Interventions for hyperhidrosis in secondary care : a systematic review and value-of-information analysis

Background: Hyperhidrosis is uncontrollable excessive sweating that occurs at rest, regardless of temperature. The symptoms of hyperhidrosis can significantly affect quality of life. The management of hyperhidrosis is uncertain and variable. Objective: To establish the expected value of undertaking additional research to determine the most effective interventions for the management of refractory primary hyperhidrosis in secondary care. Methods: A systematic review and economic model, including a value-of-information (VOI) analysis. Treatments to be prescribed by dermatologists and minor surgical treatments for hyperhidrosis of the hands, feet and axillae were reviewed; as endoscopic thoracic sympathectomy (ETS) is incontestably an end-of-line treatment, it was not reviewed further. Fifteen databases (e.g. CENTRAL, PubMed and PsycINFO), conference proceedings and trial registers were searched from inception to July 2016. Systematic review methods were followed. Pairwise meta-analyses were conducted for comparisons between botulinum toxin (BTX) injections and placebo for axillary hyperhidrosis, but otherwise, owing to evidence limitations, data were synthesised narratively. A decision-analytic model assessed the cost-effectiveness and VOI of five treatments (iontophoresis, medication, BTX, curettage, ETS) in 64 different sequences for axillary hyperhidrosis only. Results and conclusions: Fifty studies were included in the effectiveness review: 32 randomised controlled trials (RCTs), 17 non-RCTs and one large prospective case series. Most studies were small, rated as having a high risk of bias and poorly reported. The interventions assessed in the review were iontophoresis, BTX, anticholinergic medications, curettage and newer energy-based technologies that damage the sweat gland (e.g. laser, microwave). There is moderate-quality evidence of a large statistically significant effect of BTX on axillary hyperhidrosis symptoms, compared with placebo. There was weak but consistent evidence for iontophoresis for palmar hyperhidrosis. Evidence for other interventions was of low or very low quality. For axillary hyperhidrosis cost-effectiveness results indicated that iontophoresis, BTX, medication, curettage and ETS was the most cost-effective sequence (probability 0.8), with an incremental cost-effectiveness ratio of £9304 per quality-adjusted life-year. Uncertainty associated with study bias was not reflected in the economic results. Patients and clinicians attending an end-of-project workshop were satisfied with the sequence of treatments for axillary hyperhidrosis identified as being cost-effective. All patient advisors considered that the Hyperhidrosis Quality of Life Index was superior to other tools commonly used in hyperhidrosis research for assessing quality of life. Limitations: The evidence for the clinical effectiveness and safety of second-line treatments for primary hyperhidrosis is limited. This meant that there was insufficient evidence to draw conclusions for most interventions assessed and the cost-effectiveness analysis was restricted to hyperhidrosis of the axilla. Future work: Based on anecdotal evidence and inference from evidence for the axillae, participants agreed that a trial of BTX (with anaesthesia) compared with iontophoresis for palmar hyperhidrosis would be most useful. The VOI analysis indicates that further research into the effectiveness of existing medications might be worthwhile, but it is unclear that such trials are of clinical importance. Research that established a robust estimate of the annual incidence of axillary hyperhidrosis in the UK population would reduce the uncertainty in future VOI analyses

Importance of anorectal manometry after defi nitive surgery for Hirschsprung’s disease in children

Objectives: The purpose of this investigation is to evaluate anorectal function after defi nitive surgery for Hirschsprung’s disease (HD) by  anorectal manometry.Materials and Methods: We evaluated the anorectal manometric  assessment of 18 children who were operated for HD. Functional outcomeswere determined by a questionnaire. Rectoanal inhibitory refl ex (RAIR) and maximum anal resting pressure (MARP) were monitored. The results were compared between obstructive patients and asymptomatic patients. Results: The median age at defi nitive operation was 19 months (range 12–72 months). Anorectal manometry was performed in 14 male and 4 female patients. All the cases underwent three staged procedure for HD  and modifi ed Duhamel procedure was performed as defi nitive procedure for all the patients. Mean age was 4.3 months (range 25 days to 5 years) at time of diagnosis. Post-operative enterocolitis or severe constipation  was observed in seven patients (38.8%). There were no patients with incontinence. Eighteen patients underwent anorectal manometry meanly 2 years after defi nitive operation. RAIR was absent in 14 (77.7%) patients and abnormal in 4 (22.2%). There were no signifi cant differences in the MARP values between symptomatic and asymptomatic patients. Conclusion: The results of our study showed that the majority of the  patients have impaired anorectal motility. There were no signifi cantdifferences in the results of the functional studies for the seven patients with symptoms of obstruction or constipation when compared with  asymptomatic patients after surgery for HD.Key words: Hirschsprung’s disease, anorectal manometry, constipation, enterocolitis, complication

Effects of the menstrual cycle on injection pain due to rocuronium

WOS: 000325732900009PubMed: 23965205Study Objective: To investigate the effect of the menstrual cycle on rocuronium injection pain. Design: Prospective, randomized, double-blinded study. Setting: Academic medical center. Patients: 80 ASA physical status 1 and 2 women scheduled for elective surgery with general anesthesia. Measurements: Patients were divided into two groups according to their time in the menstrual cycle. Forty patients at days 8 to 12 of the menstrual cycle were considered to be at the follicular phase (Group F), and 40 patients at days 20 to 24 of the menstrual cycle were considered to be at the luteal phase (Group L).Withdrawal movements were recorded. Main Results: Overall frequency of withdrawal movements was significantly higher in Group L than Group F (P < 0.001). The mean withdrawal movement score was 1.77 +/- 0.76 in Group L and 0.52 +/- 0.67 in Group F. Conclusion: Menstrual cycle phases affect the severity of rocuronium injection pain. Women exhibit greater pain sensitivity from rocuronium injection in the luteal phase than the follicular phase. (c) 2013 Elsevier Inc. All rights reserved

The Role of Preconditioning and N-Acetylcysteine on Oxidative Stress Resulting From Tourniquet-Induced Ischemia-Reperfusion in Arthroscopic Knee Surgery

Background: The aim of this study was to investigate the effects of ischemic preconditioning (IPC) and N-acetylcysteine (NAC) on oxidative stress resulting from tourniquet-induced ischemia-reperfusion (IR) period in arthroscopic knee surgery