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.