Thoracoscopic sympathectomy increases efferent cardiac vagal activity and baroreceptor sensitivity

The success rate and associated risk factors of CT-guided percutaneous radiofrequency sympathectomy in the treatment of primary hyperhidrosis: A retrospective observational trial

PURPOSE

The aim of this study was to investigate the success rate of surgical technique and associated risk factors based on the follow-up of patients who underwent CT-guided percutaneous radiofrequency sympathectomy (RFS) to treat primary hyperhidrosis (PH).

METHODS

370 patients who underwent RFS for PH treatment between January 2018 and April 2022 were enrolled. Patients responded to a questionnaire and telephone follow-up on the effects of treatment and their electronic medical records and imaging findings were reviewed. Logistic regression was performed to identify risk factors related to the success rate of surgical technique.

RESULTS

A temperature difference ≥2 °C before and after procedure was defined as a successful surgical technique. Among the 370 patients (740 sides), 637 sides had successful RFS, and the technical success rate was 86.1 %. Immediately after procedure, 636 sides (85.9 %) were completely dry, 64 (8.7 %) were partially dry, and 40 (5.4 %) were still wet. During the longest follow-up period (54 months), 103 patients relapsed. The median hyperhidrosis disease severity scale score on both sides decreased from 4 to 1 after RFS. According to logistic regression analysis, only the pre-post pulse index was associated with the success rate of surgical technique (odds ratio, 1.14; 95 % confidence interval, 1.06-1.23; p = 0.0004).

CONCLUSIONS

We observed that the immediate efficiency and success rate of surgical technique after RFS for PH treatment were relatively high, although there is a possibility of recurrence in the long term. In general, RFS is a safe and effective procedure for alleviating the symptoms of patients with hyperhidrosis.

Development and Validation of a Nomogram to Predict Recurrence of Primary Hyperhidrosis after CT-guided Percutaneous Radiofrequency Sympathectomy

PURPOSE

To evaluate the recurrence rate of primary hyperhidrosis (PH) after computed tomography (CT)-guided radiofrequency sympathectomy (RFS) and identify risk factors associated with recurrence.

MATERIALS AND METHODS

A total of 290 patients with PH who underwent CT-guided RFS were included in this retrospective cohort study. The electronic medical record was reviewed for patients' information and procedural parameters. Follow-ups were conducted for recurrence rate, and Hyperhidrosis Disease Severity Scale was used to assess presence or absence of recurrence. Stepwise regression and the least absolute shrinkage and selection operator regression algorithms were used for feature selection.

RESULTS

The recurrence rate 1 year after procedure was 17.6%. Male (hazard ratio [HR], 2.35; 95% confidence interval [CI], 1.08-5.15), low postoperative palm or foot temperature (HR, 0.77; 95% CI, 0.60-0.98), high postoperative heart rate (HR, 1.06; 95% CI, 1.02-1.10), low preoperative and postoperative hospital anxiety and depression score difference (HR, 0.59; 95% CI, 0.43-0.80), and the absence of compensatory hyperhidrosis immediately after procedure (HR, 0.46; 95% CI, 0.22-0.98) were established as independent factors affecting prognosis. A nomogram was built accordingly. The C indices of the training and testing sets were 0.773 and 0.659, respectively.

CONCLUSIONS

Follow-up results showed that the recurrence rate of PH treated with CT-guided RFS was low. This study constructed and validated a nomogram to predict the recurrence of PH 1 year after CT-guided RFS, which is convenient for interventionalists to evaluate accurately the prognosis of patients postoperatively and to identify high-risk patients who need more active treatment.

Increased Incidence of Premenstrual Syndrome in Females with Palmar Hyperhidrosis

Background: Premenstrual syndrome (PMS) is a common disorder affecting the quality of life of women of reproductive age. In a previous study, sex hormone imbalances and alterations in autonomic function were present in PMS, with parasympathetic dysfunction and sympathetic overactivity during the late luteal phase. Palmar hyperhidrosis (PH) presents with oversweating, heat and emotional stimulation, sympathetic hyperactivity and parasympathetic hypofunction. We hypothesized that the incidence of PMS is increased in females with PH. Methods: Data were retrieved from the Taiwanese National Health Insurance Database. The patients with PH were identified by the International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) disease code 780.8. Female patients matched by age and index day were used as the control group. The incidence of PMS was considered an outcome by the ICD-9-CM disease code 625.4. The factors related to PMS were analyzed by Cox regression. Results: The adjusted hazard ratio for the incidence of PMS was 1.276 (95% confidence interval: 1.05–1.488) in females with PH. Conclusions: This study found a positive correlation between PMS and female PH patients. Patients and physicians must understand the relationship of PMS with autonomic function alterations and other risk factors to prevent this problematic disorder.

Peat smoke inhalation alters blood pressure, baroreflex sensitivity, and cardiac arrhythmia risk in rats

Wildland fires (WF) are linked to adverse health impacts related to poor air quality. The cardiovascular impacts of emissions from specific biomass sources are however unknown. The purpose of this study was to assess the cardiovascular impacts of a single exposure to peat smoke, a key regional WF air pollution source, and relate these to baroreceptor sensitivity and inflammation. Three-month-old male Wistar-Kyoto rats, implanted with radiotelemeters for continuous monitoring of heart rate (HR), blood pressure (BP), and spontaneous baroreflex sensitivity (BRS), were exposed once, for 1-hr, to filtered air or low (0.38 mg/m³ PM) or high (4.04 mg/m³) concentrations of peat smoke. Systemic markers of inflammation and sensitivity to aconitine-induced cardiac arrhythmias, a measure of latent myocardial vulnerability, were assessed in separate cohorts of rats 24 hr after exposure. PM size (low peat = 0.4-0.5 microns vs. high peat = 0.8-1.2 microns) and proportion of organic carbon (low peat = 77% vs. high peat = 65%) varied with exposure level. Exposure to high peat and to a lesser extent low peat increased systolic and diastolic BP relative to filtered air. In contrast, only exposure to low peat elevated BRS and aconitine-induced arrhythmogenesis relative to filtered air and increased circulating levels of low-density lipoprotein cholesterol, complement components C3 and C4, angiotensin-converting enzyme (ACE), and white blood cells. Taken together, exposure to peat smoke produced overt and latent cardiovascular consequences that were likely influenced by physicochemical characteristics of the smoke and associated adaptive homeostatic mechanisms.

Heart rate variability as a potential diagnostic tool to predict compensatory hyperhidrosis after sympathectomy in patients with primary focal hyperhidrosis

Background

Primary focal hyperhidrosis (PFH) is associated with autonomic nervous activity, and studies investigating this association in patients with PFH are very important. Heart rate variability (HRV) is a simple and noninvasive electrocardiographic test showing activity and balance in the autonomic nervous system, which consists of sympathetic and parasympathetic components. The aims of this study are to investigate associations between autonomic nervous activity and hyperhidrosis characteristics using HRV and to investigate the association between HRV findings and compensatory hyperhidrosis (CH) after sympathectomy.

Methods

From March 2017 to March 2020, 105 subjects with PFH who underwent preoperative HRV tests and sympathectomy were analyzed. All subjects underwent bilateral thoracoscopic sympathectomy. T2 sympathectomy was conducted for craniofacial hyperhidrosis, and T3 sympathectomy was conducted for palmar hyperhidrosis. The following HRV parameters chosen to investigate the association between hyperhidrosis and autonomic nervous activity were measured by time and frequency domain spectral analysis: (I) time domain: standard deviation of normal-to-normal interval (SDNN) and square root of mean squared differences of successive normal-to-normal intervals (RMSSD), (II) frequency domain: total power (TP) of power spectral density, very low frequency (VLF), low frequency (LF), and high frequency (HF). HRV parameters were analyzed according to hyperhidrosis type (craniofacial vs. palmar type), sweat reduction, and CH after sympathectomy. In addition, the independent HRV parameters influencing CH after sympathectomy were investigated with multivariate analysis.

Results

Craniofacial hyperhidrosis was significantly more prevalent in the old age group (P<0.001). Sweat reduction after sympathectomy was significantly more prominent in palmar hyperhidrosis (P=0.037), and CH after sympathectomy was more prominent in craniofacial hyperhidrosis (P<0.001). Palmar type patients exhibited significantly larger SDNN, RMSSD, TP, LF, and HF than craniofacial type patients (all P<0.001). There were no significant differences in any HRV parameters according to sweat reduction after sympathectomy. Low-degree CH was associated with significantly larger SDNN, RMSSD, TP, LF, and HF than high-degree CH (P<0.001, P<0.001, P=0.002, P=0.001, and P<0.001, respectively). Multivariate analysis showed that HF and age group were associated with CH after sympathectomy (P=0.007 and P=0.010, respectively).

Conclusions

This study shows that HRV can provide useful insight into the pathophysiology of PFH and enhance preoperative risk stratification of CH. Large-scale, prospective studies are required to determine the predictive value of HRV in patients at risk for subsequent CH after sympathectomy.

Association between Reflux Esophagitis Incidence and Palmar Hyperhidrosis

The autonomic dysfunction in palmar hyperhidrosis (PH) includes not only sympathetic overactivity but also parasympathetic impairment. A decrease of parasympathetic tone has been noted in gastroesophageal reflux disease of neonates and adults. Patients with reflux esophagitis have a defective anti-reflux barrier. The association between reflux esophagitis and PH is deliberated in this article. The National Health Insurance Database in Taiwan was used. At first-time visits, PH patients were identified by the International Classification of Disease, 9th Revision, Clinical Modification disease code of 780.8 without endoscopic thoracic sympathectomy. Patients were matched by age and gender as control groups. The reflux esophagitis incidence was assessed using disease codes 530.11, 530.81, and 530.85. The factors related to reflux esophagitis were established by the Cox proportional regression model. The risk of reflux esophagitis in PH patients had a hazard ratio of 3.457 (95% confidence interval: 3.043-3.928) after adjustment of the other factors. We confirmed the association between reflux esophagitis and PH. Health care providers must be alerted to this relationship and other risk factors of reflux esophagitis to support suitable treatments to improve the quality of life of patients.

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.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015027803.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Left cardiac sympathetic denervation in patients with heart failure: a new indication for an old intervention?

Heart failure (HF) is characterized by an autonomic imbalance with withdrawal of vagal activity and increased sympathetic activity. Novel non-pharmacological approaches to HF aimed at increasing vagal activity are being proposed. Left cardiac sympathetic denervation (LCSD) has been shown to modify favorably the outcome of several disorders characterized by life-threatening arrhythmias triggered by increased sympathetic activity. The present manuscript discusses the rationale and the limited experimental and clinical experience suggesting a potential role for LCSD in the treatment of patients with advanced heart failure. Possible future clinical applications of LCSD may include HF patients who are intolerant to β-adrenergic blockade, HF patients who have frequent implantable cardioverter-defibrillator shocks, and HF patients in countries where the likelihood of receiving a device is limited, but the capability to perform a one in a lifetime procedure is present.