A hyperthyroid patient with bloody pericardial effusion is presented. He was hospitalized for severe dyspnea. Pericardiocentesis yielded 1.2 liters of bloody fluid. Biochemical, cytologic, and radiologic examinations failed to identify the etiology of the effusion. Upon normalization of thyroid function using antithyroid drugs, the pericardial effusion resolved without recurrence. The patient was diagnosed as Graves' disease, which rarely is complicated by bloody pericardial effusion. As it is rarely reported and not widely known, this association may be underdiagnosed. (Internal Medicine 44: 1064-1068, 2005)

ndoscopic transthoracic sympathicotomy (ETS) is a recently developed technique to divide sympathetic nerves and has been used successfully in the treatment of palmar hyperhidrosis, causalgia, or ischemia of the upper extremities. 1,2 Because of its minimal morbidity and mortality, renewed interest has been expressed in ETS as a palliative approach to patients with severe angina pectoris, who are not suitable for coronary artery bypass grafting or angioplasty. 3,4 Anatomically, the upper third or fourth thoracic, stellate, and cervical sympathetic ganglia receive the preganglionic fibers from the upper 4 thoracic segments of the spinal cord and direct the postganglionic fibers to the targets, including the heart, the upper extremities, and the cranial vessels. 5 Endoscopic transthoracic sympathicotomy blocks efferent sympathetic nerves to the heart as well as the upper extremities; however, the effect of ETS on the cardiovascular system remains unclear. The purpose of the present study was to examine the effect of Th 2-3 ETS on hemodynamic and neurohumoral responses to exercise in patients with palmar hyperhidrosis. Methods Patient SelectionTwenty-one patients with primary palmar hyperhidrosis Circulation Journal Vol.66, April 2002(10 males and 11 females, mean age 28±3 years; mean ± SEM) participated in the study. None of these patients had cardiac disease nor were receiving any drug that might affect autonomic function directly or indirectly. All patients gave their informed consent before participating. Endoscopic Transthoracic SympathicotomyThe operative technique, which has been described in detail elsewhere, 2,6 has been used in more than 400 patients with palmar hyperhidrosis at National Kanazawa Hospital since 1993. Patients were intubated with an endotracheal tube under general anesthesia and placed in a semireclining position with both arms in abduction. (In the semireclining position, the pneumothorax is located in the apical region.) Approximately 2 liters of carbon dioxide was insufflated into the pleural cavity through a Surgineedle entered via the axillary fossa. A modified urological electroresectoscope was introduced via the same incision into the axillary fossa, thus obtaining an excellent view of the upper thoracic cavity. The sympathetic chain can be identified lying over or in the immediate vicinity of the costovertebral joint. The second and third thoracic sympathetic ganglia, including rami communicantes, were destroyed by electrocautery. After exsufflation of the gas, the procedure was repeated on the opposite side. Operation time was within 30 min. The patient was discharged from hospital the day after operation and the hospital stay was 2 days. Most patients resumed work within a few days and resumed sports activities within 2 weeks. Treadmill Exercise TestSubmaximal, graded, upright treadmill exercise was performed according to a modified Bruce protocol comprising Circ J 2002; 66: 357 -361 (Received July 25, 2001; revised manuscript received December 11, 2001; accepted January 10, 20...

and Ken-ichi KOBAYASHI Central muscarinic receptors play an important role in the regulation of cardiac vagal nerve activity. We studied the inhibition of central muscarinic receptors and sympathetic nerve function in humans, since very little information is currently available on this subject. We examined the effects of graded doses of atropine (five doses, range 0.001 to 0.016 mg/kg) on heart rate, arterial pressure, heart rate variability, and muscle sympathetic nerve activity in 13 healthy young volunteers. Atropine caused biphasic effects on heart rate and the high-frequency (HF) power of R-R interval variability. At lower doses (0.002 mg/kg for heart rate, 0.001 mg/kg for HF power), atropine decreased heart rate and increased HF power. In contrast, at higher doses, atropine increased heart rate and decreased HF power. Low-dose atropine significantly attenuated muscle sympathetic nerve activity, burst rate (bursts/min) by -30.5±6.0% and burst incidence (bursts/100 heart beats) by -23.8 ± 6.9% at 0.002 mg/kg. Systolic and diastolic arterial pressure did not change with atropine infusion. Low-dose atropine (0.002 mg/kg) did not significantly affect either low frequency (LF) power or LF/HF. These results suggest that central muscarinic receptors may modulate not only cardiac vagal nerve activity but also sympathetic nerve activity in the skeletal muscle vasculature.

ndoscopic transthoracic sympathicotomy (ETS) is a safe and effective procedure that is used for the treatment of palmar hyperhidrosis. 1,2 The upper third or fourth thoracic, stellate, and cervical sympathetic ganglia receive the preganglionic fibers from the upper 4 thoracic segments of the spinal cord and direct the postganglionic fibers to the heart, upper extremities and cranial vessels. 3 Therefore, ETS results in blockade of efferent sympathetic nerves that innervate the heart and upper extremities.Natriuretic peptides are secreted into the systemic circulation in response to numerous factors, including increased atrial and/or ventricular wall tension, tachycardia, exercise, endothelin, arginine vasopressin and catecholamines. 4 An interaction between the sympathetic nervous system and the natriuretic peptide system has been suggested by experimental studies that demonstrated suppression of cardiac atrial natriuretic peptide (ANP) release in response to -adrenergic stimulation. 5,6 This is corroborated by other studies that demonstrated augmentation of cardiac natriuretic peptides by pharmacological -receptor blockade in humans. [7][8][9] However, the precise effect of the sympathetic nervous system on the natriuretic peptide system remains unclear.Therefore, we examined the effect of ETS of the second Circulation Journal Vol.69, September 2005and third thoracic sympathetic ganglia (Th2-3) on cardiac function and plasma ANP and brain natriuretic peptide (BNP) concentrations in patients with primary palmar hyperhidrosis to characterize the role of the sympathetic nervous system in the regulation of plasma natriuretic peptides. Methods Patient SelectionThirty-seven patients (19 males, 18 females, mean age 29±10 years; mean ± SD) underwent ETS for treatment of primary palmar hyperhidrosis. None had a history of cardiac disease nor were they receiving any drugs that could directly or indirectly modulate the autonomic nervous system. Written informed consent was obtained from all patients before enrollment. Study protocols were approved by the institutional committee on human research. ETSThe operative technique, which has previously been described in detail, 8,10 has been used in more than 600 patients with palmar hyperhidrosis at the Kanazawa Medical Center since 1993. Briefly, patients were intubated with an endotracheal tube under general anesthesia and placed in a semireclining position with both arms in abduction. The pleural cavity was accessed via a Surgineedle in the axillary fossa, and approximately 2 L of carbon dioxide was insufflated into the pleural cavity. A modified urological electroresectoscope was introduced via the same incision in the axillary fossa to visualize the upper thoracic cavity. The sympathetic chain was identified in the immediate vicinity of the cost- Effect of Endoscopic Transthoracic Sympathicotomy on Plasma Natriuretic Peptide Concentrations in HumansYukio Nakamura, MD; Hisashi Yoshizawa, MD; Motoaki Hirasawa, MD;Hiroshi Kida, MD; Yasushi Matsumoto, MD*; Takeshi Ueyama, MD* ...