432 CURRENT LITERATURE

surgery. After dissection of one of the skin flaps, half the excess skin was excised with the argon gas surgical unit and half with a conventional electrosurgical unit. The excised skin was then sent for histologic analysis to assess the depth of tissue damage caused by each technique. The statistically significant difference in mean distance from the cut margin to the end of cautery artifact at the level of epidermis was 0.27 mm for the argon gas surgical unit and 0.67 mm for the conventional electrosurgical unit. The standard deviation in the argon gas group was also much smaller, implying that the results were more consistent and predictable. With conventional electrocautery, there must be direct contact be- tween the electrode tip and the tissue. In contrast, argon- enhanced coagulation is based on a concept that uses ionized gas to act as an electrical bridge to conduct current between the electrode and the tissues. This creates a noncontact form of coagulation. Argon, an inert gas, is relatively safe and will not ignite materials such as linen, gauze, gloved hands, drapes, or fatty tissue, as a laser or conventional electrosurgi- cal unit might. The investigators also noted a clinically sig- nificant decrease in postoperative swelling, hematoma, ser- oma, and drain output. The reduction in bleeding has contributed to reducing the operative time. Uses now also include blepharoplasty, breast reduction, and abdomi- noplasty.-P.S. LAM

Reprint request to Dr Man: Aesthetic Ambulatory Surgical Unit, 851 Meadows Rd, Suite 222, Boca Raton, FL 33486

Baseball Injuries: A Little League Survey. Pasternack JS, Veenema KR, Callahan CM. Pediatrics 98:445, 1996

Injuries in organized youth baseball occur at a small but significant rate and have been the subject of inquiry by a number of groups. Studies indicate between 2% and 8% of players are injured per season in organized youth baseball. Forty-six percent of these injuries are head or facial injuries. Numerous medical and dental organizations have made safety recommendations over the years but some of these recommendations were not accepted in organized youth baseball. Some of these have included face protection for the batters and use of a reduced impact baseball. In this article, the investigators present data from a survey of 2,861 Little League players, ages 7 to 18. Although the programs were co-ed, no girls over the age of 12 were participating. In one league, players were required to wear a batting helmet equipped with a wire mesh face guard whereas all other players wore a standard batting helmet without a faceguard. Managers were asked to report all injuries during the season that satisfied the provided criteria. At the end of the season, the managers of the two teams were interviewed. Injuries were classified as acute (catastrophic, severe, or minor), by player hours, and the involved activities at the time of injury. Results indicated the players participated for a total of 140,932 player hours. There were no catastrophic injuries in the 66 acute injuries, but 11 were classified as severe (8 hardball, 3 softball). Injuries included torn knee ligaments, injuries to permanent teeth, and fractures. Minor injuries included contusions, sprains, fractures, lacerations, dental injuries (3), closed head injuries, abrasions, and muscle strain. Over the course of the season, 2.3% of the players sustained an acute injury, which occurred at a rate of .057 injuries per 100 player-hours, There were 4 ball-related facial injuries (all on defense) in the group wearing the batting helmet with face mask, and 3 ball-related injuries (2 on defense, 1 on offense) in the group wearing the helmet with- out the face mask. The investigators concluded that most

injuries occur on defense and would not be prevented by wearing a face mask on the batting helmet. Facial injuries would have been prevented by the batting helmet with face mask, but not by a helmet with only eye guards. The investi- gators conclude that overall, 14% of the injuries could have been prevented, but not facial injuries. Because 62% of all injuries are caused by impact with the baseball, a reduced impact baseball would seem logical, but studies have shown that these balls have not seemed to lower the incidence of catastrophic or serious injuries. Further data are needed.- ROGER ALEXANDER

Reprint requests to Dr Pasternack: Department of Emergency Medi- cine, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY 14642.

Unusual Presentations of Injuries Associated with the Mandibular Condyle in Children. McGrath CJR, Egbert MA, Tong DC, et al. Br J Oral Max Surg 34:311, 1996

Fractures of the condyle are the most common mandibular fractures seen in children, accounting for up to 67% of all mandibular injuries. In this report, the investigators review several case reports showing interesting clinical presenta- tions secondary to condylar fractures. The investigators re- view the anatomy of the condylar area, misleading signs and symptoms, and indications for surgical fracture intervention. The investigators conclude that supplemental imaging of the condyle, particularly coronal computed tomography scans, are extremely helpful in the diagnosis and management of condylar fractures.-C.E. PEOPLES III

Reprint requests to Dr McGrath: University of Wsahington Depart- ment of Oral and Maxillofacial Surgery, SB-24, Seattle, Washington 98195.

Healing of Osseous Submucous Cleft Palates with Guided Bone Regeneration. Matzen M, Kostopoulos L, Karring T. Scan J Plast Reconstr Hand Surg 30:161, 1996

The purpose of this study was to show the use of polytetra- fluoroethylene membranes for bone regeneration on experi- mentally induced submucous cleft palates in rats. An osseous submucous palatal defect was created in 58 male albino Wister rats. The animals were then randomly divided into a test and control group. The test group received two pieces of polytetrafluoroethylene membranes, one between the nasal mucosa and the defect and one between the palatal mucosa and the defect. The control group received no membranes. The animals were then sacrificed at 7 and 12 weeks. The test group showed complete regeneration of bone in the defect whereas the control group showed some bone regeneration at the periphery but there was always a residual defect. Guided tissue regeneration may provide a new alternative to cleft palate treatment, but further studies are necessary regarding the way this bone will respond to normal growth and development. - W. CARVAJAL

Reprint requests to Dr Matzen: Department of Plastic Surgery, Odense University Hospital, DK-5000, Odense C, Denmark.

Alcoholism in Women. North CS. Postgrad Med 100:221, 1996

Alcohol use disorders are present in up to 10% of female patients in U.S. medical practices, and the incidence is in- creasing. This increase has paralleled women’s successful competition with men for equality in the marketplace. Never-

CURRENT LITERATURE 433

theless, physicians fail to recognize alcoholism in the major- ity of patients, especially women. Today, 1 in 3 alcoholics is a woman. Furthermore, the incidence of alcohol-related medical complications has increased in women at a faster rate because of sex-related differences in the body’s metabo- lism of alcohol. Women tend to begin drinking later in life, engage in less binge drinking, experience shorter drinking bouts, and are less likely to drink on a daily basis or in the morning. Alcoholic women do most of their drinking at home, and are said to have a “hidden addiction.” Women enter treatment an average of 7 years into their heavy drink- ing, half of the time it take alcoholic men. They are more likely than their male counterparts to divorce as a result of their drinking-related problems, and they have more marital and family problems. Blood alcohol tend to increase up to 40% greater in women than in men drinking equal amounts, because women absorb alcohol more quickly because they have lower levels of gastric alcohol dehydrogenase. Alcohol- ism is the 3rd leading cause of death in women 35 to 55 years of age and the mortality rate in women is 4 times that of women in the general population. Unfortunately, there are no pathognomonic signs to identify alcholism. Women face unique problems in recovery. They receive less family sup- port and may find their new sobriety destabilizes their rela- tionship with their partner. Most treatment programs have been designed for men and tend to be confrontational and alcohol-focused, which alienates women. During pregnancy is a prime time to counsel a woman about entering a formal treatment program, but she should be encouraged to seek treatment for herself rather than for the baby. High rates of psychoactive drug abuse in women have been documented. Women will try to manipulate doctors into prescribing psy- choactive drugs that complicates the clinical interaction.- ROGER ALEXANDER

Reprint requests to Dr North: Department of Psychiatry, Washington University School of Medicine, 4940 Children’s Pl, St. Louis, MO 63110.

Endoscopic Sympathectomy Treatment for Craniofacial Hyperhidrosis. Ming-Chien K, Yi-Long C, Jue-Yi L, et al. Arch Surg 131:1091, 1996

Endoscopic procedures provide excellent illumination and good magnification of the operative field via a minimally invasive approach. This study shows the use of endoscopy for a T-2 segment sympathectomy to alleviate craniofacial hyperhidrosis (CH). The procedure was initially pioneered for the treatment of palmar hyperhidrosis (PH) by means of upper thoracic sympathectomy but a serendipitous finding was the reduction of the patient’s facial sudomotor activity without causing ptosis. Thirty patients with severe CH were treated for and followed-up for 4 years. Of the 30 patients in this study, 8 had concomitant PH, 18 were male and 12 were female. Under general anesthesia, a conventional operating thoracoscope was inserted into the upper thoracic cavity via the third midaxillary intercostal space. Once visu- alized, the sympathetic trunk overlaying the head of the sec- ond rib (T-2 segment) was bilaterally ablated by electrocoag- ulation while blood oxygen saturation, palmar skin temperature, and pupil size were continuously monitored. All 30 patients were successfully treated without injury to the lungs or excessive bleeding. No ptosis or miosis occurred except in 1 patient. This problem resolved 2 months later. According to the investigators, cauterizing might have oc- curred in the area near the Stellate ganglion (T-l segment)

which is located cephalic to the intended target and responsi- ble for the oculopupillary sympathetic response. The T-2 segment sends most of its postganglionic fibers to the palm, some fibers to the face but very few fibers to the eye that shows the slight dilation of the pupils and unremarkable ptosis. Postoperatively, the patients were examined at 1 week and 3 month intervals and monitored by phone up to 44 months thereafter. The technique described in this study is significantly simple, effective, and minimally invasive, how- ever it should be clear that accessory or collateral sympa- thetic pathways beyond the T-2 segment exist and postopera- tive recurrence of CH might occur. More than one third of the patients had remained satisfied with the therapeutic re- sults for longer than 1 year and based on the long-term observation of patients with PH treated by T-2 sympathec- tomy, the authors believe the results will be permanent.- H. PATWO

Reprint requests to Dr Ming-Chien: Division of Neurosurgery, Na- tional Taiwan University Hospital, No. 7 Chung-Shan S Rd, Taipei, Taiwan.

Hypertension in Women and the Elderly. Reynolds E, Baron RB. Postgrad Med 10058, 1996

There has been a decrease in morbidity and mortality from coronary artery disease (CAD) over the past 20 years caused by improved detection and treatment regimens. Nevertheless, almost 65% of the U.S. population over the age of 60 years has hypertension (defined as systolic ~140 mm Hg or dia- stolic ~90 mm Hg), which is, in turn, related to increased rates of CAD, stroke (CVA), renal disease, and death. Thirty percent have isolated systolic hypertension. Studies have shown that for every 7.5 mm Hg increase in diastolic pres- sure the risk of CAD increases 29% and the risk for stroke increases 46% (for both sexes). Prevalence is greater in blacks at all ages and in both sexes. Systolic elevations are felt to be more predictive of risk than diastolic pressures. After menopause, the number of hypertensive women out- numbers the number of hypertensive men. Clinical trials typically have not targeted young and middle-aged women, because they had a lower incidence, but extrapolated data suggest that treatment of hypertension does not confer the same protection against CAD and CVA in women as in men. Some data suggest that young and middle-aged women may be harmed by receiving stepped care for hypertension and conservative treatment may be indicated. Black women seem to respond better to treatment than white women. Drugs should be prescribed for hypertensive women only after a focused trial of lifestyle modification, including weight loss; sodium restriction, exercise, and so on. Up to 5% of women on birth control medication can experience hypertension, but the newer, multiphasic and lower-dose, monophasic oral contraceptives seem to be better. Until recently, the elderly were also often excluded from clinical studies despite their high risk for morbidity and death from hypertension-related diseases. Recent metanalyses have shown that treatment of the elderly is highly effective, and that elderly women should be treated as aggressively as elderly men, including the use of low-dose diuretics and beta blockers. It is recommended that elderly patients be treated if their systolic pressure is 2 160 mm Hg and/or their diastolic pressure is 290 mm Hg, but in younger patients the treatment threshold should be higher-ROGER ALEXANDER

Reprint Requests to Dr Baron: Department of General Internal Medi- cine, Box 0320, University of California: San Francisco, School of Medicine, 505 Pamassus Ave, San Francisco, CA 94143.0124.