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Am Fam Physician. 2001;63(10):2023-2024

Botox Is An Effective Treatment for Excessive Sweating

(59th Annual Meeting of the American Academy of Dermatology) Results of two clinical trials suggest that injections of botulinum toxin type A (Botox) can decrease perspiration at the injected area by inhibiting the release of the neurotransmitter responsible for stimulating the sweat gland in patients with palmar hyperhidrosis (excessive sweating of the palms) and axillary hyperhidrosis (excessive sweating under the arms). In a double-blind study, 19 patients with primary palmar hyperhidrosis were randomly assigned to receive placebo in one palm and a one-time treatment of 15 injections of 0.1 mL of Botox in the other palm. After 28 days, patients' ratings of clinical severity were significantly lower in the palm receiving Botox compared with the palm receiving placebo. All of the patients rated the Botox injections as “successful” at reducing the amount of perspiration, while 12 percent of patients believed the placebo injection had been successful. Patients experienced no serious adverse events, and there was no significant weakness in the hands because the Botox injection did not go deeper than the skin. In another study, 320 patients were randomized in a 3:1 ratio to receive 50 u of Botox or placebo as 2 mL injections in each armpit. After four weeks, 93.8 percent of patients treated with Botox experienced a 50 percent or greater reduction in sweat production, compared with 35.9 percent of patients in the placebo group. The mean percentage in the reduction of sweat production was 83.5 percent in patients receiving Botox and 20.8 percent in patients receiving placebo, and mean patient satisfaction was significantly higher in patients receiving Botox. Patients in both groups experienced a low occurrence of adverse events.—nicholas j. lowe, M.D., University of CaliforniaLos Angeles School of Medicine, Los Angeles, California.

Remicade Decreases Joint Damage Caused by Rheumatoid Arthritis

(64th Annual Meeting of the American College of Rheumatology) Patients receiving infliximab (Remicade) in combination with methotrexate were more likely to experience no progression of joint damage over a two-year period compared with patients receiving methotrexate alone (who experienced a rate of progression comparable with that previously reported in patients receiving a disease-modifying antirheumatic drug treatment). In addition, the subjects receiving both infliximab and methotrexate had an overall median change from baseline in radiograph scores of 0.0, compared with a median change of 4.3 in patients treated with methotrexate alone. This is according to results from the double-blind, placebo-controlled, randomized Anti-TNF Trial in Rheumatoid Arthritis with Concomitant Therapy (ATTRACT) which was conducted at 34 centers in North America and Europe during a 102-week period. A total of 428 patients already receiving methotrexate were randomized to receive 3 or 10 mg per kg of infliximab or placebo infusions administered at baseline, two and six weeks and then every four or eight weeks thereafter. The progression of joint damage was measured radiographically at baseline and weeks 30, 54 and 102 using the van der Heijde modified Sharp system, which evaluates changes in joint-space narrowing and bone erosion on a 5-point scale (a higher score indicating more damage). Radiographs were evaluated by two experienced readers who were blinded to the patients and treatment arms, with the primary end point being the median change from baseline for each patient averaged between the two readers. The median duration of disease in trial patients was 8.4 years. All patients included in the study were on stable dosages of concomitant methotrexate, corticosteroids and nonsteroidal anti-inflammatory drugs. More than one third of patients had previous joint surgery, and approximately one half were classified as functional class 3 or 4 (progressive or advanced disease). The most common adverse events included upper respiratory infection, headache, sinusitis, rash and cough.—peter e. lipsky, m.d.,Harold C. Simmons Arthritis Research Center, University of Texas Southwestern Medical Center, Dallas, Texas.

Valsartan Reduces Death and Morbidity in Heart Failure Patients

(73rd Scientific Sessions of the American Heart Association) According to results of the Valsartan Heart Failure Trial (Val-HeFT), the combined risk of death and morbidity in patients with heart failure can be significantly reduced by adding the angiotensin II receptor blocker valsartan to standard treatment (including angiotensin-converting enzyme [ACE] inhibitors, beta blockers, diuretics and digoxin). The Val-HeFT study was a randomized, double-blind, placebo-controlled trial that included 5,010 patients from 300 centers in 16 countries. The participants were 18 years or older (mean age: 62 years) with mild to severe chronic heart failure, an ejection fraction of at least 40 percent and left ventricular diastolic transverse diameter greater than 2.9 cm per m2, and most (4,005) were male. Patients were randomized to receive valsartan titrated to a target dosage of 160 mg twice daily (2,511 patients) or placebo (2,499 patients) while continuing all other appropriate therapies, which included ACE inhibitors in 93 percent of patients, beta blockers in 36 percent, diuretics in 86 percent and digoxin in 67 percent. In patients receiving valsartan, combined mortality and morbidity from heart failure decreased by a significant 13.3 percent, and this benefit was especially significant in patients who were not receiving beta blockers or ACE inhibitors. The rate of all-cause mortality was similar between the two groups. Patients receiving valsartan had a 27.5 percent reduction in the number of hospitalizations for heart failure, experienced a better quality-of-life as measured by the Minnesota Living with Heart Failure questionnaire, and showed a 22.9 percent improvement in their New York Heart Association (NYHA) classification, indicating favorable effects on disease progression. The rate of discontinuation because of side effects was only slightly higher in patients receiving valsartan (9.9 percent) compared with patients receiving placebo (7.2 percent). The most common adverse events were dizziness, hypotension and renal impairment.—jay n. cohn, m.d.,University of Minnesota Medical School, Minneapolis, Minnesota.

Vaccine Reduces Illness in Children Attending Day Care

(40th Interscience Conference on Antimicrobial Agents and Chemotherapy) Results of a two-year study of 264 children aged 12 to 35 months from eight day care centers in Israel showed that the use of the 9-valent pneumococcal conjugate vaccine significantly reduced the number of illnesses caused by pneumococcal bacteria and subsequent antibiotic use for those illnesses in children attending day care as well as in their unvaccinated younger siblings. One half of the children received the vaccine and one half were given the control vaccine. Each child was monitored for two years for episodes of lower respiratory infections (e.g., bronchitis, asthma and pneumonia), otitis media and upper respiratory infections, fever and use of antibiotics. Siblings of the vaccinated children were less likely than siblings of the unvaccinated children to test positive for the pneumococcal bacteria covered by the vaccine (21 versus 34 percent), test positive for pneumococcal strains that are resistant to at least one antibiotic (21 versus 41 percent) and test positive for pneumococcal strains that are resistant to at least two antibiotics (16 versus 32 percent). The vaccine used in the study targeted the seven strains of pneumococcal bacteria that cause 80 percent of the pneumococcal disease in the United States and are most likely to be resistant to antibiotics (similar to the 7-valent pneumococcal vaccine called Prevnar) plus two pneumococcal strains most prevalent in countries outside of the United States. The study also found that vaccination with the pneumococcal conjugate vaccine resulted in a 15 percent reduction in all respiratory tract infections, a 17 percent reduction in the incidence of otitis media and a 20 percent reduction in antibiotic use for lower respiratory infection.—ron dagen, m.d.,Ben-Gurion University of the Negev, Beer-Sheva, Israel.

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