 68: intestine n = 36 (52.9%), ovary n = 14 (20.6%), omentum n = 11 (16.2%), appendix n = 5 (7.4%) and Meckel's diverticulum n = 2 (2.9%). Among the n = 18 girls in IOR group, n = 14 (77.8%) had ovaries incarcerated. For LHR, the hook method was used in 376 (54.6%) and purse-string suture in 313 (45.4%), with two conversions in IOR group. Mean followup was 15 months (3-80 months), with one (0.15%) testicular atrophy, and 4 (0.58%) recurrences in MRDS and 1 (0.15%) in IOR. All five cases were closed with pursestring technique. Total recurrence rate was 0.73%; significantly higher (P = 0.014) with pursestring (n = 5, 1.6%) than with the hook (none). CONCLUSION: Hook and purse-string methods are equally popular in LHR for paediatric incarcerated hernias, with 50% hernia reductions possible at the time of surgery. Recurrence rate is low and comparable with non-incarcerated hernias; however, it is significantly higher in purse-string method than hook technique.

[Sleep habits among preschool- and schoolchildren]. / Alvási szokások és alvásminoség óvodás- és iskoláskorú gyermekek körében.

BACKGROUND AND PURPOSE: Objective - Our aim is to evaluate sleep habits, sleep quality and influencing factors among preschool- and schoolchildren. METHODS: Two questionnaires were recorded. Questionnaire 1 dealt with sleeping habits, breastfeeding and health behavior of preschool children and infant, and it contained the abbreviated version of the Children's Sleep Habits Questionnaire. Questionnaire 2 dealt with health behavior and the application of sleep hygiene rules, as well as it contained the Athens Insomnia Scale. Subjects - We assessed a total of 1063 questionnaires: 516 kindergarten children participated in our online survey across the country; 547 primary and secondary school students participated in the 2nd questionnaire survey in Szolnok. RESULTS: Parents' observation shows that the average nighttime sleeping time of kindergarten children is 10 hours 20 minutes on weekdays and 10 hours 36 minutes on weekends. The most popular sleeping habits in kindergarten age: teal reading (65.1%) and co-sleeping (42.8%). Parents of infants used breastfeeding (50.4%) and rocking (43.2%) most frequently before sleep. Co-sleeping has a positive influence on the length of lactation. Among the preschool sleeping habits we have proved a number of positive effects of teal reading, while watching television have negative effects. The sleep quality of school-age children according to the Athens Insomnia Scale is 6.11 points (SD: 4.11), 19% of the children are insomniac. Their sleep time is 7 hours 31 minutes on weekdays and 9 hours 30 minutes on weekends. The usage of good health behavior and sleep hygiene rules positively influence sleep quality and sleep duration. CONCLUSION: With our results, we would like to draw the attention of children and parents to the importance of sleeping and using sleep hygiene rules.

Complications in children with percutaneous endoscopic gastrostomy (PEG) placement.

INTRODUCTION: The aim of this study was to analyze the complication rates and mortality in association with different operative techniques of percutaneous endoscopic gastrostomy (PEG), age, underlying diseases and other risk factors. Moreover, analysis of the indications of PEG insertion and the underlying comorbidities was also performed. METHODS: This study performs a literature analysis of PEG-related complications in children. Literature was searched on PubMed® (1994-2017) using terms "percutaneous endoscopic gastrostomy", "complications", "mortality" and "children". RESULTS: Eighteen articles with 4631 patients were analyzed. The mean age was 3 years (0-26 years). Operative techniques were: pull technique in 3507 (75.7%), 1 stage PEG insertion in 449 (9.7%), introducer technique in 435 (9.4%), image-guided technique in 195 (4.2%) and laparoscopic-assisted PEG in 45 (1.6%). Most frequent indications for PEG insertion were dysphagia (n = 859, 32.6%), failure to thrive (n = 723, 27.5%) and feeding difficulties (n = 459,17.4%). Minor complications developed in n1518 patients (33%), including granulation  (n = 478, 10.3%), local infection (n = 384, 8.3%) and leakage (n = 279, 6%). In 464 (10%) patients, major complications occurred; the most common were systemic infection (n = 163, 3.5%) and cellulitis (n = 47, 1%). Severe complication like perforation occurred in less than 0.3%. Patients with lethal outcomes (n = 7, 0.15%) had severe comorbidities; and the cause of mortality was sepsis in all cases. Prematurity or young age did not affect complication rate. Patients with ventriculoperitoneal (VP) shunt had higher risk of major complications. In high-risk patients, laparoscopic-assisted PEG insertion had less major and severe complication than traditional pull technique. CONCLUSIONS: PEG is a safe operative technique; although minor complications are relatively common and occur in up to 1/3 of patients, there is a fairly low rate of severe complications. Two-thirds of PEG patients have at least one comorbidity. Patients with VP shunt have higher risk of major complications. In high-risk patients, laparoscopic-assisted PEG is recommended.

[Training for pediatric surgeons through the keyhole]. / Gyermeksebészeti szakképzés kulcslyukon keresztül.

INTRODUCTION AND AIM: Minimally invasive techniques are gaining popularity in pediatric surgery, confident knowledge in endoscopies is one of the main purposes of the training. This survey analyzed the laparoscopic training for pediatric surgeons. METHOD: We sent questionnaires to all trainees and pediatric surgeons specialized after 2012 by e-mail. The questionnaire focused on their opportunities for laparoscopy during the training and their subjective opinions. RESULTS: 34 questionnaires were sent by email. 17 trainees and 11 specialists responded (82%). The rate of endoscopic surgeries is 15% in the clinical centers without trauma surgery, and 2-10% in other training centers. Routine laparoscopies are performed in all centers, and in 40-60% of the centers, advanced endoscopies are also applied. Half of the surgeons performed laparoscopy in the first 2 years of training. An average of 20 laparoscopies were carried out by trainees in the 3-6th year. 50% of the trainees had the opportunity to use pelvitrainer, however, video-watching (100%) is the most common preparation before endoscopies. The surgeons' subjective opinion about having enough laparoscopic experience by the time of the specialty exam was yes: n = 6 (21%), sufficient: n = 12 (43%) and no: n = 10 (36%). The training could be more effective with more equipment, free courses on pelvitrainers or animal models, and with more patient and dedicated attitude of the instructors. CONCLUSION: Laparoscopy is in everyday practice in major centers, however, trainees do not have enough experience in terms of its confident use. Endoscopic training could be better with the regular use of pelvitrainers and more surgical practice. Revision of the operation list and the rise in the number of laparoscopies are necessary. Orv Hetil. 2018; 159(43): 1747-1753.

[The cognitive effects of ecstasy]. / Az ecstasy hatása a kognitív funkciókra.

The recreational drug ecstasy is widely used among dance clubbers for its acute euphoric and entactogenic effects. Ecstasy exerts its acute effects by increasing the extracellular concentration of monoamines in the brain by reversing the functions of reuptake mechanisms. These elevations in extracellular monoamine concentrations result in wake promoting effects, body hyperthermia and reductions in local cerebral blood flow. However, on the long-run, ecstasy reduces serotonin concentration and density of serotonergic markers in several brain areas. Functional deficits, like sleep disturbances, anxiogenic- and aggressive behavioral responses and mood disorders also may occur. However, one of the most prominent adverse effects is related to the cognitive functions. Following ecstasy use attenuated retro- and prospective memory and defective higher order cognitive functions can be observed, especially in heavy users. Several studies indicated the involvement of the endocannabinoid system, the sleep regulating centers and the hypothalamic-pituitary-adrenal axis based on or parallel to serotonergic damage in these processes. Recent evidence, however, also showed that changes in one of the latter systems can influence the functions of each other. In this review we summarize the related literature, and propose a complex mechanism for the long-lasting cognitive deficits following heavy ecstasy use.

Activation of 5-HT3 receptors leads to altered responses 6 months after MDMA treatment.

The recreational drug "Ecstasy" [3,4-methylenedioxymethamphetamine (MDMA)] has a well-characterised neurotoxic effect on the 5-hydroxytryptamine (5-HT) neurons in animals. Despite intensive studies, the long-term functional consequencies of the 5-HT neurodegeneration remains elusive. The aim of this study was to investigate whether any alteration of 5-hydroxytryptamine-3 (5-HT(3)) receptor functions on the sleep-wake cycle, motor activity, and quantitative EEG could be detected 6 months after a single dose of 15 mg/kg of MDMA. The selective 5-HT(3) receptor agonist m-chlorophenylbiguanide (mCPBG; 1 mg/kg, i.p.) or vehicle was administered to freely moving rats pre-treated with MDMA (15 mg/kg, i.p.) or vehicle 6 months earlier. Polysomnographic and motor activity recordings were performed. Active wake (AW), passive wake (PW), light slow wave sleep (SWS-1), deep slow wave sleep (SWS-2), and paradoxical sleep were classified. In addition, EEG power spectra were calculated for the second hour after mCPBG treatment for each stage. AW increased and SWS-1 decreased in the second hour after mCPBG treatment in control animals. mCPBG caused significant changes in the EEG power in states with cortical activation (AW, PW, paradoxical sleep). In addition, mCPBG had a biphasic effect on hippocampal theta power in AW with a decrease in 7 Hz and a stage-selective increase in the upper range (8-9 Hz). Effects of mCPBG on the time spent in AW and SWS-1 were eliminated or reduced in MDMA-treated animals. In addition, mCPBG did not increase the upper theta power of AW in rats pre-treated with MDMA. These data suggest long-term changes in 5-HT(3) receptor function after MDMA.

MDMA treatment 6 months earlier attenuates the effects of CP-94,253, a 5-HT1B receptor agonist, on motor control but not sleep inhibition.

The possible long-term effects of the recreational drug "ecstasy" (3,4-methylenedioxymethamphetamine, MDMA) on the function of 5-hydroxytryptamine-1B (5-HT(1B)) receptor in sleep and motor control were investigated using a selective 5-HT(1B) receptor agonist, 5-propoxy-3-(1,2,3,6-tetrahydro-4-pyrinzidyl)-1H-pyrrolo([3,2-b])pyridine hydrochloride (CP-94,253; 5 mg/kg). CP-94,253 or vehicle was administered to freely moving rats pre-treated with MDMA (15 mg/kg) or vehicle 6 months earlier, and polygraphic recording for 24 h and motor activity measurements were performed. Active wake (AW), passive wake (PW), light slow wave sleep (SWS-1), deep slow wave sleep (SWS-2), paradoxical sleep (PS), and diurnal rhythm were analyzed for the whole period. In additional, the EEG power spectrum was calculated for the second hour after the acute treatment for AW, PW, SWS-1, and SWS-2. 5-HT transporter (5-HTT) immunohistochemistry was measured in brain areas related to sleep and motor control 6 months after MDMA treatment. CP-94,253 increased AW and PW, decreased SWS-2 and PS, and altered parameters of diurnal rhythm in control animals. CP-94,253 decreased the EEG power spectra at higher frequencies. The effects of CP-94,253 on AW and diurnal rhythm were reduced or eliminated in MDMA-treated animals. MDMA treatment decreased 5-HTT fibre density in posterior hypothalamus, tuberomammillary nucleus, caudate putamen and ventrolateral striatum. These data suggest that long-term changes in 5-HT(1B) receptor function occur after serotonergic damage caused by a single dose of MDMA.

Decrease in REM latency and changes in sleep quality parallel serotonergic damage and recovery after MDMA: a longitudinal study over 180 days.

The recreational drug ecstasy [3,4-methylenedioxymethamphetamine (MDMA)], has been found to selectively damage brain serotonin neurons in experimental animals, and probably in human MDMA users, but detailed morphometric analyses and parallel functional measures during damage and recovery are missing. Since there is evidence that serotonin regulates sleep, we have compared serotonergic markers parallel with detailed analysis of sleep patterns at three time-points within 180 d after a single dose of 15 mg/kg MDMA in male Dark Agouti rats. At 7 d and 21 d after MDMA treatment, significant(30-40%), widespread reductions in serotonin transporter (5-HTT) density were detected in the cerebral cortex, hippocampus, most parts of the hypothalamus, and some of the brainstem nuclei. With the exception of the hippocampus, general recovery was observed in the brain 180 d after treatment. Transient increases followed by decreases were detected in 5-HTT mRNA expression of dorsal and median raphe nuclei at 7 d and 21 d after the treatment. Significant reductions in rapid eye movement (REM) sleep latency, increases in delta power spectra in non-rapid eye movement sleep and increased fragmentation of sleep were also detected, but all these alterations disappeared by the 180th day. The present data provide evidence for long-term, albeit, except for the hippocampus, transient changes in the terminal and cellular regions of the serotonergic system after this drug. Reduced REM latency and increased sleep fragmentation are the most characteristic alterations of sleep consistently described in depression using EEG sleep polygraphy.

The bcl-2/IgH rearrangement in a population of 204 healthy individuals: occurrence, age and gender distribution, breakpoints, and detection method validity.

This study assessed prevalence, frequency, age and gender distribution and breakpoint locations, and detection method validity for the bcl-2/IgH rearrangement in 204 healthy individuals. For this purpose, both classic two-step, nested, semi-quantitative PCR as well as a newly established sequence-specific, hybridization probe-based real-time quantitative PCR (RQ-PCR) were employed and tested for their sensitivity and specificity for detecting t(14;18) positive cells in healthy blood donors. Interestingly, almost a quarter (24%; 39/204) of all healthy individuals carried the translocation, confirming data of one large prior report [Summers KE, Goff LK, Wilson AG, Gupta RK, Lister TA, Fitzgibbon J. Frequency of the Bcl-2/IgH rearrangement in normal individuals: implications for the monitoring of disease in patients with follicular lymphoma. J Clin Oncol 2001;19(2):420-4]. Regarding presence as well as frequency of the translocation, no correlation to age (mean frequency 2.0:10(4), with a median of or=40 years) nor gender was detected. Comparing the two PCR approaches, a 95.1% concordance (194/204) regarding t(14;18) detection was determined for nested and RQ-PCR, with nested PCR being slightly more sensitive (reproducible detection limit l:10(5) cells versus 1:10(4); maximum detection limit l:10(6) versus 1:10(5)). Sequence analysis confirmed individual breakpoints for all samples analyzed (29/29), indicating detection validity for both PCR approaches and ruling out contamination. The breakpoint location distribution pattern appeared to be comparable to the pattern seen with follicular lymphoma (FL) patient collectives. In conclusion, clonal bcl-2/IgH rearrangements are indeed a very frequent observation in healthy individuals, and appear to be independent of age and gender in regard to presence and frequency. This represents a conflicting finding in context of potential biological significance, and presents a potential disruptive factor for minimal residual disease (MRD) monitoring in FL patients. Prospective future trials will have to clarify the biological significance of this important observation.

Secondary end-to-end repair of extensive facial nerve defects: surgical technique and postoperative functional results.

BACKGROUND: Repair of the transected facial nerve is imperative for restoration of muscle function, including the ability to produce appropriate facial expressions. Injury might involve the main trunk and its several branches. Restoration of function presupposes meticulous repair of all injured nerve branches. METHODS: Here we report three cases of secondary tension-free end-to-end coaptation of a transected trunk and branches of the facial nerve by removal of the superficial part of the parotid gland. RESULTS: Facial tone and symmetry at rest and motion were achieved. In two patients, a slight residual synkinesis is observed under stress. CONCLUSIONS: Direct end-to-end coaptation of the facial nerve and its branches by the technique described should be considered before deciding on grafts or rerouting procedures to deal with gaps of up to 15 mm. This technique is not recommended in the presence of infection and nerve defects. Intensive postoperative physiotherapy is required for optimal results.

Increased wakefulness, motor activity and decreased theta activity after blockade of the 5-HT2B receptor by the subtype-selective antagonist SB-215505.

Serotonin-2 receptor antagonists, like ritanserin, greatly enhance deep slow wave sleep (SWS-2) and low-frequency EEG power in humans and rodents. 5-HT(2A) and 5-HT(2C) receptors may be involved in these effects, but the role of the 5-HT(2B) receptor is still unclear. To investigate the role of the 5-HT(2B) receptor in regulation of the sleep-wake cycle, the subtype-selective antagonist SB-215505 (0.1, 0.3 and 1.0 mg kg(-1) i.p.) was administered to Sprague-Dawley rats at light onset (beginning of passive phase). EEG, EMG and motor activity were recorded during the subsequent 8 h. SB-215505 dose-dependently increased wakefulness (W) at the expense of the intermediate stage of sleep, paradoxical sleep (PS) and SWS-2 in the first hour. Parallel to increased W, significantly increased motor activity was found. Spectral analysis of the EEG in W showed a dose-dependent decrease in power density in the 3-8 Hz frequency range (maximum effect at 6 Hz). In light slow wave sleep and SWS-2, the drug reduced low-frequency (<8 Hz) EEG power, suggesting decreased sleep intensity after SB-215505 treatment. In PS, the drug dose-dependently decreased EEG power solely in the theta (6-9 Hz) band, primarily affecting the peak power value (7 Hz). The well-known SWS-2 enhancing effect of 5-HT(2) receptor antagonists is mediated by 5-HT(2A) and/or 5-HT(2C) receptors. In contrast, blockade of 5-HT(2B) receptors increases motor activity and W along with decreased theta activity during W and PS. Activation of 5-HT(2B) receptors may contribute to initiation of sleep and to theta generation during W and PS under physiological conditions.

Effect of two noncompetitive AMPA receptor antagonists GYKI 52466 and GYKI 53405 on vigilance, behavior and spike-wave discharges in a genetic rat model of absence epilepsy.

The present study was conducted to investigate the effects of two noncompetitive alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor antagonists, GYKI 52466 and GYKI 53405 (the racemate of talampanel) on the generation of spike-wave discharges (SWD) parallel with the vigilance and behavioral changes in the genetic absence epilepsy model of WAG/Rij rats. Intraperitoneal (i.p.) administration of GYKI 52466 (1-[4-aminophenyl]-4-methyl-7,8-methylenedioxy-5H-2,3-benzodiazepine; 3, 10 and 30 mg/kg, i.p.), the prototypic compound of the 2,3-benzodiazepine family, caused a fast dose-dependent increase in the number and cumulative duration of SWD. These changes were accompanied by dose-dependent increase in duration of light slow wave sleep (SWS1) and passive awake, vigilance states associated with the presence of SWD. In addition a short, transient behavioral activation occurred that was followed by strong ataxia and immobility, decrease of active wakefulness and increase in deep slow wave sleep. GYKI 53405 (7-acetyl-5-(4-aminophenyl)-8-methyl-8,9-dihydro-7H-1,3-dioxolo[4,5-b][2,3]benzodiazepine, the racemate of talampanel, 16 mg/kg, i.p.) failed to affect any measure of SWD and vigilance. When used as a pretreatment, GYKI 52466 (10 mg/kg) slightly attenuated SWD-promoting effects of the 5-HT1A receptor agonist 8-OH-DPAT, it decreased cumulative duration and average time of paroxysms. In conclusion, AMPA receptors play moderate role in regulation of epileptic activity, and some of these effects are connected to their effects on vigilance in this model.

Effects of a single dose of 3,4-methylenedioxymethamphetamine on circadian patterns, motor activity and sleep in drug-naive rats and rats previously exposed to MDMA.

RATIONALE: Despite the well documented neurochemical actions of 3,4-methylenedioxymethamphetamine (MDMA), acute effects in rats previously exposed to the drug have not been extensively explored. OBJECTIVE: To examine motor activity and vigilance effects of MDMA in drug-naive rats and in rats exposed to the drug 3 weeks earlier. METHODS: MDMA (15 mg/kg, i.p.) was administered to Dark Agouti rats. Motor activity, wakefulness, light slow wave sleep (SWS-1), deep slow wave sleep (SWS-2) and paradoxical sleep (PS), sleep and PS latencies were measured. Acrophases and amplitudes of the 24 h cycles were calculated by cosinor analysis. In parallel groups, local cerebral glucose utilization (lCMRglu) and (3H)-paroxetine binding were measured in motor areas of the brain. RESULTS: In drug-naive rats MDMA caused marked increases in motor activity and wakefulness for at least 5-6 h. Circadian patterns of motor activity and sleep/vigilance parameters were altered up to 5 days after treatment. Despite most parameters tending to return to normal, there were still significant effects of MDMA on motor activity, wakefulness, and SWS-2 28 days later. Acute MDMA administration caused significant increases in lCMRglu, but after 3 weeks lCMRglu was decreased in the same brain areas. No significant change in [3H]paroxetine binding was observed in motor areas, although significant reductions were seen elsewhere (neocortex -81%). In rats exposed to MDMA 3 weeks earlier, most acute effects induced by MDMA administration were similar to those in drug-naive rats, but shorter duration of the acute effects were found in motor activity and vigilance. CONCLUSIONS: Our findings provide evidence that MDMA use can lead to long-term changes in regulation of circadian rhythms, motor activity and sleep generation.

Adventitial stripping of the radial and ulnar arteries in Raynaud's disease.

Adventitial stripping of the palmar arch, the palmar common digital arteries, or the proper digital arteries is a last resort in the treatment of refractory primary or secondary Raynaud's phenomenon. Seven patients who had adventitial stripping of the ulnar and radial arteries proximal to the wrist and resection of the nerve of Henle, if identifiable, are presented. All of them were evaluated by telethermography, acral rheography, and a questionnaire before and after surgery. All were asymptomatic after surgery with satisfactory healing of the ulcers at the fingertips. None of them relapsed during the follow-up time of 1.5 years.