What is the treatment for hyperhidrosis?

Hyperhidrosis At A Glance

• Hyperhidrosis, or excessive sweating, is a common disorder.
• Axillary hyperhidrosis is excess sweating of the underarms.
• Palmoplantar hyperhidrosis is excess sweating of the palms and soles.
• Hyperhidrosis usually occurs in people who are otherwise healthy.
• The approach to treating hyperhidrosis generally proceeds from OTC antiperspirants to prescription antiperspirants, iontophoresis, oral anticholinergic medications, Botox, and surgery.

Aluminum chloride hexahydrate

When regular antiperspirants fail, as they often do, to remedy hyperhidrosis most doctors start by recommending aluminum chloride hexahydrate (Drysol), a prescription-strength version of aluminum chloride. It is applied just before bedtime seven to 10 nights in a row, then roughly once a week thereafter to maintain improvement. This treatment works reasonably well for many patients whose problem is excessive underarm sweating, but is not satisfactory for most of those with palm and sole sweating.The main side effect with Drysol is irritation, which can sometimes, but not always, be overcome by reducing the frequency of use or applying antiinflammatory medications such as lotions containing hydrocortisone.

Iontophoresis

Iontophoresis was introduced over 50 years ago as a treatment for excessive sweating. Its exact mechanism of action is still unclear. The procedure uses water to conduct an electric current to the skin which combats production of sweat. Current is applied typically for 10-20 minutes per session, initially with two to three sessions per week followed by a maintenance program of treatments at one- to three-week intervals, depending upon the patient's response. Iontophoresis treatments sound potentially painful but, in fact, they are not.

Botox

Botulinum toxin (Botox), a muscle poison much in the news as a cosmetic treatment for wrinkles, has actually been used in many areas of medicine for some time, such as in the treatment of muscle spasms, and certain types of headaches. Its latest medical niche is the treatment of excessive underarm sweating.

Surgery

Thoracic sympathectomy is surgical interruption of the sympathetic nerves responsible for sweating. Sympathectomy is an operation intended to destroy part of the nerve supply to the sweat glands in the skin. The surgeon inserts a special endoscopic instrument into the chest between two ribs just below the armpit. The lung is briefly deflated to better visualize and destroy the nerves. Sympathectomy is both effective and risky

Percutaneous Endoscopic Gastrostomy

What is percutaneous endoscopic gastrostomy (PEG)?

Percutaneous endoscopic gastrostomy (PEG) is a surgical procedure for placing a feeding tube without having to perform an open operation on the abdomen (laparotomy). A gastrostomy (a surgical opening into the stomach) is made percutaneously (through the skin) using an endoscope (a flexible, lighted instrument) to determine where to place the feeding tube in the stomach and secure it in place.

What is the purpose of PEG?

The aim of PEG is to feed those who cannot swallow. Irrespective of the age of the patient or their medical condition, the purpose of PEG is to provide fluids and nutrition directly into the stomach.

Who does PEG?

PEG is done by a doctor. The doctor may be a general surgeon, an otolaryngologist (ENT specialist), a gastroenterologist (GI specialist), etc.

Where is PEG done?

PEP is performed in a hospital or outpatient surgical facility.

How is PEG done?

Local anesthesia (usually lidocaine or another spray) is used to anesthetize the throat. An endoscope (a flexible, lighted instrument) is passed through the mouth, throat and esophagus to the stomach. The doctor then makes a small incision (cut) in the skin of the abdomen and pushes an intravenous cannula (an IV tube) through the skin into the stomach and sutures (ties) it in place.

When can the PEG patient go home?

The patient can usually go home the same day or the next morning.

What are the possible complications with PEG?

Possible complications include wound infection (as in any kind of surgery) and dislodging or malfunction of the tube.

What are the advantages of PEG?

PEG takes less time, carries less risk and costs less than a classic surgical gastrostomy which requires opening the abdomen. Therefore, when feasible, PEG is preferable to a classic gastrostomy.

SCID

A combined deficiency of the immune system's two major weapons -- antibodies and T cells -- are genetically missing or disabled. Severe combined immunodeficiency disease (SCID) is rare. The chances of a child being born with SCID are about one in 500,000 births. Until recent years, it was always fatal.

There are a number of different causes of SCID. Each is caused by a different genetic defect, and each develops along a different pathway:

• X-linked SCID, the most common type, a genetic flaw damages molecules that allow T cells and B cells to receive signals from crucial growth factors.

• ADA deficiency results from the lack of an enzyme called adenosine deaminase (ADA) that helps cells, especially immune cells, to get rid of toxic byproducts. Without ADA, poisons build up and kill the lymphocytes.

• Purine nucleoside phosphorylase (PNP) deficiency results from a similar enzyme problem, but B cells are less affected and the immunodeficiency is less severe, although affected patients may have other problems (neurologic).

• Yet another type of SCID is known as MHC class II deficiency or bare lymphocyte syndrome. MHC molecules are specialized proteins found on the surface of body cells and play an important role in bone marrow transplantation. Class II MHC molecules, which appear on many immune cells, allow B cells and other immune cells to recognize, interact with, and activate T cells. Without this B cell/T cell communication, the immune defenses are compromised.

Whatever the underlying problem that causes SCID, the consequences are nearly always the same. The child lacks almost all immune defenses, develops life-threatening infections, and needs major treatment to survive beyond infancy. Although the specifics vary from case to case, these children are vulnerable to serious infections caused by bacteria, as is typical with a B cell deficiency, and also by viruses and opportunistic germs, as is the case with a T cell deficiency.

Usually by the time a baby is three months old, he or she (because many cases of SCID are X-linked, SCID is more common in boys than in girls) is likely to have persistent thrush or extensive diaper rash. Weakened by chronic diarrhea, the baby may stop growing and gaining weight. Some children develop a sharp, persistent cough with Pneumocystis pneumonia, blood disorders, or chronic hepatitis. Meningitis and blood poisoning pose a constant threat.

Viruses that are not harmful in children with normal immunity can pose a serious danger. For example, the virus that causes chicken pox (varicella) can trigger a severe infection in the lungs and the brain of SCID patients. Other threats come from the viruses that cause cold sores (herpes simplex) and measles (rubeola).

The treatment of SCID constitutes a medical emergency. The immediate concern is to bring any current infections under control, and to strengthen the baby's weakened condition with adequate nutrition. IVIG may help to bolster the immune responses. A lasting remedy, however, requires a more drastic approach. A bone marrow transplant from a matched donor or parent is arranged as quickly as possible. Children whose SCID is due to ADA deficiency have another alternative. Injections of PEG-ADA will protect them against recurrent infections, allow them to control ordinary childhood infections such as chicken pox, and make it feasible for them to lead nearly normal lives.

Severe combined immunodeficiency disease has also been called the boy-in-the-bubble disease or bubble boy disease.

BYE BYE ABO BLOOD GROUPS

Scientists have developed a way of converting one blood group into another.

· The technique potentially enables blood from groups A, B and AB to be converted into group O negative, which can be safely transplanted into any patient. The method, which makes use of newly discovered enzymes, may help relieve shortages of blood for transfusions.

· The work, led by the University of Copenhagen, is reported in the journal Nature Biotechnology.

· Using incompatible blood during a transfusion can put a patient's life in danger.

· The blood cells of people with group A and B blood contain one of two different sugar molecules, which act as "antigens", triggering an immune system response.

· People with AB blood have both types of molecule, while those with group O blood have neither.

· People produce antibodies against the antigens they lack.

· This means groups A, B and AB can only be given to patients with compatible blood, while O - as long as it is rhesus negative - can be given to anyone.

· The new technique works by using bacterial enzymes to cut sugar molecules from the surface of red blood cells.

· After a search of 2,500 fungi and bacteria the researchers discovered two bacteria - Elizabethkingia meningosepticum and Bacterioides fragilis - which contained potentially useful enzymes.

· They found that enzymes from both bacteria were able to remove both A and B antigens from red blood cells.

· .

· "The method may enable manufacture of universal red cells, which would substantially reduce pressure on the blood supply."

· The new process cannot do anything about another antigen that can trigger an immune response. Blood which carries this antigen is known as rhesus positive.

· This means that only rhesus negative blood can be used to create the new type of group O supplies.

• ENDO-BETA-GALACTOSIDASE FROM BACTEROIDES FRAGILIS. The new enzymes, discovered after detailed exploration of the great diversity of known bacteria available, come from bacteria with sometimes unlikely names such as Elizabethkingia, (Queen Elizabeth). These enzymes can remove the galactose or N-acetylgalactosamine molecules present on the surface of the red blood cells characterizing the A, B and AB antigens. The prohibitive cost and low efficiency of previously known enzymes meant that using them for blood group conversion was not viable. But these new enzymes have an unusual catalytic mechanism that changes that.

Are You Right Eyed Or Left Eyed?

A person has two hands, two legs, two eyes, two cerebral hemispheres. But it is only at first sight that a human being is a symmetric creature. Firstly, we have a leading hand, the right one with the majority of people, secondly, we have a leading eye. Thirdly, the brain is functionally asymmetric: the left hemisphere (with the right-handers) is mainly connected with abstract-logical thinking and to a larger extent - with speech, the right hemisphere – with image sensitivity.

Coming back to eyes, the right eye is the leading one among the two thirds of people, and the left one among one third of people. Special tests have been developed to determine this. Do these individual differences influence the visual information perception process, for example, perception of texts, on the left and on the right?

The experiment involved all right-handed students, but some of them had the right eye leading, the others – the left eye leading. All probationers were offered to read a text on the PC screen, the text being placed either in the right or in the left part of the screen, while the probationers’ head was oriented to the center (in such conditions, visual information from the left half-field of vision was addressed to the right hemisphere, and vice versa). It has turned out that the “left-eyed” probationers read the text quicker when it is placed on the left, than the text placed on the right. As for the “right-eyed” individuals, no such differences were noticed with them.

More detailed analysis has proved that when the “left-eyed” probationers were reading the left-side text, the brain perceived (during a single eye fixation on some text fragment) more symbols than in case of reading the right-hand text.

In other words, in the left half-field of vision, glance fixation is characterized by higher “information capacity”. This is directly connected with the speed of reading: the more symbols the glance perceives during one fixation, the quicker a person reads. There is one more sign of successfulness of reading: in the course of reading, the glance periodically returns back to the already read word (apparently due to difficulty of perception). Thus, in the left-sided text, the “left-eyed” probationers made less returns than they did in the right-sided text, which means higher successfulness of the “left” text recognition. Besides, the majority of the “left-eyed” persons performed faster quick eye movements – saccades – to the left than to the right.

Physiologists can only make assumptions about the reasons for such differences.

As all the probationers are right-handed persons, the control over their leading right hand is performed by the left hemisphere. With the right-eyed, the same left hemisphere also controls the leading right eye. As for the left-eyed persons, the leading left eye is controlled by the right hemisphere, which is free from control over the leading hand’s movements.

And this works out better. Therefore, the “left-eyed” persons read quicker on their left.

Where can this knowledge prove useful? Apparently, it makes sense to take the leading eye into account for production of various video-products, for example, training ones. Special objects (spoons, door-handles) are produced, even though not in Russia, for the left-handed, but there is nothing special made for the “left-eyed” persons. Maybe this will be done in the future

Teens Eat Poorly Now, May Breathe Worse Later

• A lack of fruit and fish in teenagers' diets may keep them from attaining full lung capacity and set them up for later respiratory problems.
• In a study, low fruit intake was associated with 1.3% lower lung function than predicted while low vitamin C intake was associated with the same degree of lung capacity impairment (both P≤0.05).
• Low intake of fruit, vitamin E, and n-3 fatty acid consumption was also linked to respiratory symptoms, including chronic bronchitis, wheezing and asthma.
• These relatively small effects were "not likely to have a functional impact on current respiratory health, but if these effects are being felt in the teen years when their lung function should be close to optimal levels, it's possible that they won't achieve their optimal levels and that the complaints of chronic bronchitis and wheeze may cause them to loose lung function by airway remodeling.
• “This "may have long-term consequences because lower pulmonary function in adults has been associated with increased morbidity and earlier mortality.
• Vitamin E intake in the lowest quantity below 5.2 mg per day was associated with an increased likelihood of reported asthma (11.6% versus 8.5%, adjusted OR 1.48, P≤0.05) compared with higher intake.

Intake of dietary n-3 fatty acids in daily vitamin C intake in the lowest quintile below 85 mg, although in the range of the IOM-recommended 65 to 90 mg per day, was associated with:

• Lower forced vital capacity (4.56 versus 4.61 L, difference -1.3%, 95% CI -2.4 to -0.02) compared with higher intake adjusted for calories.
• A trend toward lower FEV₁ (3.91 versus 3.95 L, difference -1.0%, 95% CI -2.2 to 0.1) compared with higher intake adjusted for calories.
• Higher odds of forced vital capacity less than 85% of predicted (odds ratio 1.63, 95% CI 1.05 to 2.50, P=0.03) compared with higher intake.

"This suggests the current daily recommended intake for vitamin C may not be adequate to protect lung function,"

Intake of dietary n-3 fatty acids in the lowest quintile below 22 mg was associated with:

• Chronic bronchitic symptoms (26.3% versus 20.0%, OR 1.37, P≤0.05).
• Wheeze (44.0% versus 37.0%, OR 1.34, P≤0.01).
• Asthma (12.7% versus 8.2%, OR 1.68, P≤0.01).

Teen smoking in combination with low antioxidant vitamin C intake showed even greater risk for respiratory symptoms.

The researchers also pointed out that an observational study "cannot establish the temporal relationship between diet and respiratory outcomes. It may be that the critical period for diet's effect on the respiratory system is during early childhood when there is rapid differentiation and growth."

Buerger's Disease

Etiology and Pathophysiology:Smoking is very closely related to Buerger's disease and smoking history is one of the criterion for diagnosing the disease. In general if the patient absolutely abandons smoking the course of the disease will be invariably benign, but if smoking continues any treatment will ultimately be futile. Though "passive smoking" has adverse effect on cardiovascular system, non smokers should never develop the disease. Active smokers can be indentified by measuring levels of continine, the major metabolite of nicotine in urine. Since all smokers do not develop the disease an immunopathogenesis is considered probable. It has been proposed in Japanese that presence of a gene linked to some HLA antigens might control the susceptibility to the disease. Hypercoagulable state has been observed in association with the disease. Hepatitis B Virus and rickettssiosis may contribute to pathogenesis, but this role is uncertain.

Buergers disease is an inflammatory occlusive disease which involves all layers of medium sized and small arteries of the extremities. Involved superficial veins bear a close resemblance to those in the affected artery. Majority of the patients develop critical limb ischemia with trophic lesions are distal to ankle, the anklebrachial doppler index could be normal in early stage. Toe pressures can be measured and if it is less than 30 mm Hg, the healing of ulcers is unlikely. The disease though commences peripherally, may gradually extend proximately occluding the larger arteries.

Clinical Presentation : varies with the stage of the disease. The patients may present with foot claudication and later with calf claudication. Gangrene and ulceration may follow the above symptoms, but many times they may occur without previous history of claudication. The stepwise progession of the disease as seen in atherosclerasis may not occur in Buergers disease. Parasthesia, coldness and skin colour changes are common complaints. Dependent rubor and slow venous filling are commonly seen. Gangrene and ulceration usually follow minor trauma and with development of secondary infection they may progress proximally and are associated with intolerable rest pain.

Recurrent superficial thrombophlebitis marked by redness and tenderness over the affected vain, can occur in arm, leg or the foot. The symptoms usually disappear over 2-3 weeks, leaving behind blackish-brown pigmentation. "Phlebitis migrans" is characteristic of Buergers disease, but is often missed both by the patient and the doctor.

Of 255 patients treated by shionaya from an institution in India 98% were males. The major presenting symptoms were.

1. Parasthesia, Coldness, Cyanosis - 37%
2. Gangrene or Ulcer - 18%
3. Foot Claudication - 15%
4. Calf Claudication - 16%
5. Rest pain - 10%
6. Thrombophlebitis - 3%

On continuous follow up-72% develop Ulcer/Gangrene, 42% develop phlebitis migrans and about 90% eventually have upper extremity involvement. In the above series 83% had 3 or 4 limb involvement and 17% had 2 limb involvement and NONE had a single limb involvement.

In our experience with about 80 patients with Buergers disease, we have not seen a single patient without ulcer or gangrene!

The criteria for diagnosis of Burgers disease include (1) History of smoking (2) Onset before the age of 50 years (3) Infrapopliteal arterial occlusive disease (4) Either upper limb involvement or phlebitis migrans (5) Absence of atherosclerotic risk factors other than smoking. Arteriographic findings serve as supporting evidence and will be discussed later..