Tratamiento del síndrome de Raynaud con toxina botulínica tipo A / Treatment of Raynaud's syndrome with botulinum toxin type A

El fenómeno de Raynaud es un trastorno vasoespástico de las arterias digitales por la exposición al frío o al estrés, el cual genera isquemia que se manifiesta con cianosis o palidez, dolor y úlceras crónicas; es una afección incapacitante para el paciente y de difícil manejo para el cirujano de mano. Se clasifica en primario y secundario. El primario es la forma de presentación más frecuente. Las modalidades de tratamiento están dirigidas a prevenir el vasoespasmo exagerado, fomentando la respuesta vasodilatadora y con ello disminuyendo la sintomatología, que es en la mayoría de los casos incapacitante. Se ha descrito el uso de la toxina botulínica A para aquellos casos severos y refractarios, con mala evolución, con el que se obtuvieron buenos resultados. Este sería un tratamiento de baja morbilidad, con escasos efectos adversos, que puede ofrecer un alivio del dolor rápido y duradero, contribuyendo además a la cicatrización de úlceras crónicas. De esta manera mejora la calidad de vida de los pacientes y evita tratamientos invasivos y la amputación. El propósito de este trabajo fue realizar una revisión bibliográfica incluyendo a los trabajos más importantes y relevantes hasta el momento en el tratamiento de la toxina botulínica A en el síndrome de Raynaud. Se presenta además un caso clínico refractario al tratamiento médico que fue tratado en la Cátedra de Cirugía Plástica, Reparadora y Estética del Hospital de Clínicas, Montevideo, Uruguay

Raynaud's phenomenon is a vasospastic disorder of the digital arteries due to exposure to cold or stress, which generates ischemia that manifests with cyanosis or paleness, pain, and chronic ulcers; it is a disabling condition for the patient and difficult to manage for the hand surgeon. It is classified into primary and secondary. Primary is the most common form of presentation. Treatment modalities are aimed at preventing exaggerated vasospasm, promoting the vasodilator response and thereby reducing symptoms, which are disabling in most cases. The use of botulinum toxin A has been described for those severe and refractory cases, with poor evolution, with which good results were obtained. This would be a low morbidity treatment, with few adverse effects, which can offer rapid and long-lasting pain relief, also contributing to the healing of chronic ulcers. In this way, it improves the quality of life of patients and avoids invasive treatments and amputation. The purpose of this work was to carry out a bibliographic review including the most important and relevant works to date on the treatment of botulinum toxin A in Raynaud's syndrome. In addition, a clinical case refractory to medical treatment that was treated in the Chair of Plastic, Reconstructive and Aesthetic Surgery of the Hospital de Clínicas, Montevideo, Uruguay, is also presented.

Botulinum toxin A (IncobotulinumtoxinA) and pneumoperitoneum image-guided for hernia repair with loss of dominance.

Post-incisional ventral hernia is estimated at 5-30%, when the content of the abdominal cavity migrates to the hernial sac (HSV), with a HSV/abdominal cavity volume ratio > 25%, conditioning systemic changes defined as "loss of domain". A 27-year-old male presented with ventral hernia with loss of domain that required pre-operative preparation techniques, using application of botulinum toxin A (IncobotulinumtoxinA) and pneumoperitoneum, both guided by image. A ventral plasty was performed with adequate return of the viscera to the abdominal cavity. The combination of both techniques seems to be a safe procedure to carry out a tension-free repair.

La hernia ventral postincisional se estima en 5 al 30%, cuando el contenido de la cavidad abdominal migra al saco herniario, con una relación VSH/VCA > 25% condicionando cambios sistémicos se define como "pérdida de dominio". Masculino de 27 años con hernia ventral con pérdida de dominio que ameritó técnicas de preparación preoperatoria, utilizando toxina botulínica A (IncobotulinumtoxinA) y neumoperitoneo, ambos guíados por imagen. Se realizó una plastia ventral con adecuado regreso de las vísceras a la cavidad abdominal. La combinación de ambas técnicas es un procedimiento seguro para realizar una reparación libre de tensión.

Análisis descriptivo de coste de tratamiento de la espasticidad con diferentes tipos de toxina botulínica A, a lo largo de un año / Descriptive analysis of the annual cost of treating spasticity with different types of botulinum toxin A

Introducción: La toxina botulínica A es el tratamiento de elección para la espasticidad localizada. Sin embargo, no se tiene un conocimiento real de su repercusión económica.El objetivo de este trabajo es describir los costes reales del tratamiento de la espasticidad en adultos con toxina botulínica A en una consulta de espasticidad de un Servicio de Rehabilitación, a lo largo de un año.MétodosSe ha realizado la revisión retrospectiva de todos los actos médicos llevados a cabo a lo largo del año 2017. Se han recogido el tipo de toxina utilizado (incobotulinumtoxin A, onabotulinumtoxin A, abobotulinumtoxin A), las unidades inyectadas, la región anatómica y el tiempo transcurrido entre infiltraciones. Se han obtenido los costes de la medicación y los costes indirectos, como los de personal o los fungibles.ResultadosEste es el primer trabajo que describe los costes reales del tratamiento de la espasticidad en adultos con toxina botulínica A en España. En 2017 se realizaron 510 actos de infiltración en 164 pacientes. El coste total de tratamiento de espasticidad en nuestro servicio fue de 116.789,70 €. El coste medio anual por paciente fue 603,64 € para onabotulinumtoxin A, de 642,69 € para abobotulinumtoxin A y de 707,59 € para incobotulinumtoxin A.ConclusionesNuestro estudio económico de actividad clínica real sigue una pauta similar a la descrita en los modelos teóricos publicados en la literatura. Las diferentes características de cada toxina y la imposibilidad de establecer una equivalencia entre las unidades de cada una de ellas impiden la comparación directa de estos costes. (AU)

Introduction: Botulinum toxin A is the first-line treatment for localised spasticity. However, the economic impact of this treatment is not fully known.This study aimed to describe the real costs of botulinum toxin A for the treatment of adult patients with spasticity at a spasticity clinic pertaining to a rehabilitation service, over a period of one year.MethodsWe retrospectively reviewed all medical procedures carried out during the year 2017. We collected data on the type of toxin used (incobotulinumtoxin A, onabotulinumtoxin A, or AAbobotulinumtoxin A), the number of units injected, the anatomical region, and the time elapsed between infiltrations. The costs of medication and indirect costs, such as staff and consumables, were also calculated.ResultsThis is the first study to describe the real costs of botulinum toxin treatment of spasticity in adult patients in Spain. In 2017, 510 infiltration procedures were performed in 164 patients. The total cost of treating spasticity in our service was €116 789.70. The mean annual cost per patient was €603.64 for onabotulinumtoxin A, €642.69 for abobotulinumtoxin A, and €707.59 for incobotulinumtoxin A.ConclusionsOur economic study of real clinical practice is consistent with the theoretical models published in the literature. The different characteristics of each toxin and the inability to establish an equivalence between the units of each drug prevents us from directly comparing these costs. (AU)

Consenso ibérico de buenas prácticas clínicas en tratamientos estéticos con toxina botulínica tipo A / Iberian consensus of good clinical practices in aesthetic treatments with Abobotulinum toxin A

Introducción y objetivo: Con la evolución de la experiencia en el uso de la toxina botulínica tipo A para tratamientos estéticos se necesitan guías actualizadas de buenas prácticas clínicas. El objetivo de este trabajo fue desarrollar recomendaciones actualizadas para buenas prácticas en el uso clínico diario, con el fin de optimizar el manejo del paciente estético y los resultados obtenidos con la toxina botulínica tipo A. Material y método: Un panel de 44 participantes con amplia experiencia en el uso de la toxina Abobotulinum se reunió para revisar y discutir la evidencia disponible y la práctica clínica en la aplicación estética de la toxina Abobotulinum A. Resultados: Los temas discutidos para la creación de este consenso incluyeron cuestiones directamente relacionadas con el uso y las propiedades de la toxina botulínica tipo A (Azzalure®) y temas generales relativos a la práctica clínica: precisión y campo de efecto de la toxina botulínica tipo A, duración del efecto, rapidez en el inicio de acción, protocolos de tratamiento, tratamientos combinados de toxina botulínica tipo A y ácido hialurónico para mayor satisfacción del paciente y armonía facial, recomendaciones post-tratamiento, diagnóstico y valoración previa del paciente para un efecto óptimo, edad en la que los pacientes comienzan a ser tratados con la toxina y su recomendación como tratamiento preventivo según las escalas de envejecimiento Glogau I o II, manejo de las expectativas del paciente y valoración de la satisfacción del mismo. Conclusiones: Este consenso ha recogido las opiniones, consejos y experiencia de médicos estéticos con amplia experiencia en el uso de la toxina botulínica tipo A para ayudar a los profesionales a conseguir los mejores resultados posibles en términos de eficacia y satisfacción del paciente. (AU)

Background and objective: With the evolution of the experience in the use of botulinum toxin type A for aesthetic treatments, updated guidelines of good clinical practices are needed. The objective of this work was to develop updated recommendations for good practices in daily clinical use, in order to optimize the mana- gement of the aesthetic patient and the results obtained with botulinum toxin type A. Methods: A panel of 44 participants with extensive experience in the use of Abobotulinum toxin met to review and discuss the available evidence and clinical practice in the aesthetic application of Abobotulinum toxin A. Results: The topics discussed for the creation of this consensus included questions directly related to the use and properties of botulinum toxin type A (Azzalure®) and general topics related to clinical practice: precision and field of effect of botulinum toxin type A, duration of effect, speed of onset of action, treatment protocols, combined treatments of botulinum toxin type A and hyaluronic acid for greater patient satisfaction and facial harmony, post-treatment recommendations, diagnosis and prior assessment of the patient for optimal effect, age at which patients begin to be treated with the toxin and its recommendation as a preventive treatment according to the Glogau I or II aging scales, management of patient expectations and assessment of patient satisfaction. Conclusions: This consensus has collected the opinions, advice and experience of aesthetic doctors with extensive experience in the use of botulinum toxin type A to help professionals achieve the best possible results in terms of efficacy and patient satisfaction. (AU)

Descriptive analysis of the annual cost of treating spasticity with different types of botulinum toxin A.

INTRODUCTION: Botulinum toxin A is the first-line treatment for localised spasticity. However, the economic impact of this treatment is not fully known. This study aimed to describe the real costs of botulinum toxin A for the treatment of adult patients with spasticity at a spasticity clinic pertaining to a rehabilitation service, over a period of one year. METHODS: We retrospectively reviewed all medical procedures carried out during the year 2017. We collected data on the type of toxin used (incobotulinumtoxin A, onabotulinumtoxin A, or Abobotulinumtoxin A), the number of units injected, the anatomical region, and the time elapsed between infiltrations. The costs of medication and indirect costs, such as staff and consumables, were also calculated. RESULTS: This is the first study to describe the real costs of botulinum toxin treatment of spasticity in adult patients in Spain. In 2017, 510 infiltration procedures were performed in 164 patients. The total cost of treating spasticity in our service was 116 789.70. The mean annual cost per patient was 603.64 for onabotulinumtoxin A, 642.69 for abobotulinumtoxin A, and 707.59 for incobotulinumtoxin A. CONCLUSIONS: Our economic study of real clinical practice is consistent with the theoretical models published in the literature. The different characteristics of each toxin and the inability to establish an equivalence between the units of each drug prevents us from directly comparing these costs.

Descriptive analysis of the annual cost of treating spasticity with different types of botulinum toxin A. / Análisis descriptivo de coste de tratamiento de la espasticidad con diferentes tipos de toxina botulínica A, a lo largo de un año.

INTRODUCTION: Botulinum toxin A is the first-line treatment for localised spasticity. However, the economic impact of this treatment is not fully known. This study aimed to describe the real costs of botulinum toxin A for the treatment of adult patients with spasticity at a spasticity clinic pertaining to a rehabilitation service, over a period of one year. METHODS: We retrospectively reviewed all medical procedures carried out during the year 2017. We collected data on the type of toxin used (incobotulinumtoxin A, onabotulinumtoxin A, or AAbobotulinumtoxin A), the number of units injected, the anatomical region, and the time elapsed between infiltrations. The costs of medication and indirect costs, such as staff and consumables, were also calculated. RESULTS: This is the first study to describe the real costs of botulinum toxin treatment of spasticity in adult patients in Spain. In 2017, 510 infiltration procedures were performed in 164 patients. The total cost of treating spasticity in our service was €116 789.70. The mean annual cost per patient was €603.64 for onabotulinumtoxin A, €642.69 for abobotulinumtoxin A, and €707.59 for incobotulinumtoxin A. CONCLUSIONS: Our economic study of real clinical practice is consistent with the theoretical models published in the literature. The different characteristics of each toxin and the inability to establish an equivalence between the units of each drug prevents us from directly comparing these costs.

Preoperative botulinum A toxin as an adjunct for abdominal wall reconstruction: a single-center early experience at an Academic Center in New York / Toxina botulínica A pré-operatória como adjuvante na reconstrução da parede abdominal: experiência inicial em Centro Acadêmico em Nova York

ABSTRACT Introduction: the botulinum toxin A (BTA) has been used to achieve a chemical component separation, and it has been used with favorable outcomes for the repair of complex ventral hernia (CVH) with and without loss of domain (LD). The aim of this study is to describe our early experience with the chemical component separation in the United Sates. Methods: a retrospective observational study of all patients who underwent ventral hernia repair for CVH with or without LD between July 2018 and June 2020. Preoperative BTA was injected in all patients via sonographic guidance bilaterally, between the lateral muscles to achieve chemical denervation before the operation. Patient demographics, anatomical location of the hernia, perioperative data and postoperative data are described. Results: 36 patients underwent this technique before their hernia repair between July 2018 to June 2020. Median age was 62 years (range 30-87). Median preoperative defect size was 12cm (range 6-25) and median intraoperative defect size was 13cm (range 5-27). Median preoperative hernia sac volume (HSV) was 1338cc (128-14040), median preoperative abdominal cavity volume (ACV) was 8784cc (5197-18289) and median volume ration (HSV/ACV) was 14%. The median OR time for BTA administration was 45 minutes (range 28-495). Seroma was the most common postoperative complication in 8 of the patients (22%). Median follow up was 43 days (range 0-580). Conclusion: preoperative chemical component separation with BTA is a safe and effective adjunct to hernia repair in CVH repairs where a challenging midline fascial approximation is anticipated.

RESUMO Introdução: a toxina botulínica A (TBA) tem sido usada para alcançar a separação química dos componentes, com resultados favoráveis para o reparo de hérnias ventrais complexas (HVC) com ou sem perda de domínio (PD). O objetivo deste estudo é descrever nossa experiência inicial com a separação química dos componentes nos Estados Unidos. Métodos: estudo retrospectivo observacional com todos os pacientes submetidos a reparo de hérnia ventral complexa com ou sem PD entre julho de 2018 e junho de 2020. A TBA pré-operatória foi injetada em todos os pacientes, guiada por ultrassonografia, bilateralmente entre os músculos laterais para alcançar a denervação química antes da operação. Dados demográficos dos pacientes, local da hérnia, dados peri-operatórios e pós-operatórios são descritos. Resultados: 36 pacientes foram submetidos a esta técnica antes do reparo da hérnia. A idade mediana foi 62 anos (30-87). O tamanho mediano pré-operatório do defeito herniário foi 12cm (6-25) e o defeito mediano intra-operatorio foi 13cm (5-27). O volume mediano do saco herniário pré-operatório foi 1.338mL (128-14.040), o volume mediano da cavidade abdominal pré-operatório foi 8.784 (5.197-18.289) mL e a razão dos volumes foi 14%. A duração mediana da operação para aplicação da TBA foi 45 minutos (28-495). O seroma foi a complicação mais comum no pós-operatório, em oito pacientes (22%). O seguimento pós-operatório mediano foi de 43 dias (0-580). Conclusão: a separação pré-operatória de componentes com TBA é tratamento adjuvante seguro e eficaz em reparos de HVC em que aproximação da fáscia é antecipadamente desafiadora.

Aplicación de toxina botulínica en el tratamiento de la distonía. Experiencia en un hospital de tercer nivel / Application of botulinum toxin in the treatment of dystonia. Experience in a tertiary hospital

Introducción. La distonía es un trastorno del movimiento que produce afectaciones funcionales a quienes la padecen; la aplicación de toxina botulínica es el tratamiento de elección debido a su seguridad. Objetivo. Describir losresultadosclínicos del uso a largo plazo de toxina botulínica en un grupo de pacientes con diagnóstico de distonía atendidos en un hospital de tercer nivel de complejidad de Bogotá, Colombia. Métodos. Estudio observacional. Se revisaron las historiasclínicas de los pacientescon diagnóstico de distonía atendidos en la clínica de espasticidad y distonía de una institución de salud. El dolorse evaluó con la escala visual análoga (EVA)yla percepción de mejoría de síntomas(recuperación de los arcos de movilidad y disminución de movimientos involuntarios); además, el especialista que realizó la aplicación de la toxina botulínica analizó el comportamiento de estas variables en el tiempo. Resultados. Se incluyeron 28 pacientes, el tipo de distonía más frecuente fue la cervical (75%) y el promedio de tiempo de tratamiento fue de 4,95 años (DE=2,89). Se encontró una reducción de dolor del 79,32%, la cual se mantuvo en el tiempo (p<0,05); además, la percepción de síntomas por parte del paciente tuvo una mejoría del 83,75% (p<0,05) y la apreciación de resultados por parte del fisiatra fue del 88,39% (p=0,157). Conclusiones. La toxina botulínica en el manejo de la distonía en la población de estudio mostró ser un tratamiento seguro y eficaz, esto posterior a varios ciclos de aplicación.

Introduction. Dystonia is a movement disorder that causes functional impairment to those who suffer from it; the application of botulinum toxin is the treatment of choice due to its safety. Objective. To describe the clinical results of the long-term use of botulinum toxin in a group of patients with a diagnosis of dystonia treated in a third level hospital in Bogota, Colombia. Methods. Observational study. The clinical histories of patients with a diagnosis of dystonia attended at the spasticity and dystonia clinic of a health institution were reviewed. Pain was evaluated with the visual analog scale (VAS) and the perception of symptom improvement (recovery of mobility arcs and reduction of involuntary movements); in addition, the specialist who performed the application of botulinum toxin analyzed the behavior of these variables over time. Results. Twenty-eight patients were included, the most frequent type of dystonia was cervical (75%) and the average treatment time was 4.95 years (SD=2.89). A pain reduction of 79.32% was found, which was maintained over time (p<0.05); in addition, the perception of symptoms by the patient had an improvement of 83.75% (p<0.05) and the appreciation of results by the physiatrist was 88.39% (p=0.157).

Protocolo de sedación con sevoflurano para la infiltración de toxina botulínica tipo A en parálisis cerebral infantil / Sevoflurane sedation protocol in children with cerebral palsy undergoing botulinum toxin-A injections

Objetivo Describir nuestra experiencia con un protocolo basado en el uso de sevoflurano para la sedación y analgesia durante la infiltración de toxina botulínica tipo A (BoNT-A), en niños con parálisis cerebral (PC), especialmente en términos de seguridad y eficacia. Material y métodos Estudio observacional retrospectivo de pacientes con PC a los que se realizó infiltración con BoNT-A bajo sedación con sevoflurano desde noviembre de 2012 hasta diciembre de 2019. Se revisaron las características demográficas, las características clínicas y funcionales, la efectividad de la sedación, los eventos adversos (EA) y la satisfacción del profesional. Resultados Se realizaron 387 sedaciones en 74 pacientes diagnosticados de PC. La sedación efectiva se logró en el 100% de los procedimientos, facilitando la colaboración durante la infiltración y la satisfacción del profesional. Se notificaron EA en el 6,02% de los procedimientos, siendo los más frecuentes las náuseas y los vómitos (3,88%) y la hipoxemia transitoria (2,07%). No se informaron EA graves. No se encontró asociación entre la incidencia de EA y las variables clínicas, funcionales o el riesgo antes de la anestesia. Conclusiones La sedación con sevoflurano muestra resultados prometedores en términos de seguridad y efectividad para el manejo de la agitación y el dolor durante la infiltración de BoNT-A en nuestra práctica clínica diaria. Además, puede facilitar la infiltración, permitir la exploración bajo sedación e infiltración multinivel con buena tolerancia (AU)

Objective This study aimed to describe our experience with a protocol based on sevoflurane sedation to control pain and agitation during botulinum toxin-A (BoNT-A) infiltration in children with cerebral palsy (CP), especially in terms of safety and efficacy. Material and methods We conducted a retrospective observational study of patients diagnosed with CP who underwent BoNT-A infiltration with sevoflurane sedation from November 2012 to December 2019. Demographic, clinical and functional characteristics, the effectiveness of sedation, adverse events (AE) and professional satisfaction were reviewed. Results A total of 387 sedations were successfully performed in 74 patients. Effective sedation was achieved in 100% of procedures, facilitating collaboration during infiltration and improving professional satisfaction. AE were reported in 6.02% of the procedures, the most frequent being nausea and vomiting (3.88%) and transient hypoxemia (2.07%). There were no severe AE. No association was found between the incidence of AE and the clinical and functional variables or risk before anaesthesia. Conclusion Sevoflurane sedation shows promising results in terms of safety and effectiveness for the management of agitation and pain during BoNT-A infiltration in our daily clinical practice. In addition, it can facilitate infiltration, allowing examination under sedation and multilevel infiltration with good tolerance (AU)

[Sevoflurane sedation protocol in children with cerebral palsy undergoing botulinum toxin-A injections]. / Protocolo de sedación con sevoflurano para la infiltración de toxina botulínica tipo A en parálisis cerebral infantil.

OBJECTIVE: This study aimed to describe our experience with a protocol based on sevoflurane sedation to control pain and agitation during botulinum toxin-A (BoNT-A) infiltration in children with cerebral palsy (CP), especially in terms of safety and efficacy. MATERIAL AND METHODS: We conducted a retrospective observational study of patients diagnosed with CP who underwent BoNT-A infiltration with sevoflurane sedation from November 2012 to December 2019. Demographic, clinical and functional characteristics, the effectiveness of sedation, adverse events (AE) and professional satisfaction were reviewed. RESULTS: A total of 387 sedations were successfully performed in 74 patients. Effective sedation was achieved in 100% of procedures, facilitating collaboration during infiltration and improving professional satisfaction. AE were reported in 6.02% of the procedures, the most frequent being nausea and vomiting (3.88%) and transient hypoxemia (2.07%). There were no severe AE. No association was found between the incidence of AE and the clinical and functional variables or risk before anaesthesia. CONCLUSION: Sevoflurane sedation shows promising results in terms of safety and effectiveness for the management of agitation and pain during BoNT-A infiltration in our daily clinical practice. In addition, it can facilitate infiltration, allowing examination under sedation and multilevel infiltration with good tolerance.

Localization of the centers of intramuscular nerve dense regions of the rotator cuff muscles: a guide for botulinum toxin A injection for spasticity accompanied by shoulder pain / Localización de los centros de las regiones densas del nervio intramuscular de los músculos del manguito rotador: una guía para la inyección de toxina botulínica A por espasticidad con dolor de hombro

To accurately localize the centers of intramuscular nerve dense regions (CINDRs) of rotator cuff muscles. Twenty adult cadavers were used. The curves on skin connecting the superior angle of scapula with the acromion, and with the inferior angle of scapula were designed as the horizontal (H) and longitudinal (L) reference lines, respectively. One side of the rotator cuff muscles were removed and subjected to Sihler's staining to show intramuscular nerve dense regions, and the contralateral muscles' CINDRs were labeled with barium sulfate and scanned by computed tomography (to determine body surface projection points (P)). The intersection of the longitudinal line from point P to line H, and that of the horizontal line from point P to line L, were recorded as PH and PL, respectively. The projection of CINDRs on the anterior body surface across the saggital plane was defined as P' and the line connecting P to P' was recorded as Line PP'. Percentage positions of CINDRs of PH and PL on lines H and L, and the depths on line PP' were determined under the Syngo system. Two, four, one, and one CINDRs were identified in supraspinatus, infraspinatus, teres minor, and subscapularis muscles, respectively. The positions of PH of these CINDRs on the H-line are as follows: supraspinatus, 25.43 % and 26.59 %; infraspinatus, 53.85 %, 34.63 %, 35.96 % and 58.17 %; teres minor, 74.50 %; and subscapularis, 20.33 %. The PL on the L-line: supraspinatus, 11.09 % and 14.83 %; infraspinatus, 21.59 %, 27.93 %, 48.55 % and 57.52 %; teres minor, 68.28 %; and subscapularis, 52.82 %. The depth on line PP': supraspinatus, 24.83 % and 25.40 %; infraspinatus, 21.55 %, 16.10 %, 10.01 % and 8.14 %; teres minor, 13.27 %; and subscapularis, 22.88 %. The identification of these CINDRs should provide the optimal target position for injecting botulinum toxin A to treat rotator cuff muscles spasticity accompanied by shoulder pain and to improve the efficiency and efficacy of blocking target localization.

Con el objetivo de localizar con precisión los centros de las regiones densas del nervio intramuscular (CRDNI) de los músculos del manguito rotador, se utilizaron veinte cadáveres adultos. Las curvas en la piel que conectan el ángulo superior de la escápula con el acromion y con el ángulo inferior de la escápula se determinaron como líneas de referencia horizontales (H) y longitudinales (L), respectivamente. Se extrajo de un lado los músculos del manguito rotador y se sometió a la tinción de Sihler para mostrar regiones densas de nervios intramusculares, y los CRDNI de los músculos contralaterales se marcaron con sulfato de bario y se escanearon mediante tomografía computarizada (para determinar los puntos de proyección de la superficie corporal (P)). La intersección de la línea longitudinal desde el punto P a la línea H, y de la línea horizontal desde el punto P a la línea L, se registraron como PH y PL, respectivamente. La proyección de CRDNI en la superficie del cuerpo anterior a través del plano sagital se definió como P 'y la línea que conecta P a P' se registró como Línea PP '. Las posiciones porcentuales de los CRDNI de PH y PL en las líneas H y L, y las profundidades en la línea PP 'se determinaron bajo el sistema Syngo. Se identificaron dos, cuatro, uno y un CINDR en los músculos supraespinoso, infraespinoso, redondo menor y subescapular, respectivamente. Las posiciones de PH de estos CRDNI en la línea H son las siguientes: supraespinoso, 25,43 % y 26.59 %; infraspinatus, 53,85 %, 34,63 %, 35,96 % y 58,17 %; redondo menor, 74,50 %; y subescapular, 20,33 %. El PL en la línea L: supraespinoso, 11.09 % y 14.83 %; infraspinatus, 21,59 %, 27,93 %, 48,55 % y 57,52 %; redondo menor, 68.28 %; y subescapular, 52,82 %. La profundidad en la línea PP ': supraespinoso, 24,83 % y 25,40 %; infraspinatus, 21,55 %, 16,10 %, 10,01 % y 8,14 %; redondo menor, 13.27 %; y subescapularis, 22,88 %. La identificación de estos CRDNI debería proporcionar la posición objetivo óptima para inyectar la toxina botulínica A para tratar la espasticidad de los músculos del manguito rotador acompañada de dolor en el hombro y para mejorar la eficiencia y la eficacia del bloqueo de la localización del objetivo.

[Sedation-analgesia protocol for the injection of botulinum toxin A in cerebral palsy]. / Protocolo sedoanalgésico para la infiltración de toxina botulínica A en parálisis cerebral.

OBJECTIVE: To evaluate the impact of the sedation-analgesia technique on the pain experienced by the patient. METHODS: This cross-sectional study was conducted on consecutive patients with cerebral palsy (CP) who underwent infiltration with botulinum toxin A (BoTNA). The patients were divided into 4 different groups according to the analgesic strategy assigned: Group I, without sedation or topical anaesthetic cream; Group II, inhalation of nitrous oxide; Group III, deep intravenous sedation; and Group IV, light sedation with benzodiazepines. Pain was assessed with different scales depending on patient age. Parents were asked to rate their satisfaction with their child's comfort by using a 5-point Likert-type scale. The primary end-point was the proportion of patients that experienced a pain level equal or lower than 2, according to pain scales, in the different study groups. RESULTS: Of the 124 patients included in the study, 56 (45.2%) experienced a pain level ≤2. In the Group III a significantly greater proportion of patients were classified with a pain level score ≤2, P<.001, as compared with all the study groups, respectively. The BoTNA injection was guided by ultrasonography in 109 (87.9%) patients, and by palpation in 15 (12.1%). CONCLUSION: The results of this study suggested that, in patients with CP treated with BoTNA injections, the sedation-analgesic strategy had a significant impact on the pain experienced by the subject. Selecting an appropriate analgesic strategy is crucial for reducing the stress associated with the administration of BoTNA injections in children with CP.

Evidence and experience with onabotulinumtoxinA in chronic migraine: Recommendations for daily clinical practice. / Evidencia y experiencia de bótox en migraña crónica: Recomendaciones para la práctica clínica diaria.

OnabotulinumtoxinA has been demonstrated to be effective as a preventive treatment in patients with chronic migraine (CM). Five years after the approval of onabotulinumtoxinA in Spain, the Headache Study Group of the Spanish Society of Neurology considered it worthwhile to gather a group of experts in treating patients with CM in order to draw up, based on current evidence and our own experience, a series of guidelines aimed at facilitating the use of the drug in daily clinical practice. For this purpose, we posed 12 questions that we ask ourselves as doctors, and which we are also asked by our patients. Each author responded to one question, and the document was then reviewed by everyone. We hope that this review will constitute a practical tool to help neurologists treating patients with CM.

Experience with botulinum toxin in chronic migraine. / Experiencia con toxina botulínica en la migraña crónica.

OBJECTIVE: The purposes of this study were to describe our 16-month experience with onabotulinumtoxinA (OnabotA) for the treatment of chronic migraine (CM) in the Spanish province of Segovia, evaluate its benefits, and determine clinical markers of good response to treatment. PATIENTS AND METHODS: Prospective study of patients with CM who received OnabotA for 16 months. The effectiveness of OnabotA was evaluated based on the reduction in the number of headache days, pain intensity, and side effects. We used two-way analysis of variance (ANOVA) to assess the effects of treatment according to the time factor. We studied the correlation between treatment effects and other variables using a linear regression model to establish the clinical markers of good response to treatment. RESULTS: We included 69 patients who met the diagnostic criteria for CM. Patients underwent an average of 2 infiltrations. Mean age was 43 years; 88.4% were women. The number of headache days and pain intensity decreased significantly (P < .005); improvements remained over time. We found a negative correlation between the reduction in pain intensity and the number of treatments before OnabotA. CONCLUSION: The beneficial effects of OnabotA for CM continue over time. OnabotA is a safe and well-tolerated treatment whose use for refractory CM should not be delayed since early treatment provides greater benefits.

Análise de custo-efetividade da toxina onabotulínica A no tratamento preventivo da migrânea crônica sob a perspectiva do sistema privado de saúde do Brasil / Cost-effectiveness analysis of onabotulinumtoxinA in the preventive treatment of chronic migraine under the Brazilian private health care system perspective

Objetivo: Avaliar o custo-efetividade da toxina onabotulínica A (TB) versus ausência de tratamento "não tratar" (NT) da migrânea crônica refratária a pelo menos dois medicamentos em um Sistema de Saúde Suplementar. Métodos: Modelo analítico de decisão simulou desfechos e custos em 24 semanas. Os desfechos clínicos foram: dias com cefaleia (DC); dias com cefaleia moderada/severa (DCMS); episódios de cefaleia (EC); dias com migrânea (DM) e episódios de migrânea (EM). Para o braço NT, utilizaram-se os valores basais do placebo. Para o braço TB, utilizaram-se os valores basais aplicando as reduções relacionadas ao uso do tratamento. Os custos incluídos foram custos médicos diretos. Os dados que subsidiaram as análises foram extraídos da literatura. Avaliou-se uma aplicação de TB (155U) a cada 12 semanas, totalizando duas aplicações em 24 semanas. Custos foram extraídos de bases oficiais do Brasil. Considerou-se taxa de descontinuação de 3,8% para TB na semana 24. Análises de sensibilidade probabilística (ASP) e univariada (ASU) foram realizadas para o desfecho DM. Resultados: O uso de TB proporcionou redução de 52,42% nos DC; 47,97% nos DCMS; 37,60% nos EC; 50,49% nos DM; 35,68% nos EM e uma redução de R$ 1.193 com consulta médica e hospitalização. Houve incremento de R$ 8.646 com aplicação da TB, resultando numa Razão de Custo-Efetividade Incremental (RCEI) de R$ 142,16/DC; R$ 155,35/DCMS; R$ 198,22/EC; R$ 147,61/DM e R$ 208,85/EM. A ASP e ASU comprovaram os resultados do caso base. Conclusão: Uso de TB proporciona redução dos desfechos clínicos, variando de 44% a 49%, além de redução de 54% a 60% nos custos com visitas médicas e hospitalização.

Objective: To evaluate the cost-effectiveness of onabotulinumtoxinA (OT) versus "no treatment" (NT) of chronic refractory migraine to at least two drugs in the Supplementary Brazilian Health Care System. Methods: An analytical decision model simulated outcomes and costs at 24 weeks. Clinical outcomes were: days with headache (DH); days with moderate/severe headache (DMSH); headache episodes (HE); days with migraine (DM) and episodes of migraine (EM). For the NT arm, the baseline values of placebo were used. For the OT arm, baseline values were used as reductions related to treatment use. Costs included were direct medical costs. The data that supported the analyzes were extracted from the literature. One OT application (155U) was evaluated every 12 weeks totaling 2 applications in 24 weeks. Costs were extracted from Brazilian official databases. A 3.8% discontinuation rate was considered for OT at week 24. Probabilistic (PSA) and univariate (USA) sensitivity analyzes were performed for the DM outcome. Results: The use of OT provided a reduction of 52.42% in DH; 47.97% in DMSH; 37.60% in HE; 50.49% in DM; 35.68% in EM and a reduction of R$ 1,193 with medical visits and hospitalization. There was an increase of R$ 8,646 with OT application; resulting in an incremental cost-effectiveness ratio (ICER) of R$ 142.16/DH; R$ 155.35/DMSH; R$ 198.22/HE; R$ 147.61/DM and R$ 208.85/EM. PSA and USA proved the base case results. Conclusion: Use of OT provides a reduction in clinical outcomes ranging from 44% to 49%, as well as a reduction of 54% to 60% in costs with medical visits and hospitalization.

Botulinum toxin type A as treatment of partially accommodative esotropia.

OBJECTIVE: To determine the effectiveness of a botulinum toxin type A injection in both medial rectus muscles in patients with partially accommodative esotropia. Residual deviation and stability of strabismus were evaluated at 18 months follow up. METHOD: A prospective, analytical, quasi-experimental study was conducted on a cohort of 21 patients who underwent total cycloplegic refraction and with a residual deviation of at least 14 DP. A botulinum toxin type A dose of 5 IU was injected into each medial rectus muscle for a residual deviation greater than 18 DP, with a dose of 2.5 IU being used for a deviation between 14 and 18 DP. Multivariate logistic regression analyses were performed to relate residual deviation to variables recorded as potential predictors. RESULTS: A total of 21 patients were included, 33.3% (n=7) males and 66.6% (n=14) females. Mean visual acuity was -.28±.25 logMAR for right eye (range 0 to -1) and -.42±.31 logMAR for left eye (range 0 to -1.3). Mean angle of residual deviation before application of botulinum toxin was 40.95±8.6DP without spectacles correction, and 22.3±7.99 DP with full cycloplegic refraction. Adverse effects were ptosis in 14.2% (n=3), diplopia 23.8% (n=5), and vertical deviation in 33% (n=7). One patient had a poor outcome, therefore required surgical treatment. At one year follow up, 85.71% of patients showed good results with esotropia of 12 DP or less, dropping to 71.43% at 18 months of follow up. CONCLUSION: Botulinum toxin type A is an effective long-term treatment with a good response in 71.43% of patients. No predictors of good response were demonstrated.

Tratamiento del estrabismo paralítico con toxina botulínica A / Treatment of paralytic strabismus with botulinum toxin A

Objetivos: evaluar los resultados obtenidos con el uso de la toxina botulínica A en la corrección del estrabismo paralítico e identificar los factores asociados que influyen sobre la respuesta terapéutica. Métodos: se realizó un estudio descriptivo en una serie de 93 casos con estrabismo paralítico, que recibieron tratamiento con toxina botulínica A. Resultados: se diagnosticaron 53 casos con estrabismo leve, 38 moderado y solo dos en estado grave. El tiempo de evolución y la gravedad clínica fueron los factores asociados que interfirieron con la respuesta terapéutica. Conclusiones: la toxina botulínica A es efectiva en la mayoría de los casos tratados. Los mejores resultados se obtienen en los casos con menor grado de desviación y con menor tiempo de evolución entre el inicio del estrabismo y la inyección del medicamento(AU)

Objectives: to assess the results of the use of botulinum toxin A in correcting paralytic strabismus and to identify those associated factors that have an impact on the therapeutic response. Methods: a descriptive study of a series of 93 cases with paralytic strabismus which were treated with botulinum toxin A. Results: fifty three cases were diagnosed with mild, 38 with moderate and just two with severe strabismus. The time of progression and the clinical severity were related factors that influence the therapeutic response. Conclusions: botulinum toxin A is effective in most of cases. The best results are achieved in those people with lower deviation degree and less time of progression elapsed from the onset of strabismus to the administration of the injected medication(AU)

Resultados del tratamiento de la orbitopatía tiroidea y factores que influyen sobre la respuesta terapéutica / Results of the treatment of thyroid orbinopathy and factors affecting the therapeutic response

Objetivo: evaluar los resultados del tratamiento de la orbitopatía tiroidea y determinar cuáles son los factores que influyen sobre ellos. Métodos: se realizó un estudio observacional en una cohorte de 82 pacientes con orbitopatía tiroidea, durante el período 1997-2009.Resultados: en los casos con orbitopatía tiroidea activa, la corticoterapia se inició a los 19 meses de evolución y no fue satisfactoria en la mayoría de ellos, por lo que para preservar la visión se realizaron varias intervenciones quirúrgicas. Los factores que influyeron sobre la respuesta terapéutica fueron el tabaquismo y la actividad de la orbitopatía tiroidea (OR= 30,479 y OR= 14,557, respectivamente). Se obtuvieron buenos resultados con el uso de la toxina botulínica A y con la cirugía en la corrección del estrabismo y la retracción.Conclusiones: el diagnóstico y el tratamiento precoz es la conducta terapéutica ideal para los pacientes con orbitopatía tiroidea. El tabaquismo y la actividad de la orbitopatía tiroideainterfirieren en la respuesta terapéutica. La toxina botulínica A y la cirugía son efectivas en la corrección del estrabismo y la retracción palpebral de la orbitopatía tiroidea(AU)

Objective: to evaluate the results of the treatment of thyroid orbinopathy and to determine the factors affecting them.Methods: observational study of a cohort of 82 patients with thyroid orbinopathy during the 1997-2009 period. Results: corticosteroid-bases therapy began nineteen months after the onset of disease and was unsatisfactory in most of cases with active thyroid orbitopathy, so it was necessary to perform several surgeries to preserve the vision. The influential factors on the therapeutic response were smoking and thyroid orbinopathy activity (OR= 30,479 and OR= 14,557, respectively). Good results were attained with botilinum toxin A and strabismus correction surgery and retraction. Conclusions: early diagnosis and treatment is the best therapy for patients with thyroid orbinopathy. Smoking and thyroid orbinopathy negatively affect the therapeutic response. Botulinum toxin A and surgery are effective options in the strabismus correction and palpebral retractions of thyroid orbinopathy(AU)

Tratamiento del estrabismo paralítico con toxina botulínica A / Treatment of paralytic strabismus with botulinum toxin A

Objetivos: evaluar los resultados obtenidos con el uso de la toxina botulínica A en la corrección del estrabismo paralítico e identificar los factores asociados que influyen sobre la respuesta terapéutica. Métodos: se realizó un estudio descriptivo en una serie de 93 casos con estrabismo paralítico, que recibieron tratamiento con toxina botulínica A. Resultados: se diagnosticaron 53 casos con estrabismo leve, 38 moderado y solo dos en estado grave. El tiempo de evolución y la gravedad clínica fueron los factores asociados que interfirieron con la respuesta terapéutica. Conclusiones: la toxina botulínica A es efectiva en la mayoría de los casos tratados. Los mejores resultados se obtienen en los casos con menor grado de desviación y con menor tiempo de evolución entre el inicio del estrabismo y la inyección del medicamento(AU)

Objectives: to assess the results of the use of botulinum toxin A in correcting paralytic strabismus and to identify those associated factors that have an impact on the therapeutic response. Methods: a descriptive study of a series of 93 cases with paralytic strabismus which were treated with botulinum toxin A. Results: fifty three cases were diagnosed with mild, 38 with moderate and just two with severe strabismus. The time of progression and the clinical severity were related factors that influence the therapeutic response. Conclusions: botulinum toxin A is effective in most of cases. The best results are achieved in those people with lower deviation degree and less time of progression elapsed from the onset of strabismus to the administration of the injected medication(AU)

Resultados del tratamiento de la orbitopatía tiroidea y factores que influyen sobre la respuesta terapéutica / Results of the treatment of thyroid orbinopathy and factors affecting the therapeutic response

Objetivo: evaluar los resultados del tratamiento de la orbitopatía tiroidea y determinar cuáles son los factores que influyen sobre ellos. Métodos: se realizó un estudio observacional en una cohorte de 82 pacientes con orbitopatía tiroidea, durante el período 1997-2009. Resultados: en los casos con orbitopatía tiroidea activa, la corticoterapia se inició a los 19 meses de evolución y no fue satisfactoria en la mayoría de ellos, por lo que para preservar la visión se realizaron varias intervenciones quirúrgicas. Los factores que influyeron sobre la respuesta terapéutica fueron el tabaquismo y la actividad de la orbitopatía tiroidea (OR= 30,479 y OR= 14,557, respectivamente). Se obtuvieron buenos resultados con el uso de la toxina botulínica A y con la cirugía en la corrección del estrabismo y la retracción. Conclusiones: el diagnóstico y el tratamiento precoz es la conducta terapéutica ideal para los pacientes con orbitopatía tiroidea. El tabaquismo y la actividad de la orbitopatía tiroideainterfirieren en la respuesta terapéutica. La toxina botulínica A y la cirugía son efectivas en la corrección del estrabismo y la retracción palpebral de la orbitopatía tiroidea(AU)

Objective: to evaluate the results of the treatment of thyroid orbinopathy and to determine the factors affecting them. Methods: observational study of a cohort of 82 patients with thyroid orbinopathy during the 1997-2009 period. Results: corticosteroid-bases therapy began nineteen months after the onset of disease and was unsatisfactory in most of cases with active thyroid orbitopathy, so it was necessary to perform several surgeries to preserve the vision. The influential factors on the therapeutic response were smoking and thyroid orbinopathy activity (OR= 30,479 and OR= 14,557, respectively). Good results were attained with botilinum toxin A and strabismus correction surgery and retraction. Conclusions: early diagnosis and treatment is the best therapy for patients with thyroid orbinopathy. Smoking and thyroid orbinopathy negatively affect the therapeutic response. Botulinum toxin A and surgery are effective options in the strabismus correction and palpebral retractions of thyroid orbinopathy(AU)