Frey's syndrome: a preventable phenomenon.

Gustatory sweating, or Frey's syndrome, is a fairly common sequela of partial or radical parotidectomy, submaxillary gland surgery, or radical neck dissection. It is caused by an anastomotic communication with facial sweat glands by parasympathetic secretomotor nerve fibers intended for the excised parotid gland; treatments, whether surgical or topical, generally have been less than satisfactory. We present the first documented prophylactic approach to Frey's syndrome that is performed during and as part of parotidectomy. The surgery involves use of the superficial aponeurotic system (SMAS) as an interposing flap to interrupt the anastomotic nerve communication with the sweat glands. The SMAS is derived from the fascia in the periauricular cheek and neck area that is continuous with the platysma muscle. In a prospective study in 55 patients undergoing elective parotidectomy, the SMAS flap was elevated during the beginning of the operative procedure once it had been determined that fashioning of the flap would in no way compromise tumor excision. In all cases, at follow-up, there has been no clinical evidence of development of Frey's syndrome. We have shown that the development of the SMAS flap in parotid gland resections is an effective new approach both as a preventative measure against Frey's syndrome and as an aesthetic improvement over the usual defect typical of parotidectomies.     

Vaccine preventable viral diseases in developing countries

There are several viral infectious diseases with a high impact on developing countries which can be prevented by immunization with existing vaccines. The most important are poliomyelitis, measles, hepatitis B and yellow fever. Vaccines against poliomyelitis and measles used within the framework of the WHO/Expanded Programme on Immunization prevent about 1.4 million deaths from measles and 360,000 cases of paralytic polio per year in developing countries, but about 1.5 million measles' deaths and 200,000 cases of paralytic polio still occur. Hepatitis B infection and its sequelae are responsible for over 50 million infections and one million deaths annually. Highly effective hepatitis B vaccines are now available and the price of these vaccines for the developing world has fallen dramatically. Despite the availability of a safe and efficacious yellow fever vaccine since 1937, 5400 cases of this disease with 3200 deaths were reported in Africa and South America from 1986 to 1988. Because of the efficacy of existing vaccines and the lack of animal reservoirs or vectors, systematic vaccination programmes within the framework of the Expanded Programme on Immunization (EPI) could theoretically eliminate and even eradicate poliomyelltis, measles and hepatitis B. Many different obstacles need to be overcome before these goals are realized.This paper was presented at the IUMS Symposium on New Developments in Diagnosis and Control of Infectious Diseases held in conjunction with the Eighth International Congress of Virology, Berlin, Germany, 24–31 August 1990.     

Evolutionary suicide

The great majority of species that lived on this earth have gone extinct. These extinctions are often explained by invoking changes in the environment, to which the species has been unable to adapt. Evolutionary suicide is an alternative explanation to such extinctions. It is an evolutionary process in which a viable population adapts in such a way that it can no longer persist. In this paper different models, where evolutionary suicide occurs are discussed, and the theory behind the phenomenon is reviewed.     

Supporting irrational suicide

In this essay, we present three case studies which suggest that sometimes we are better off supporting a so–called irrational suicide, and that emotional or psychological distress – even if medically controllable – might justify a suicide. We underscore how complicated these decisions are and how murky a physician's moral role can be. We advocate a more individualized route to end–of–life care, eschewing well–meaning, principled, generalizations in favor of a highly contextualized, patient–centered, approach. We conclude that our Western traditions of promoting reasoned behavior and life themselves may at times be counter–productive.     

Neuroeconomics of suicide

Suicidal behavior is a leading cause of injury and death worldwide. Suicide has been associated with psychiatric illnesses such as depression and schizophrenia, as well as economic uncertainty, and social/cultural factors. This study proposes a neuroeconomic framework of suicide. Neuroeconomic parameters (e.g., risk-attitude, probability weighting, time discounting in intertemporal choice, and loss aversion) are predicted to be related to suicidal behavior. Neurobiological and neuroendocrinological substrates such as serotonin, dopamine, cortisol (HPA axis), nitric oxide, serum cholesterol, epinephrine, norepinephrine, gonadal hormones (e.g., estradiol and progesterone), dehydroepiandrosterone (DHEA) in brain regiouns such as the orbitofrontal/dorsolateral prefrontal cortex and limbic regions (e.g., the amygdala) may supposedly be related to the neuroeconomic parameters modulating the risk of suicide. The present framework puts foundations for "molecular neuroeconomics" of decision-making processes underlying suicidal behavior.