C-Arm Guided Percutaneous Radiofrequency Thoracic Sympathectomy for Treatment of Primary Palmar Hyperhidrosis in Comparison with Local Botulinum Toxin Type A Injection, Randomized Trial

BACKGROUND

Hyperhidrosis is a disorder associated with detrimental effects on patients' quality of life, occupational activities, and social interactions.

OBJECTIVES

This study compares C-arm guided percutaneous radiofrequency (RF) ablation of the second and third thoracic sympathetic ganglions and local intradermal botulinum toxin type A (BTX-A) injection for the treatment of primary palmar hyperhidrosis. It focuses on clinical effectiveness, patient satisfaction, quality of life, safety, and the time at which repetition of the procedure is needed over one-year follow-up.

STUDY DESIGN

This is a randomized single-blinded trial.

SETTING

This study took place in a single hospital.

METHODS

Eighty patients with primary palmar hyperhidrosis were randomly assigned to one of 2 interventions: local intradermal BTX-A injection (n = 40) or C-arm guided percutaneous RF ablation (n = 40). The Dermatology Life Quality Index (DLQI) questionnaire and the Hyperhidrosis Disease Severity Scale (HDSS) were used for assessment at one week, one month, and 2, 6, and 12 months after intervention. The number of patients who required repetition of the procedure later on and the time at which they needed it were recorded, and possible side effects were assessed.

RESULTS

HDSS scores in the RF group were statistically significantly lower than in the BTX-A group at one week, one month, and 2, 6, and 12 months of follow-up. DLQI scores in the RF group were statistically significantly lower than in the BTX-A group at 6- and 12-month follow-up, whereas at one week, one month, and 2 months of follow-up, there was no statistically significant difference between both groups. The number of patients who required that the procedure be repeated was statistically significantly lower in the RF group than in the BTX-A group. The time at which patients needed repetition of the procedure in the BTX-A group was about 3 to 7 months after the first intervention. All patients in this group showed an increase in HDSS scores within this one-year follow-up. In the RF group, however, only one patient complained of increased HDSS scores after 8 months. There was no statistically significant difference in side effects between both groups.

LIMITATIONS

The first limitation of this study is that results were based on subjective scales. The second is the radiation exposure associated with the technique described.

CONCLUSIONS

This study supports percutaneous C-arm guided RF ablation of the second and third thoracic sympathetic ganglions and local intradermal BTX-A injection as safe, effective options and rapid lines of treatment of primary palmar hyperhidrosis. However, percutaneous RF ablation proved to be more effective, with longer effectiveness time and better patient satisfaction, compared to local intradermal BTX-A injection.

KEY WORDS

Botulinum toxin, hyperhidrosis, quality, radiofrequency ablation.

Modulation of the activated protein C pathway in severe haemophilia A patients: The effects of thrombomodulin and a factor V-stabilizing fab

INTRODUCTION

The thrombomodulin (TM)/activated protein C (APC) system is a key regulator of haemostasis, limiting amplification and propagation of the formed blood clot to the injury site. Dampening APC's inhibition of factor V (FV) and factor VIII (FVIII) may be a future strategy in developing next-generation therapeutic targets for haemophilia treatment.

AIMS

To determine ex vivo the respective concentration-dependent effects of TM and a FV-stabilizing Fab on the APC regulatory pathway in severe FVIII-deficient blood and plasma.

METHODS

Ten severe haemophilia A subjects and one healthy control were enrolled. Blood was spiked with TM (0, 1, 2.5, 5, 10, 20.0 nmol/L) and FV-stabilizing Fab (0, 3, 15, 65, 300 nmol/L). The respective effects were compared to FVIII concentrations of 3- and 10% using rotational thromboelastometry clotting time (CT) and thrombin generation analysis (TGA).

RESULTS

With 1 and 2.5 nmol/L TM, 5% FVIII resulted in CT similar to the absence of TM, suggesting it completely reversed the effect of APC. Increasing TM concentrations also reduced peak thrombin generation and ETP. The addition of 300 nmol/L FV-stabilizing Fab returned CT to nearly baseline, but for most subjects was less than the effects of 3- or 10% FVIII. The FV-stabilizing Fab produced similar or greater thrombin generation compared to samples with 3- or 10% FVIII.

CONCLUSIONS

The FV-stabilizing Fab resulted in enhanced CT and TGA parameters consistent with FVIII levels of 3- and 10%. Additional studies need to further characterize how modulating the APC pathway may prove beneficial in developing new haemophilia drug targets.

Coated platelets and severe haemophilia A bleeding phenotype: Is there a connection?

INTRODUCTION

Coated platelets are a subpopulation of platelets that possess highly prothrombotic properties. Previous observational data suggest that bleeding phenotype in severe haemophilia A is associated with coated platelet levels. Haemophilia A patients with higher coated platelet levels may have a mild bleeding phenotype; those with lower levels may have a more severe bleeding phenotype.

AIM

The aim of the study was to test the hypothesis that coated platelet levels are correlated with clinical bleeding phenotype.

METHODS

This cross-sectional, observational study enrolled 20 severe haemophilia A patients, including 15 with severe and five with a mild bleeding phenotype, and a control group of 12 healthy volunteers. The haemophilia bleeding phenotype was determined by the patient's medical history and haemophilia treatment centre records. Blood was obtained from each patient by venipuncture and platelets were analysed by flow cytometry.

RESULTS

Patients categorized as having a severe bleeding phenotype experienced a median eight bleeds per year compared to one bleed annually in the mild bleeding phenotype group. Both groups had similar total platelet counts and fibrinogen levels. There was no difference in coated platelet percentage between severe and mild bleeding phenotype (17 and 16% respectively), however, both groups had significantly lower % coated platelets compared to controls (44%, P < 0.0001).

CONCLUSION

Coated platelet levels were not associated with bleeding phenotype in this study; however, these data may suggest coated platelet levels are lower in haemophilia patients relative to healthy volunteers.

Early hemostatic responses to trauma identified with hierarchical clustering analysis

BACKGROUND

Trauma-induced coagulopathy is a complex multifactorial hemostatic response that is poorly understood.

OBJECTIVES

To identify distinct hemostatic responses to trauma and identify key components of the hemostatic system that vary between responses.

PATIENTS/METHODS

A cross-sectional observational study of adult trauma patients at an urban level I trauma center emergency department was performed. Hierarchical clustering analysis was used to identify distinct clusters of similar subjects according to vital signs, injury/shock severity, and comprehensive assessment of coagulation, clot formation, platelet function, and thrombin generation.

RESULTS

Among 84 total trauma patients included in the model, three distinct trauma clusters were identified. Cluster 1 (N = 57) showed platelet activation, preserved peak thrombin generation, plasma coagulation dysfunction, a moderately decreased fibrinogen concentration and normal clot formation relative to healthy controls. Cluster 2 (N = 18) showed platelet activation, preserved peak thrombin generation, and a preserved fibrinogen concentration with normal clot formation. Cluster 3 (N = 9) was the most severely injured and shocked, and showed a strong inflammatory and bleeding phenotype. Platelet dysfunction, thrombin inhibition, plasma coagulation dysfunction and a decreased fibrinogen concentration were present in this cluster. Fibrinolytic activation was present in all clusters, but was particularly increased in cluster 3. Trauma clusters were most noticeably different in their relative fibrinogen concentration, peak thrombin generation, and platelet-induced clot contraction.

CONCLUSIONS

Hierarchical clustering analysis identified three distinct hemostatic responses to trauma. Further insights into the underlying hemostatic mechanisms responsible for these responses are needed.

Failure of corn trypsin inhibitor to affect the thrombin generation assay in plasma from severe hemophiliacs

BACKGROUND

The thrombin generation assay (TGA) is an important global coagulation assay; however, it suffers from the lack of preanalytical standardization. The addition of corn trypsin inhibitor (CTI) to blood collection tubes before TGA has been previously advocated to block the contact activation pathway. Emerging data, however, suggest that CTI may only be necessary when minimal tissue factor (TF) concentrations < 1 pmol are used.

OBJECTIVES

To determine whether blood collection tubes containing CTI influenced TGA parameters.

METHODS

This cross-sectional, observational study performed the TGA using TF 1 pmol L(-1) in 15 healthy volunteers, 14 severely factor VIII (FVIII)-deficient patients, and 15 severely FVIII-deficient patients with documented FVIII inhibitors. TGA was conducted using blood tubes that contained CTI 33 μg mL(-1) and no CTI.

RESULTS

CTI markedly reduced peak thrombin (P = 0.002) and endogenous thrombin potential (P < 0.001) in the healthy volunteers but had no significant effect on TGA parameters in severely FVIII-deficient patients or those with inhibitors.

CONCLUSIONS

This lack of effect raises additional questions regarding the need for CTI as a preanalytical addition to blood collection tubes during TGA in severe hemophiliacs, particularly when activating samples with TF 1 pmol L(-1) .