There are Many Causes of Acne
1) Heredity
2) Cosmetics and Products
Fatty ingredients such as waxes and oils can clog pores.
3) Oily skin
4) Diet
Fast food and processed food can cause acne. Excessive salt and sugar, fats, and msg have also been known to trigger acne breakouts.
5) Clogged Pores
6) Bacteria
7) Hormones
The male hormone testosterone cause an increase in oil production. These hormones increase during puberty, when teen acne is first evident. In females, acne is not as severe because they produce less testosterone.
8) Stress
Stress causes hormonal fluctuations and increased sebum production.
9) Environmental Irritants
Touching the face, using the phone, wearing hats, dirty
pillows, and makeup are examples of ordinary environmental causes of acne.
Saturday, March 14, 2009
Friday, March 6, 2009
Hyperhidrosis
What is Hyperhidrosis?
People with palmar hyperhidrosis may be embarrassed to hold hands or be hesitant to shake hands because of having excessively wet palms, often feeling as if they must wipe their palms on their clothing first. People with palmar hyperhidrosis may have difficulty holding onto objects or tools or may have difficulty using computer keyboards, typewriters, or pens. Papers they handle may become wet, and metal objects that they use repeatedly may become rusty. Individuals with palmar hyperhidrosis may find it difficult to play a musical instrument or perform a job requiring the wearing of gloves (eg, food handler, perioperative nurse).
Patients with palmar hyperhidrosis may find that it aggravates eczematous dermatitis, and they may have a predisposition to bacterial and fungal infections. As a result, these people may become withdrawn socially and suffer from low self-esteem. They even may develop psychiatric problems, such as social anxiety disorders.
Sweating is a physiological response to body overheating. It is controlled by the heat regulatory center in the hypothalamus. As the temperature of the environment rises, the body is cooled by vasodilatation of the cutaneous blood vessels and the production of sweat. The sweat then evaporates from the surface of the skin and cools the body.(2)
Sweat glands are tubular structures consisting of a coiled portion deep within the dermis that secretes sweat and a duct through which the sweat travels to the skin. Cholinergic sympathetic nerve fibers on or near the glandular cells elicit the secretion of sweat.
The secretory portion of the gland secretes a fluid called precursor secretion. Concentrations of the constituents of this fluid are modified as the fluid travels through the duct to the pore. When sweat glands are stimulated normally, the precursor secretion passes slowly through the duct where most of the sodium and chloride content is reabsorbed. The concentration of sodium and chloride can fall as low as 5 mEq per liter. This reduces the fluid's osmotic pressure, and most of the water is reabsorbed, thus concentrating other ions in the fluid.
In normal sweating, urea, lactic acid, and potassium ions are very concentrated. When the sweat glands are stimulated strongly by the sympathetic nervous system, large amounts of precursor secretion are formed. Sweat flows so rapidly through the duct that little of the water and slightly more than one-half of the sodium and chloride are reabsorbed, leaving sodium and chloride concentrations as high as 50 to 60 mEq per liter. In these situations, a large loss of sodium chloride and water can occur.(3)
The human body contains two types of sweat glands--apocrine and eccrine. Their location and characteristics differ slightly.
Apocrine sweat glands. The apocrine sweat glands are confined to the axillae, areolas of the nipples, the anogenital area, and the external auditory meatus. They are simple, coiled tubes and are 10 times larger than eccrine glands. The sweat from these glands is milky, contains fat and cholesterol, and can have a strong odor. The apocrine glands begin to function at puberty.
Eccrine sweat glands. The eccrine glands are present on the entire surface of the body but are most numerous on the palms, soles of the feet, face, axillae, and, to a lesser degree, the back and chest. They are coiled tubular glands that open onto the skin through pores. These sweat glands have a rich blood supply and are innervated by the sympathetic nervous system (Figure 1). Nerves stimulate the glands to secrete a plasma-like fluid that is hypotonic (ie, 0.3% to 0.5% sodium chloride) and contains small amounts of potassium, lactic acid, glucose, and urea. Myoepithelial cells, through their contraction, aid in the expulsion of sweat. Acetylcholine and other cholinergic agents increase sweating. Atropine and anticholinergic agents inhibit sweating.(4)
CAUSES OF HYPERHIDROSIS
There are many causes of hyperhidrosis. It can be caused by
* emotional factors,
* a warm environment,
* exercise,
* spinal cord injuries, and
* familial dysautonomia (eg, Riley-Day syndrome--an inherited congenital disease occurring mainly in children of Ashkenazic Jewish decent and characterized by a decrease in the number of small unmyelinated autonomic and peripheral fibers that carry pain, temperature, and taste sensations; Nail-patella syndrome--an inherited multisystem disorder characterized by dystrophic nails, hypoplastic or absent patellae, and renal disease).
Hyperhidrosis can be cold-induced, gustatory (ie, stimulated by eating), olfactory (ie, stimulated by strong smells), compensatory (ie, areas of the body become affected by hyperhidrosis after the areas originally affected by hyperhidrosis have been disrupted by surgery or other means), or idiopathic.(5) This article discusses treatment for idiopathic or primary palmar hyperhidrosis.
TREATMENT
Treatment should be directed at the underlying cause whenever possible. Affected individuals should wear light clothing, keep the environment cool, and replenish water and sodium chloride lost through sweating. Topical applications of aluminum chloride or aluminum chlorhydroxide may be used to block the openings of the sweat ducts. They must be reapplied frequently (ie, three to four times per day) because excessive sweating unblocks the ducts.
A 20% alcohol solution of aluminum chloride hexahydrate is the most effective topical solution. It blocks the openings to the sweat ducts and should be applied at night, covered with plastic wrap, and washed off in the morning. The skin needs to be dried thoroughly before application. The solution is used daily, weekly, or whenever needed. Skin rashes may result from this treatment; therefore, it should not be applied to freshly shaved skin.(6) Glutaraldehyde and tannic acid also may be used topically, but they can cause skin irritation and brownish skin discoloration.
Iontophoresis can create a temporary blockage of the sweat duct. This is accomplished by directing a mild electric current through the skin in a shallow tap water bath. The electric current shocks the sweat glands, and they stop producing sweat temporarily. The iontophoresis machine is used for 20 minutes a few times per week and may cause sweating to stop for weeks. It can be used at home but is only useful for palms, feet, and axillae.(7) Surgical excision of axillary apocrine sweat glands rarely is performed and may result in infection, hidradenitis, and scarring.(8) Locally applied astringents (eg, potassium permanganate) may provide temporary local relief. Antiperspirant with aluminum salts also may be used to block the ducts.
Anticholinergic medications, such as atropine, oxyphencyclimine, glycopyrrolate, and propantheline bromide, inhibit parasympathetic effects, but these often cause dry mouth, blurred vision, or constipation. These medications usually are taken several times per day. Patients can use them regularly to try to control sweating or only when in situations that cause excessive sweating, such as public speaking or business meetings. Multiple medications and schedules are tried to determine a treatment schedule that works best for the individual patient, depending on the severity of his or her hyperhidrosis.
Botulinum toxin injections sometimes are used for focal hyperhidrosis of the axillae, palms, and feet. Botulinum toxin is a potent neurotoxin that blocks the cholinergic nerve terminals. It is effective only at the site of injection and may be painful and expensive. The injections usually are effective for three to 12 months.(9) In 1998, German neurologists and dermatologists used intracutaneous injections of botulinum toxin on 11 patients with focal hyperhidrosis. Sweating was abolished completely in all patients in three to seven days, but some reactivation of sweat gland function was observed four months after treatment.(10) Biofeedback, hypnosis, and psychotherapy have been tried with variable results. Early in the twentieth century, irradiation of the skin was used to atrophy the sweat glands; however, this treatment has been abandoned.
As sweating is mediated through the sympathetic nervous system, selective sympathectomy appears to be the most effective method to permanently rid patients of palmar hyperhidrosis.(12) Sympathectomy abolishes eccrine sweating in areas supplied by post-ganglionic fibers. In the past, an open surgical technique was used. This generally was performed via transthoracic, supraclavicular, transcervical, transaxillary, or dorsal thoracic surgery. These surgeries involved long hospital stays, large scars, increased morbidity, and long recuperative periods for patients.
THORACOSCOPIC SYMPATHECTOMY
The advent of thoracoscopic surgery has made surgical treatment for palmar hyperhidrosis much more attractive. The procedure generally is performed on an outpatient basis, with the patient going home a few hours after the surgery. After the procedure, patients have two one-inch scars hidden in the axillae. At present, patients undergoing this procedure at New York Presbyterian Hospital, New York, have gained relief from hyperhidrosis. Patients are referred by dermatologists or they refer themselves to this program. Many patients have learned about this procedure on the Internet or from other patients who have benefited from the surgery.
The surgeon sees and evaluates the patient while performing a physical examination and taking a clinical history. He or she explains the surgical procedure, potential complications, and side effects to the patient and obtains written informed consent for the surgery and a consent for the administration of blood products if necessary. Patients who typically undergo this procedure are in their twenties and thirties. They find this condition to be embarrassing and believe that their lives have been affected negatively by the condition. The surgeon schedules the patient for elective surgery and sends him or her to the preadmission testing area of the hospital for blood tests (eg, complete blood count; prothrombin time; partial thromboplastin time; eosinophil sedimentation rate; sodium, potassium, chloride, glucose, and carbon dioxide levels; blood urea nitrogen; creatinine; calcium; thyroid profile). The thyroid profile is drawn to rule out thyroid disease as a cause of the hyperhidrosis. A chest x-ray and electrocardiogram also are performed. The anesthesia care provider interviews the patient, explains his or her plans for anesthesia, and obtains informed consent. The anesthesia care provider instructs the patient not to eat or drink after midnight the night before surgery; however, no other special preparations are needed.
On the day of surgery, the patient arrives at the ambulatory surgery unit (ASU) one and one-half hours before surgery is scheduled. In the ASU, the patient changes into a hospital gown, and the admitting nurse takes vital signs and checks the chart for a history and physical examination, blood work, and signed consent forms. The nurse performs a systems assessment of the patient that includes
* the patient's general health,
* any previous surgeries,
* existing medical conditions or disabilities,
* routine medications, and
* pregnancy status, if applicable.
He or she questions the patient about allergies, including those to medications, food, and latex. The nurse verifies that the surgery will be bilateral and that the patient will accept a blood transfusion, if necessary. The nurse asks the patient to remove all jewelry, dentures, hearing aides, contact lenses, and any other prostheses. Hearing or sight impaired patients are allowed to retain their heating aids or glasses until induction. The nurse verifies that the patient has an escort to take him or her home after recovery from anesthesia. Table 1 provides a nursing care plan.
The perioperative circulating nurse greets the patient, explains the anticipated procedures, and transports the patient to the OR where the anesthesia care provider inserts an IV line and an arterial line to continuously monitor vital signs during the surgical procedure. The anesthesia care provider administers a general anesthetic and intubates the patient with a double-lumen endotracheal tube. The double-lumen tube allows the anesthesia care provider to selectively ventilate one lung while the other lung is deflated. This allows the surgeon to better see the surgical field.
Surgical team members place the patient in the supine position with his or her arms extended at right angles on padded arm boards to allow a transaxillary incision (Figure 2). Care is taken to not extend the patient's arms past 90 degrees, which could cause nerve damage. The nurse ensures that the safety belt is in place, pads any bony prominences, inspects the patient's skin for problems, and applies an electrosurgical dispersive pad. He or she shaves the patient's axillae and preps the chest and axillae with an antimicrobial solution. The surgeon and scrub person drape the patient using sterile split sheets and an iodophor-impregnated adhesive drape.
The surgeon, assistant, and scrub person all stand on one side of the patient to perform the surgery on the initial side. The circulating nurse positions a monitor on each side of the patient to allow the surgeon to view the surgical field from either side. The scrub person and circulating nurse attach the camera and light source to the thoracoscope and the unipolar and bipolar cords to the electrosurgical unit. The surgeon asks the anesthesia care provider to deflate one of the patient's lungs, makes a one-inch transverse incision in the axillae between the patient's second and third ribs, and inserts a disposable. 11.5-mm thoracic port into the incision (Figure 3). The 11.5-mm port accommodates the 0-degree, 5-mm thoracoscope, as well as any instruments used, through a single incision.
The surgeon then identifies the sympathetic nerve chain at the T-2 level (Figure 4). He or she opens the pleura in the posterior thoracic cavity using an endoscopic scissor (Figures 5 and 6), grasps the nerve between the T-2 and the T-3 levels with an endoscopic bipolar forcep (Figure 7), and cauterizes it (Figure 8).
The surgeon removes the disposable thoracic port, inserts a 20-Fr thoracic catheter into the thoracic cavity, closes the soft tissues, and submerges the other end of the chest tube in a bowl of saline (Figure 9). He or she then asks the anesthesia care provider to reinflate the patient's lung and sustain lung expansion at 30 mm Hg of pressure. As the patient's lung reexpands, air is forced out of the thoracic cavity, causing bubbling in the bowl of saline. When the bubbling stops, the surgeon quickly removes the catheter, and closes the remainder of the incision. A sterile adhesive bandage strip is placed on the incision. The surgeon, assistant, and scrub person then move to the patient's opposite side and repeat the procedure.
The anesthesia care provider awakens and extubates the patient in the OR and helps surgical team members transport him or her to the postanesthesia care unit (PACU) for recovery. In the PACU, nurses observe the patient for any sign of pneumothorax (eg, pain on one side, difficulty breathing, uneven breath sounds in the chest). A chest x-ray is taken in the PACU to ascertain that no pneumothorax has occurred. The surgeon gives the patient a prescription for acetaminophen with codeine to be taken every four hours if needed for pain and instructs the patient to keep the incision dry. The patient's activities are limited only by discomfort, but he or she is advised to take a few days off from work. The nurse discharges the patient with instructions to return to the surgeon's office for a postoperative check in one week.
COMPLICATIONS
The patient is warned preoperatively of possible complications, including
* infection;
* bleeding, which would require the surgeon to perform a small thoracotomy incision and necessitate a possible overnight stay;
* compensatory sweating, usually in the feet, axillae, or trunk; and
* Homer's syndrome, which occurs because of damage to the sympathetic nerve fibers of the face and results in an ipsilateral small pupil, dry face, and slight ptosis (ie, drooping) of the eyelid.(13)
CASE STUDY
Mr R is a 34-year-old man with palmar hyperhidrosis. His occupation entails installing specialized components in computers. Computer components may not be exposed to moisture, which can damage them. He feels uncomfortable shaking hands at business meetings because of his sweaty palms. He feels uncomfortable in his sexual life, although his wife says she does not mind. His nine-year-old daughter often says to him, "Ugh, Daddy, your hands are always wet."
Mr R tried an aluminum chlorhydroxide product but found he could not handle computer components with particles of aluminum chlorhydroxide on his hands. He also tried iontophoresis, but he says with a full-time job, a nine-year-old daughter, and a three-month-old son, he could not find the time to soak his hands in a bath for 30 to 60 minutes every day for seven days. He found an Internet site from a Swedish facility that introduced him to thoracoscopic sympathectomy, and he was referred to a physician by his father-in-law, who is a dermatologist. Mr R decided to have the elective bilateral thoracoscopic sympathectomy because he felt hampered in his professional life and embarrassed in his personal life. He is a healthy male with no previous surgical history. He has no cardiac disease, respiratory symptoms, endocrine symptoms, genitourinary problems, musculoskeletal problems, or other neurological problems. His surgeon tested him for abnormal thyroid function, which can cause hyperhidrosis, and all tests were within normal limits. Mr R denied tobacco and alcohol use.
Nurses in the ambulatory surgery department admitted Mr R for a bilateral thoracoscopic sympathectomy without complications. The surgery lasted one and one-half hours. Mr R emerged from general anesthesia without incident and was transferred to the PACU. When interviewed in the PACU, he was very pleased that his palms no longer felt sweaty. He was sure that his daughter and wife would be thrilled. He was delighted that he had only a one and one-half inch incision in each axilla and little discomfort. Mr R left for home later that afternoon with his wife.
When more conservative therapies fail, patients may benefit from undergoing thoracoscopic sympathectomy for primary palmar hyperhidrosis. One study of 400 patients found that those who underwent sympathectomy showed 100% immediate relief from palmar sweating. The posterior surgical approach used on these patients, however, lasted two to three hours and involved a four- to five-day hospital stay.(14) The 45 patients who underwent the procedure at the New York Presbyterian Hospital between 1998 and 2000 received immediate relief of palmar sweating. Their surgeries lasted one and one-half to two hours, and all but one of the patients returned home a few hours after the procedure. This patient experienced bleeding that necessitated a mini-thoracotomy and an overnight hospital stay. Thorocoscopic sympathectomy is safe and effective, and the result is a life-changing experience for patients.
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http://www.curesweatypalms.com
Hyperhidrosis is excessive sweating beyond physiologic sweating which results in profuse sweating of the palms, underarms (axillae), feet (plantar) and face. It is of unknown etiology and afflicts in one form or another, 10% of the population. Primary hyperhidrosis is a common disorder that causes excesive sweating in the palms, axilla and soles of the feet. It results from excessive cholinergic stimulation of the eccrine glands from the sympathetic trunk.
What is known about hyperhidrosis is that it causes severe occupational, emotional and social distress.
Patients describe hyperhidrosis of the palms as so debilitating that it interferes with their social interaction with others. They cannot shake hands with others for fear of "sweating" and "turning off" business acquaintances or friends, social friends and sexual mates. The simple prospect of someone extending a hand for a handshake causes more emotional stress, indeed making the hyperhidrosis worse.
Others complain of sweating in the face and scalp, or simply "blushing" excessively. This response is quick in onset and last minutes. Often, patients remark that they feel the "blushing" and it bothers them very much, making a social interaction quite disabling from an emotional standpoint.
In large reported series, 15% to as much of 50% of patients with hyperhidrosis have a family history of hyperhidrosis.
Is There A Stigma Associated with Hyperhidrosis?
Definitely yes. As a matter of fact, it depends on the severity and location of hyperhidrosis or facial blushing.
In a survey conducted at the Center for Less Invasive Cardiac Surgery and Robotic Heart Surgery at kaleida Health, 50 consecutive patients were surveyed regarding this subeject and found to have significant social phobias associated with having hyperhidrosis.
We found that the problems were most significant for palmar hyperhidrosis as it interfered with the most common form of initial interpersonal interaction, namely the handshake.
Next were patients who suffered from both facial blushing and palmar hyperhidrosis. The facial blushing seemed to have alerted the person itself of the problem during interaction with others, made them uncomfortable, and sometimes limited their initiative to go out and say hello to people in business or social situations.
Next most commonly stigmatized group were patients who had facial hyperhidrosis alone. These were the minority in terms of number as patients with facial blushing also typically have assciated palmar and axillary hyperhidrosis.
In summary, patients have different mechanisms to deal with hyperhidrosis in social situations. Most with axillary and palmar hyperhidrosis hide their hands under their arms, behind their backs or placed under their thighs to prevent the "handshake." Many hide their hands in long sleeve shirts to cover the palms and have quick access to dry their hands before the mandatory "handshake." Others will always have a cold drink in their hands and pretend that their hands were cold and clammy because the drink was in their hands. In our study, defense mechanisms existed in over 92 % of studied patients.
What can be done for Hyperhidrosis?
Surgical Intervention
Hyperhidrosis surgery has come a long way in the last decade. Traditionally, large incisions were made in the chest to surgically interrupt the sympathetic trunk, all in an effort to treat hyperhidrosis.
With the advent of minimally invasive techniques to work in the chest via endoscopes and surgical instruments, Dr. Karmanoukian and other cardiothoracic surgeons who have taken an interest in endoscopic thoracic sympathectomy have evolved a procedure which is very effective in treating patients with sweating of the hands, underarms, face, scalp as well as patients that have facial blushing.
Dr. Karamanoukian has seen over and over again, how debilitating hyperhidrosis is to both young and adult patients. Given his area of expertise in robotic surgery, he has used this technology to further minimize the surgical trauma associated with treating hyperhidrosis. Dr. Karamanoukian is the author of a dozen books in cardiac surgery and thorcic surgery. He has also written 3 books that specifically deal with topics relating to Board Certification in Cardiothoracic Surgery. He has also authored more than 130 scientific articles in the field of cardiothoracic surgery and robotics. He is Board Certified in both General and Thoracic Surgery with a specific interest in advanced endoscopic surgery and robotic surgery.
The Surgical Answer: Endoscopic Thoracic Sympathectomy
This is the most durable treatment for hyperhidrosis in experienced hands. Clipping the thoracic sympathetic trunk at the appropriate levels will immediately eliminate hyperhidrosis. It is quite dramatic to see a patient wake up from anesthesia and to take note of a dry hand or axilla. With modification of the level of sympathectomy, compensatory hyperhidrosis is also minimized or eliminated.
Medical Therapy
Astringents
Conservative medical treatments such as Drysol and Drionics are the initial treatment for hyperhidrosis. These medications are astringents that dry up the sweat glands.
Topical Antiperspirants
These agents are applied directly to the skin in the affected areas of the body and can cause skin irritation. They are quite messy on clothing and unfortunately, have short periods of efficacy, requiring frequent reapplications.
Anticholinergic Medications
Anticholinergic medications aim to suppress the cholinergic stimulation of the eccrine sweat glands by the sympathetic nerve trunks to eliminate or reduce excessive sweating. However, they can cause significant adverse effects, limiting their usefulness.
Iontopheresis
Iontopheresis is an alternative treatment which utilizes an electrical stimulation to the hands. Patients are instructed to bathe thier hands in an electrolyte containing solution through which an electrical current is passed. This "stuns" the sweat glands of the hand, in effect decreasing the "sweat reflex" for periods of hours to weeks. Most patients find this mode of treatment as ineffective and not of durable benefit.
How About Botox?
Is Botox only for the rich and famous? Injection of botulinum toxin (Botox) into the area of excessive sweating has been shown to cause temporary benefit in hyperhidrosis. Botix affects nerve endings and decreases the transmission of nerve impulses to sweat glands, effectively reducing the production of sweat.
Multiple injections in the palms of the hand or armpit have been described as "painful" by most patients and quite costly as most health insurance companies do not pay for these treatments. Repeated injections are nearly always required to maintain an adequate level of dryness.
In general, surgery is contemplated only when the less invasive medical treatments have failed to provide adequate treatment. This is an important point, as most insurers want documented failure of conservative therapy before endoscopic thoracic sympathectomy is approved.
What's Best for Me?
Talking to your physician should help point you in the right direction. After a thorough discussion, surgery may be the definitive solution.
Botulinum Toxin A for Axillary Hyperhidrosis (Excessive Sweating)
ABSTRACT
Background Treatment of primary focal hyperhidrosis is often unsatisfactory. Botulinum toxin A can stop excessive sweating by blocking the release of acetylcholine, which mediates sympathetic neurotransmission in the sweat glands.
Methods We conducted a multicenter trial of botulinum toxin A in 145 patients with axillary hyperhidrosis. The patients had rates of sweat production greater than 50 mg per minute and had had primary axillary hyperhidrosis that was unresponsive to topical therapy with aluminum chloride for more than one year. In each patient, botulinum toxin A (200 U) was injected into one axilla, and placebo was injected into the other in a randomized, double-blind manner. (The units of the botulinum toxin A preparation used in this study are not identical to those of other preparations.) Two weeks later, after the treatments were revealed, the axilla that had received placebo was injected with 100 U of botulinum toxin A. Changes in the rates of sweat production were measured by gravimetry.
Results At base line, the mean (±SD) rate of sweat production was 192±136 mg per minute. Two weeks after the first injections the mean rate of sweat production in the axilla that received botulinum toxin A was 24±27 mg per minute, as compared with 144±113 mg per minute in the axilla that received placebo (P<0.001).>
Conclusions Intradermal injection of botulinum toxin A is an effective and safe therapy for severe axillary hyperhidrosis.
Source Information
From the Department of Dermatology, Ludwig-Maximilians-Universität (M.H., G.P.), and the Department of Neurology, Technische Universität München (A.O.C.-B.) - both in Munich, Germany.
An intramedullary tumor presenting with hyperhidrosis
Abstract
A case of a cervical intramedullary tumor is reported whose presentation was with disabling hyperhidrosis. The symptom resolved after surgical debulking of the tumor. Hyperhidrosis as a presenting manifestation of an intramedullary tumor has not been reported earlier.
Introduction
We report an unusual case of hyperhidrosis in a middle-aged woman, as a presenting feature of an intramedullary cervical tumor. We could not locate any similar case in the literature.
Case Report
A 56-year-old lady presented with difficulty in using her hands as the initial complaint for a period of 6 months. This was followed by excessive sweating involving her head and neck area, so much so that she had to use 10-12 handkerchiefs daily to wipe herself. By the time she was seen at the Clinic, she had also started experiencing difficulty in walking "with a tendency to fall forwards" and had also developed urgency of micturition. However her main disabling symptom was hyperhidrosis.
On examination, she had a mild spastic quadriparesis. She was also observed to have wasting and weakness of the small muscles of her hands. There was excessive sweating in her face and head and neck area, without significantly increased sweating in her trunk or limbs. MR scan of her cervical spine showed a large intramedullary space-occupying lesion extending from the level of the foramen magnum down to the D2 level. A syrinx was identified both above and below the level of the lesion. She declined surgery initially only to return after 2 months with advanced neurological deficits. At this time she had marked spastic quadriparesis, disabling hyperhidrosis, urge incontinence, decreased sensation to pinprick below her sternal angle, and diminished posterior column sensations in her lower limbs. She could barely stand unaided, was dyspnoeic and had abdominal respiration without much excursion of her chest wall. The tumor was debulked after performing a C2 to D2 laminectomy.
Postoperatively the patient had dramatic and complete cessation of her hyperhidrosis. Her spastic quadriparesis gradually improved, and at the time of discharge she was able to walk unaided and was able to pass urine normally. She had no respiratory problem. A follow-up MR scan was done after 6 months and the T1 weighted Gadolinium enhanced image [Figure - 1] showed a small residual tumor. The histopathological examination confirmed that the tumor was an astrocytoma.
Discussion
Intramedullary spinal cord tumors can present with a variety of symptoms.[1] Neck or back pain is often the earliest symptom.[2] Sensory symptoms frequently antedate the motor symptoms and are consistent with the central location of the lesion within the spinal cord. Involvement of the descending autonomic pathways, which are located between the corticospinal and spinothalamic tracts may cause both sympathetic and parasympathetic disturbances below the level of the lesion.
Hyperhidrosis has been described in spinal cord injured patients,[3],[4] and also in post-traumatic syringomyelia.[5] A syndrome of autonomic dysreflexia has been described[6] which occurs in patients with lesions of the spinal cord above the D6 spinal level. This is characterized by exaggerated autonomic responses to stimuli which may be innocuous in normal individuals. In our patient it is likely that there was involvement of the sympathetic fibers in the upper cervical cord or in the ciliospinal center of Budge at the C8-D2 segmental level.
Hyperhidrosis in this instance may be postulated to have occurred as a result of overactivity of the sympathetic fibers due to irritation by the tumor. It may be hypothesized that had no treatment been done, the hyperhidrosis may have gradually progressed to anhydrosis.
Thoracoscopic Sympathectomy for Palmar Hyperhidrosis
Hyperhidrosis is excessive sweating beyond the physiological need. It usually affects the palms, axillae, and soles and may affect the face, groin, and legs. Symptoms usually appear at puberty and may cause psychological and social problems, as well as occupational and educational difficulties. Between 0.6% and 1% of the general population are affected by hyperhidrosis.(1)People with palmar hyperhidrosis may be embarrassed to hold hands or be hesitant to shake hands because of having excessively wet palms, often feeling as if they must wipe their palms on their clothing first. People with palmar hyperhidrosis may have difficulty holding onto objects or tools or may have difficulty using computer keyboards, typewriters, or pens. Papers they handle may become wet, and metal objects that they use repeatedly may become rusty. Individuals with palmar hyperhidrosis may find it difficult to play a musical instrument or perform a job requiring the wearing of gloves (eg, food handler, perioperative nurse).
Patients with palmar hyperhidrosis may find that it aggravates eczematous dermatitis, and they may have a predisposition to bacterial and fungal infections. As a result, these people may become withdrawn socially and suffer from low self-esteem. They even may develop psychiatric problems, such as social anxiety disorders.
Sweating is a physiological response to body overheating. It is controlled by the heat regulatory center in the hypothalamus. As the temperature of the environment rises, the body is cooled by vasodilatation of the cutaneous blood vessels and the production of sweat. The sweat then evaporates from the surface of the skin and cools the body.(2)
Sweat glands are tubular structures consisting of a coiled portion deep within the dermis that secretes sweat and a duct through which the sweat travels to the skin. Cholinergic sympathetic nerve fibers on or near the glandular cells elicit the secretion of sweat.
The secretory portion of the gland secretes a fluid called precursor secretion. Concentrations of the constituents of this fluid are modified as the fluid travels through the duct to the pore. When sweat glands are stimulated normally, the precursor secretion passes slowly through the duct where most of the sodium and chloride content is reabsorbed. The concentration of sodium and chloride can fall as low as 5 mEq per liter. This reduces the fluid's osmotic pressure, and most of the water is reabsorbed, thus concentrating other ions in the fluid.
In normal sweating, urea, lactic acid, and potassium ions are very concentrated. When the sweat glands are stimulated strongly by the sympathetic nervous system, large amounts of precursor secretion are formed. Sweat flows so rapidly through the duct that little of the water and slightly more than one-half of the sodium and chloride are reabsorbed, leaving sodium and chloride concentrations as high as 50 to 60 mEq per liter. In these situations, a large loss of sodium chloride and water can occur.(3)
The human body contains two types of sweat glands--apocrine and eccrine. Their location and characteristics differ slightly.
Apocrine sweat glands. The apocrine sweat glands are confined to the axillae, areolas of the nipples, the anogenital area, and the external auditory meatus. They are simple, coiled tubes and are 10 times larger than eccrine glands. The sweat from these glands is milky, contains fat and cholesterol, and can have a strong odor. The apocrine glands begin to function at puberty.
Eccrine sweat glands. The eccrine glands are present on the entire surface of the body but are most numerous on the palms, soles of the feet, face, axillae, and, to a lesser degree, the back and chest. They are coiled tubular glands that open onto the skin through pores. These sweat glands have a rich blood supply and are innervated by the sympathetic nervous system (Figure 1). Nerves stimulate the glands to secrete a plasma-like fluid that is hypotonic (ie, 0.3% to 0.5% sodium chloride) and contains small amounts of potassium, lactic acid, glucose, and urea. Myoepithelial cells, through their contraction, aid in the expulsion of sweat. Acetylcholine and other cholinergic agents increase sweating. Atropine and anticholinergic agents inhibit sweating.(4)
CAUSES OF HYPERHIDROSIS
There are many causes of hyperhidrosis. It can be caused by
* emotional factors,
* a warm environment,
* exercise,
* spinal cord injuries, and
* familial dysautonomia (eg, Riley-Day syndrome--an inherited congenital disease occurring mainly in children of Ashkenazic Jewish decent and characterized by a decrease in the number of small unmyelinated autonomic and peripheral fibers that carry pain, temperature, and taste sensations; Nail-patella syndrome--an inherited multisystem disorder characterized by dystrophic nails, hypoplastic or absent patellae, and renal disease).
Hyperhidrosis can be cold-induced, gustatory (ie, stimulated by eating), olfactory (ie, stimulated by strong smells), compensatory (ie, areas of the body become affected by hyperhidrosis after the areas originally affected by hyperhidrosis have been disrupted by surgery or other means), or idiopathic.(5) This article discusses treatment for idiopathic or primary palmar hyperhidrosis.
TREATMENT
Treatment should be directed at the underlying cause whenever possible. Affected individuals should wear light clothing, keep the environment cool, and replenish water and sodium chloride lost through sweating. Topical applications of aluminum chloride or aluminum chlorhydroxide may be used to block the openings of the sweat ducts. They must be reapplied frequently (ie, three to four times per day) because excessive sweating unblocks the ducts.
A 20% alcohol solution of aluminum chloride hexahydrate is the most effective topical solution. It blocks the openings to the sweat ducts and should be applied at night, covered with plastic wrap, and washed off in the morning. The skin needs to be dried thoroughly before application. The solution is used daily, weekly, or whenever needed. Skin rashes may result from this treatment; therefore, it should not be applied to freshly shaved skin.(6) Glutaraldehyde and tannic acid also may be used topically, but they can cause skin irritation and brownish skin discoloration.
Iontophoresis can create a temporary blockage of the sweat duct. This is accomplished by directing a mild electric current through the skin in a shallow tap water bath. The electric current shocks the sweat glands, and they stop producing sweat temporarily. The iontophoresis machine is used for 20 minutes a few times per week and may cause sweating to stop for weeks. It can be used at home but is only useful for palms, feet, and axillae.(7) Surgical excision of axillary apocrine sweat glands rarely is performed and may result in infection, hidradenitis, and scarring.(8) Locally applied astringents (eg, potassium permanganate) may provide temporary local relief. Antiperspirant with aluminum salts also may be used to block the ducts.
Anticholinergic medications, such as atropine, oxyphencyclimine, glycopyrrolate, and propantheline bromide, inhibit parasympathetic effects, but these often cause dry mouth, blurred vision, or constipation. These medications usually are taken several times per day. Patients can use them regularly to try to control sweating or only when in situations that cause excessive sweating, such as public speaking or business meetings. Multiple medications and schedules are tried to determine a treatment schedule that works best for the individual patient, depending on the severity of his or her hyperhidrosis.
Botulinum toxin injections sometimes are used for focal hyperhidrosis of the axillae, palms, and feet. Botulinum toxin is a potent neurotoxin that blocks the cholinergic nerve terminals. It is effective only at the site of injection and may be painful and expensive. The injections usually are effective for three to 12 months.(9) In 1998, German neurologists and dermatologists used intracutaneous injections of botulinum toxin on 11 patients with focal hyperhidrosis. Sweating was abolished completely in all patients in three to seven days, but some reactivation of sweat gland function was observed four months after treatment.(10) Biofeedback, hypnosis, and psychotherapy have been tried with variable results. Early in the twentieth century, irradiation of the skin was used to atrophy the sweat glands; however, this treatment has been abandoned.
As sweating is mediated through the sympathetic nervous system, selective sympathectomy appears to be the most effective method to permanently rid patients of palmar hyperhidrosis.(12) Sympathectomy abolishes eccrine sweating in areas supplied by post-ganglionic fibers. In the past, an open surgical technique was used. This generally was performed via transthoracic, supraclavicular, transcervical, transaxillary, or dorsal thoracic surgery. These surgeries involved long hospital stays, large scars, increased morbidity, and long recuperative periods for patients.
THORACOSCOPIC SYMPATHECTOMY
The advent of thoracoscopic surgery has made surgical treatment for palmar hyperhidrosis much more attractive. The procedure generally is performed on an outpatient basis, with the patient going home a few hours after the surgery. After the procedure, patients have two one-inch scars hidden in the axillae. At present, patients undergoing this procedure at New York Presbyterian Hospital, New York, have gained relief from hyperhidrosis. Patients are referred by dermatologists or they refer themselves to this program. Many patients have learned about this procedure on the Internet or from other patients who have benefited from the surgery.
The surgeon sees and evaluates the patient while performing a physical examination and taking a clinical history. He or she explains the surgical procedure, potential complications, and side effects to the patient and obtains written informed consent for the surgery and a consent for the administration of blood products if necessary. Patients who typically undergo this procedure are in their twenties and thirties. They find this condition to be embarrassing and believe that their lives have been affected negatively by the condition. The surgeon schedules the patient for elective surgery and sends him or her to the preadmission testing area of the hospital for blood tests (eg, complete blood count; prothrombin time; partial thromboplastin time; eosinophil sedimentation rate; sodium, potassium, chloride, glucose, and carbon dioxide levels; blood urea nitrogen; creatinine; calcium; thyroid profile). The thyroid profile is drawn to rule out thyroid disease as a cause of the hyperhidrosis. A chest x-ray and electrocardiogram also are performed. The anesthesia care provider interviews the patient, explains his or her plans for anesthesia, and obtains informed consent. The anesthesia care provider instructs the patient not to eat or drink after midnight the night before surgery; however, no other special preparations are needed.
On the day of surgery, the patient arrives at the ambulatory surgery unit (ASU) one and one-half hours before surgery is scheduled. In the ASU, the patient changes into a hospital gown, and the admitting nurse takes vital signs and checks the chart for a history and physical examination, blood work, and signed consent forms. The nurse performs a systems assessment of the patient that includes
* the patient's general health,
* any previous surgeries,
* existing medical conditions or disabilities,
* routine medications, and
* pregnancy status, if applicable.
He or she questions the patient about allergies, including those to medications, food, and latex. The nurse verifies that the surgery will be bilateral and that the patient will accept a blood transfusion, if necessary. The nurse asks the patient to remove all jewelry, dentures, hearing aides, contact lenses, and any other prostheses. Hearing or sight impaired patients are allowed to retain their heating aids or glasses until induction. The nurse verifies that the patient has an escort to take him or her home after recovery from anesthesia. Table 1 provides a nursing care plan.
The perioperative circulating nurse greets the patient, explains the anticipated procedures, and transports the patient to the OR where the anesthesia care provider inserts an IV line and an arterial line to continuously monitor vital signs during the surgical procedure. The anesthesia care provider administers a general anesthetic and intubates the patient with a double-lumen endotracheal tube. The double-lumen tube allows the anesthesia care provider to selectively ventilate one lung while the other lung is deflated. This allows the surgeon to better see the surgical field.
Surgical team members place the patient in the supine position with his or her arms extended at right angles on padded arm boards to allow a transaxillary incision (Figure 2). Care is taken to not extend the patient's arms past 90 degrees, which could cause nerve damage. The nurse ensures that the safety belt is in place, pads any bony prominences, inspects the patient's skin for problems, and applies an electrosurgical dispersive pad. He or she shaves the patient's axillae and preps the chest and axillae with an antimicrobial solution. The surgeon and scrub person drape the patient using sterile split sheets and an iodophor-impregnated adhesive drape.
The surgeon, assistant, and scrub person all stand on one side of the patient to perform the surgery on the initial side. The circulating nurse positions a monitor on each side of the patient to allow the surgeon to view the surgical field from either side. The scrub person and circulating nurse attach the camera and light source to the thoracoscope and the unipolar and bipolar cords to the electrosurgical unit. The surgeon asks the anesthesia care provider to deflate one of the patient's lungs, makes a one-inch transverse incision in the axillae between the patient's second and third ribs, and inserts a disposable. 11.5-mm thoracic port into the incision (Figure 3). The 11.5-mm port accommodates the 0-degree, 5-mm thoracoscope, as well as any instruments used, through a single incision.
The surgeon then identifies the sympathetic nerve chain at the T-2 level (Figure 4). He or she opens the pleura in the posterior thoracic cavity using an endoscopic scissor (Figures 5 and 6), grasps the nerve between the T-2 and the T-3 levels with an endoscopic bipolar forcep (Figure 7), and cauterizes it (Figure 8).
The surgeon removes the disposable thoracic port, inserts a 20-Fr thoracic catheter into the thoracic cavity, closes the soft tissues, and submerges the other end of the chest tube in a bowl of saline (Figure 9). He or she then asks the anesthesia care provider to reinflate the patient's lung and sustain lung expansion at 30 mm Hg of pressure. As the patient's lung reexpands, air is forced out of the thoracic cavity, causing bubbling in the bowl of saline. When the bubbling stops, the surgeon quickly removes the catheter, and closes the remainder of the incision. A sterile adhesive bandage strip is placed on the incision. The surgeon, assistant, and scrub person then move to the patient's opposite side and repeat the procedure.
The anesthesia care provider awakens and extubates the patient in the OR and helps surgical team members transport him or her to the postanesthesia care unit (PACU) for recovery. In the PACU, nurses observe the patient for any sign of pneumothorax (eg, pain on one side, difficulty breathing, uneven breath sounds in the chest). A chest x-ray is taken in the PACU to ascertain that no pneumothorax has occurred. The surgeon gives the patient a prescription for acetaminophen with codeine to be taken every four hours if needed for pain and instructs the patient to keep the incision dry. The patient's activities are limited only by discomfort, but he or she is advised to take a few days off from work. The nurse discharges the patient with instructions to return to the surgeon's office for a postoperative check in one week.
COMPLICATIONS
The patient is warned preoperatively of possible complications, including
* infection;
* bleeding, which would require the surgeon to perform a small thoracotomy incision and necessitate a possible overnight stay;
* compensatory sweating, usually in the feet, axillae, or trunk; and
* Homer's syndrome, which occurs because of damage to the sympathetic nerve fibers of the face and results in an ipsilateral small pupil, dry face, and slight ptosis (ie, drooping) of the eyelid.(13)
CASE STUDY
Mr R is a 34-year-old man with palmar hyperhidrosis. His occupation entails installing specialized components in computers. Computer components may not be exposed to moisture, which can damage them. He feels uncomfortable shaking hands at business meetings because of his sweaty palms. He feels uncomfortable in his sexual life, although his wife says she does not mind. His nine-year-old daughter often says to him, "Ugh, Daddy, your hands are always wet."
Mr R tried an aluminum chlorhydroxide product but found he could not handle computer components with particles of aluminum chlorhydroxide on his hands. He also tried iontophoresis, but he says with a full-time job, a nine-year-old daughter, and a three-month-old son, he could not find the time to soak his hands in a bath for 30 to 60 minutes every day for seven days. He found an Internet site from a Swedish facility that introduced him to thoracoscopic sympathectomy, and he was referred to a physician by his father-in-law, who is a dermatologist. Mr R decided to have the elective bilateral thoracoscopic sympathectomy because he felt hampered in his professional life and embarrassed in his personal life. He is a healthy male with no previous surgical history. He has no cardiac disease, respiratory symptoms, endocrine symptoms, genitourinary problems, musculoskeletal problems, or other neurological problems. His surgeon tested him for abnormal thyroid function, which can cause hyperhidrosis, and all tests were within normal limits. Mr R denied tobacco and alcohol use.
Nurses in the ambulatory surgery department admitted Mr R for a bilateral thoracoscopic sympathectomy without complications. The surgery lasted one and one-half hours. Mr R emerged from general anesthesia without incident and was transferred to the PACU. When interviewed in the PACU, he was very pleased that his palms no longer felt sweaty. He was sure that his daughter and wife would be thrilled. He was delighted that he had only a one and one-half inch incision in each axilla and little discomfort. Mr R left for home later that afternoon with his wife.
When more conservative therapies fail, patients may benefit from undergoing thoracoscopic sympathectomy for primary palmar hyperhidrosis. One study of 400 patients found that those who underwent sympathectomy showed 100% immediate relief from palmar sweating. The posterior surgical approach used on these patients, however, lasted two to three hours and involved a four- to five-day hospital stay.(14) The 45 patients who underwent the procedure at the New York Presbyterian Hospital between 1998 and 2000 received immediate relief of palmar sweating. Their surgeries lasted one and one-half to two hours, and all but one of the patients returned home a few hours after the procedure. This patient experienced bleeding that necessitated a mini-thoracotomy and an overnight hospital stay. Thorocoscopic sympathectomy is safe and effective, and the result is a life-changing experience for patients.
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Wednesday, March 4, 2009
Abdomen Pain after Child Birth
It is a known fact that your body will take at least six weeks post delivery to regain its natural composure. During pregnancy the abdominal walls are stretched to accommodate the enlarged uterus. After delivery these abdominal muscles becomes loose and soft leading to many complications. In this period a new mother can experience several physical disturbances like afterbirth pains, perineal discomfort , abdominal pain, constipation, difficulty in passing urine, sore breasts, fatigue to name a few.
Among all these the most common occurrence is of abdominal pain. 90 % of the cases of cesarean deliveries have complained about abdomen pain. The pain is usually from the slit, and results in a feeling of discomfort caused by a sensation of pull, sting and hurt.
Gas Pain is another common source of abdominal discomfort after a cesarean birth. Usually this discomfort happens 1 to 2 days after giving birth.
To minimize the pain what s recommended here is that you move around a bit. It is advised that you change your positions frequently. The body needs some movement and the more it gets the better. However, be careful, 5-10 minutes of walk every day twice should do the trick. As the days goes by, you can increase the time frame. The aim should be to oil the mechanism of your body. You should also avoid oily food and all the carbonated drinks that might cause gas problems.
Tuesday, March 3, 2009
Herbal Remedy Anal Soreness
Anal Soreness or Anal Itching is seen more in men than the women. The reasons might vary from profuse sweating, diabetes to chronic dry skin conditions such as psoriasis and seborrhea. Some foods irritate the anus when they are expelled during a bowel movement. The most common culprits are caffeine, chocolate, beer, nuts, dairy products, and spicy food. Infections such as pinworms, yeast, and genital warts can also cause itching. Hemorrhoids, which cause painful swelling of blood vessels in the anal area, can cause itching.
To avoid anal soreness avoid spicy food. The smallest amount of black pepper, cayenne or cinnamon added to food can produce extreme itching in the anus of sensitive persons. Instead, eat raw, fresh fruits and vegetables, and whole grains for fiber to combat constipation and anal fissures, which can cause itching. Eat plain, unsweetened yogurt, kefir and other lactic acid fermented food to fight a possible candida yeast infection. Unrefined, cold-pressed flax seed oil also softens the stools and lubricates the walls of the rectum, reducing irritation.
Herbal remedies also provide effective relief of itching and irritation. If the itching is due to hemorrhoids, apply cool compresses of witch hazel to shrink blood vessels, camomile to speed healing and peppermint to relieve itching. If the itching is due to worms, take 15 drops of wormwood tincture twice daily. Dandelion root is also a gentle laxative and effective treatment for worms. Mix 2 tsp. of the root with 1 cup boiling water, simmer for ten minutes and drink three times a day. Aloe Vera and tea tree oil mixed with some olive oil rubbed on the skin also helps relieve itching.
Monday, March 2, 2009
Tips for Hair Straightening
Hair straighteners are popular nowadays. It only displays the desire of women to have great straight hair from time to time. People who have curly and wavy hair are not the only ones who use it; those who have straight hairs use it as well.
However, constant use of hair straighteners is not good news for your hair. This can be damaging to them. In order for your hair to remain healthy even after frequent use of the device, follow these helpful tips:
1. Choose a good hair straightener. If you want to have the best results, choose the best tool. Ceramic hair straighteners are good for your hair and you might want to consider that. Instead of drying your hair after use, you will notice that it will give it a healthy glow.
2. The heat distribution has to be even. The cheap straighteners with metal plates usually have this problem. A portion of it is hot enough while the other end has more than the temperature level you desire. That part will burn your hair. The good thing about having a good straightener is that you do not have to worry about problems like this. If you picked your device well, the heat will be just right all throughout the plate.
3. Use protective spray on the portion you are about to straighten. This will ensure that you will not damage your hair. Investing in protective hair products will also enhance the results. You will surely have smooth and shiny straight hair after.
4. Although straighteners do a great job, avoid using it daily. Daily exposure to heat is harmful for your hair especially if your device has a metal plate. There are devices designed for daily use though. However, your hair could use a rest day or two.
5. Before you start with the straightener, make sure to have a tangled free hair. You can run your hand through your hair while drying them, attempting to have it straightened while you do so. It will have better result and you will not need to run the device on your hair repeatedly. Use the straightener properly. Do not leave it clipped on your hair for a long period.
Hair straighteners are fun to use but it is also damaging for your hair. Keep in mind that when you are choosing a device, purchase something that will improve the condition of your hair. The ceramic hair straighteners leave your hair moisturized after straightening. Investing in good tools will save you from worrying about issues on evenly distributed heat. You will be confident that the tool you have will not burn a portion of your hair because the heat is under control. Daily use of straighteners is damaging. As much as possible, give it a break from the scorching heat occasionally during the week. Before that straightener touches your hair, prepare it. Remove any tangles from washing and drying. Finally, protect it with sprays before sliding the straightener through it.
Rheumatoid Arthritis
Rheumatoid arthritis or RA is an inflammation of the synovium in joints, with 1 to 2% of the population occurs. Are also regularly tendon sheaths and sacs in the inflammatory process. The term includes the people rheumatological foot (and in the terminology of the rheumatism foundation) many diseases. Rheumatoid arthritis, osteoarthritis, fibromyalgia, the disease Bekhterev and gout are a few examples. For doctors’ rheumatism ‘, however, usually a specific indication for rheumatoid arthritis.
A general aetiological or pathogenetic factor that a priori gives rise to the emergence of RA has not yet been found. The symptoms are caused by the formation of lysosomal enzymes (enzymes or degrading hydrolytic enzymes) that the spot produced by cells of the immune system, therefore, is an autoimmune process. This looks like a type IV hypersensitivity reaction, because of the involvement of CD4 T-cells (Th1 and Th2 cells) and that of CD8 cytotoxic T-cells, respectively, in the promotion of destruction by macrophages and B cells of the immune system and apoptosis (programmed cell death ). Although many in the very population that they have disorders with ‘rheumatism’ attention, RA is relatively rare in the strict sense, and is associated with all inflammatory reactions: pain / swelling / heat / redness and function loss and concrescence of the affected joints. In addition to RA joints can, however almost all organ systems affected. Most people with RA may, with the current state of treatment is a fairly normal life. However, a small group of patients who are seriously interested in the long term valid upgraded touches.
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