Manejo exitoso de síndrome de vejiga hiperactiva refractaria con toxina botulínica A / Successful management of refractory overactive bladder syndrome with botulinum toxin A

Introducción: El síndrome de vejiga hiperactiva (VHA) afecta hasta al 43% de las mujeres. La terapia escalonada incluye cambios de hábitos, fármacos y neuromodulación. Hasta el 40% de las pacientes llegan a requerir terapia avanzada alternativa, como toxina botulínica (TB). Objetivo: Reportar los resultados del tratamiento con toxina botulínica en mujeres con VHA refractaria a tratamiento de primera y segunda línea, en un hospital público en Chile. Método: Estudio de cohorte retrospectivo desde una base de datos recolectada prospectivamente del Hospital Sótero del Río entre 2018 y 2022. Se incluyeron 33 pacientes con tratamiento farmacológico y neuromodulación previa, con una edad promedio de 57 años, sometidas a inyección cistoscópica de TB a detrusor, analizando datos demográficos, antecedentes y complicaciones. Se realizó seguimiento con frecuencia miccional, paños/día, escala de gravedad de Sandvik (ISI) y encuesta Patient Global Impression Improvement (PGI-I). Resultados: Los datos comparativos pre/post TB, respectivamente, fueron: frecuencia miccional diurna 11/6 y nocturna 5/1; paños/día 5/3; ISI 8/3. Veinte de 33 mujeres refirieron estar excelente o mucho mejor (PGI-I). Conclusiones: Es posible realizar manejo con TB en mujeres con VHA refractaria a primera y segunda línea, con buenos resultados e impacto significativo en la calidad de vida.

Introduction: Overactive bladder syndrome (OABS) affects up to 43% of women. Staggered therapy includes habit changes, drugs, and peripheral neuromodulation. Up to 40% of patients may require advanced alternative therapy such as botulinum toxin A (BT). Objective: To report the results of treatment with TB in women with OABS refractory to first- and second-line treatment in a public hospital in Chile. Method: Retrospective cohort study from prospectively collected database from Hospital Sótero del Río between 2018 and 2022. Thirty-three patients with previous pharmacological treatment and neuromodulation were included, with an average age of 57 years, undergoing cystoscopic injection of TB to detrusor. Demographic data, history, and complications were analyzed. Follow-up was performed with voiding frequency, cloths/day, Sandvik Severity Scale (ISI) and Patient Global Impression Improvement (PGI-I) survey. Results: Comparative data pre/post TB, respectively showed: daytime voiding frequency 11/6 and nighttime 5/1; cloths/day 5/3; ISI 8/3. 20 of 33 women reported being excellent or much better (PGI-I). Conclusions: TB management in women with OABS refractory to first- and second-line treatment has good results and significant impact on quality of life.

Toxina botulínica no tratamento da enxaqueca crônica: uma revisão sistemática / Botulinum toxin in the treatment of chronic migraine: a systematic revision

A enxaqueca crônica é causada por alterações químicas do cérebro, dores unilaterais, pulsáteis de intensidade variável. A administração da toxina botulínica, neurotoxina produzida peloClostridium botulinum, é uma alternativa de tratamento. Existem diferentes preparações da toxina botulínica, capaz de inibir a liberação de acetilcolina, provocando uma inibição da contração muscular. O objetivo do estudo foi analisar a eficácia terapêutica da toxina botulínica no tratamento da enxaqueca crônica. Foi realizada uma revisão sistemática utilizando como ferramenta embasadora o método de Principais Itens para Relatar Revisões Sistemáticas e Meta-Análises, utilizando como descritores: enxaqueca crônica, toxina botulínica e tratamento. Foram analisados 21 artigos, sendo 6 metas-analises e 15 ensaios clínicos, 9 ensaios clínicos foram comparados a placebo e 6 a outras terapias. Os ensaios utilizaram uma variedade de doses de 75 até 260 UI, e incluíram pacientes com enxaqueca episódica e crônica, na qual a toxina mostrou maior eficácia. A toxina apresentou também um perfil bom de segurança, sendo relatados poucos efeitos adversos, que em geral foram leves ou moderados. O estudo concluiu que ensaios clínicos controlados indicam que a toxina botulínica tipo A foi eficaz no tratamento da enxaqueca crônica. Na comparação com os demais medicamentos demostrou eficácia semelhante perfil de tolerabilidade superior.

Chronic migraine is caused by chemical changes in the brain, unilateral, pulsating pain of varying intensity. The administration of botulinum toxin, a neurotoxin produced by Clostridium botulinum, is an alternative treatment. There are different preparations of botulinum toxin, capable of inhibiting the release of acetylcholine, promoting an inhibition of muscle contraction.The aim of the study was to analyze the therapeutic efficacy of botulinum toxin in the treatment of chronic migraine. A systematic review was carried out using the Main Items to Report Systematic Reviews and Meta-Analyses method as a supporting tool, using as descriptors: chronic migraine, botulinum toxin and treatment. Twenty-one articles were analyzed, of which 6 were meta-analyses and 15 were clinical trials, 9 clinical trials were compared to placebo and 6 to other therapies. The trials used a range of doses from 75 to 260 IU, and included patients with episodic and chronic migraine, in which the toxin was most effective. The toxin also had a good safety profile, with few adverse effects reported, which were generally mild or moderate. The study concluded that controlled clinical trials indicate that botulinum toxin type A was effective in treating chronic migraine. In comparison with the other drugs, it showed similar efficacy and a superior tolerability profile.

Prospective study of the aesthetic effect of botulinum toxin a when injected into the muscles of facial expression

Botulinum neurotoxin A (BoNT-A) causes an anticholinergic effect on neuronal fibers, which control muscle contraction and autonomic disorders. Thus, it has been widely used in facial aesthetics, decreasing the action of motor muscles and consequent wrinkles. This preliminary study evaluated the effect of BoNT-A in 77 patients, the treatment satisfaction index was defined in percentage (from 0% to 100%). The evaluation was carried out on 15th, 30th, 60th, 90th, and 180th days after BoNT. The data were analyzed using the Friedman, Student t, Mann-Whitney test with t (alpha=0.05). The results showed that at 15th and 30th days the scores were similar in all muscles with high level of satisfaction and until 90th days the scores decreased significantly for Corrugator supercilii 79.38%, Occipitofrontalis 71.46%, Orbicularis oculi 70.43%; but the satisfaction was good. At 180 days, there was a drop in effectiveness in all treated muscles since the scores decreased significantly, showing low satisfaction by the participants. This study demonstrated that the BoNT-A had attested satisfaction effect by participants for up to 90th days, but at 180th days the satisfaction was low. In the comparative analyzes between women under 40 and over 40 years of age, there was no significant differences.

Reporte de caso. Uso de toxina botulínica tipo A para la reparación de hernia ventral gigante planeada / Surgical treatment of diabetic foot based on Wagner classification, Case report

Introducción: La incidencia de eventración post quirúrgica es del 2-20%, se da mayormente en pacientes con factores de riesgo durante los primeros tres años posteriores a la cirugía inicial. La mayoría de las hernias de la pared abdominal pueden ser reparadas fácilmente, sin embargo, las hernias gigantes (>10cm de diámetro) o aquellas con pérdida de domicilio requieren métodos de expansión gradual de la pared abdominal pre y/o transoperatoriamente. Se ha descrito que posterior a la aplicación de toxina botulínica serotipo A (TBA) de forma bilateral en la pared abdominal, los defectos disminuyen clínica y tomográficamente hasta 5.25cm, por su efecto selectivo en terminaciones nerviosas periféricas colinérgicas, provocando atrofia muscular sin fibrosis. El efecto máximo ocurre al mes de la aplicación y dura 28 semanas. Esta técnica permite planear preoperatoriamente la magnitud de la cirugía. Nuestro caso, paciente masculino de 33 años. Quien ingresa por politrauma. Se realiza procedimiento quirúrgico abdominal y posteriormente se eviscera en múltiples ocasiones. Se cierra herida y posteriormente desarrolla hernia ventral gigante con la que egresa. Se realiza TC abdominal evidenciando defecto herniario de 15.9cm, con este resultado se aplica toxina botulínica serotipo A en la pared abdominal bilateral (50 unidades en cada lado) guiado por ultrasonido. 25 días después se realiza TC abdominal control que evidencia defecto herniario de 14.7cm y se decide ingreso para cirugía electiva. Se decide llevar a sala de operaciones donde se realiza hernioplastía con liberación de componentes anteriores mas colocación de malla de polietileno (cuatro semanas posteriores a la aplicación de la toxina), quedando defecto totalmente cerrado y sin tensión. Paciente con adecuada evolución posterior a intervención por lo que egresa. Actualmente sin defecto herniario recurrente. Conclusión: El uso de toxina botulínica serotipo A es un nuevo recurso prequirúrgico para la preparación de pacientes con hernias ventrales gigantes, ya que permite el cierre sin tensión en la mayoría de los casos. Además, ayuda a que transoperatoriamente la separación de componentes se realice de una mejor manera, ya que se da mejor manipulación al momento de desplazar las estructuras musculares. Idealmente se debe de realizar la intervención quirúrgica cuatro semanas posteriores a su aplicación. (AU)

ntroduction: The incidence of post-surgical eventration is 2-20%, it occurs mostly in patients with risk factors during the first three years after the initial surgery. Most abdominal wall hernias can be easily repaired, however, giant hernias (>10cm of diameter) or those with the loss of domain require methods of gradual expansion of the abdominal wall pre or intraoperatively. It has been described that after the application of botulinum toxin A bilaterally in the abdominal wall, the defect can decrease clinically and tomographically up to 5.25cm, due to its selective effect on cholinergic peripheral nerve endings, that cause muscle atrophy without fibrosis. The maximum effect occurs one month after the application and lasts 28 weeks. This technique allows to plan preoperatively the magnitude of the surgery. Description of case: A 33 year old male patient, who entered the emergency room due to polytrauma. Abdominal surgical procedure was performed and later he eviscerates on multiple occasions. The wound was closed and later he develops a giant ventral hernia with which it is discharged. An abdominal CT was performed, showing a hernia defect of 15.9cm. With this result botulinum toxin A was applied guided by ultrasound bilaterally in the abdominal wall (50 U on each side). A control abdominal CT was performed after 25 days, which it revealed a hernia defect of 14.7 cms, so admission was decided for elective surgery. The patient was taken to the operating room where a hernioplasty with anterior components separation plus the placement of a polyethylene mesh was performed (four weeks after the application of the botulinum toxin A), the hernia defect was completely close without tension. The patient had an adequate post-surgical evolution for which it was discharge. Currently without a recurrent hernia defect. Conclusion: The use of botulinum toxin A is a new pre-surgical resource for the preparation of patients with giant ventral hernias, since it allows the closure without tension in most cases. In addition, it helps transoperatively with the components separation, since there is a better manipulation at the time of displacing the muscular structures. Ideally, the surgical intervention should be performed four weeks after its application. (AU)

Botulinum toxin A (BT-A) versus low-level laser therapy (LLLT) in chronic migraine treatment: a comparison / Toxina botulínica A (BT-A) versus laser terapia de baixa potência (LLLT) em enxaqueca crônica: Uma triagem comparativa

ABSTRACT The aim of this work was to evaluate patients with chronic migraine treated with botulinum toxin A (BT-A) and compare this with low level laser therapy (LLLT), referencing: pain days, pain intensity, intake of drugs/self-medication, anxiety and sleep disorders. Methods: Patients were randomized into two groups: BT-A group (n = 18) and LLLT group (n = 18). Each patient kept three pain diaries: one before (baseline) (30 days), one during treatment (30 days) and one after the post-treatment phase (30 days). Repeated ANOVA plus the Bonferroni post-test, Student's t test, and factorial analysis were applied, and p < 0.05 was accepted as significant. Results: Our data showed that both treatments were able to reduce headache days, acute medication intake and decrease the intensity of pain. Anxiety was reduced in the BT-A group, while sleep disturbance was reduced in the LLLT group. Conclusion: Our data showed that both treatments can be used to treat chronic migraine, without notable differences between them.

RESUMO O estudo comparou pacientes com cefaleia crônica (CM) tratados com toxina botulínica A (BT-A) versus terapia a laser de baixa intensidade (LLLT), relativos a: dias de dor, automedicação, nervosismo e distúrbios do sono. Métodos: Os pacientes foram randomizados em dois grupos: Grupo BT-A (n = 18) e Grupo LLLT (n = 18). Cada paciente preencheu três diários de dor, sendo um antes do início do tratamento (30 dias), durante o tratamento (30 dias) e um após tratamento (30 dias). ANOVA e pós-teste Bonferroni, teste T de Student e análise fatorial foram utilizados e valores de p < 0,05 foram considerados significativos. Resultados: Ambos os tratamentos foram capazes de reduzir os dias de dor e a ingestão aguda de medicação. Além disso, a ansiedade foi reduzida no grupo BT-A, enquanto que o distúrbio do sono foi reduzido no grupo LLLT. Conclusão: Nossos resultados mostraram que ambos os tratamentos são eficientes contra CM, sem diferença entre eles.

Intradetrusor onabotulinumtoxinA injections are significantly more efficacious than oral oxybutynin for treatment of neurogenic detrusor overactivity: results of a randomized, controlled, 24-week trial / Injeções intradetrusoras de onabotulinumtoxinA são significativamente mais eficazes que oxibutinina oral para tratamento da hiperatividade detrusora neurogênica: resultados de estudo randomizado e controlado de 24 semanas

ABSTRACT Objective To prospectively compare the results of intradetrusor onabotulinumtoxinA injections and oral oxybutynin for urinary continence, urodynamic parameters and quality of life in patients with neurogenic detrusor overactivity due to spinal cord injury. Methods Adult patients under intermittent catheterization were randomized 1:1 to receive one injection of onabotulinumtoxinA 300U or oxybutynin 5mg, per oris, three times/day. Primary study endpoint was change in urinary incontinence episodes/24 hours and secondary study endpoints were maximum cystometric capacity, maximum detrusor pressure, bladder compliance and quality of life before randomization and at week 24. Results Sixty-eight patients participated in the trial. Significant improvements in urinary incontinence per 24 hours, all investigated urodynamic parameters and quality of life were observed in both groups. Compared with oral oxybutynin, onabotulinumtoxinA was significantly more efficacious for all parameters investigated. Non-response to treatment was higher for oral oxybutynin (23.5%) than onabotulinumtoxinA (11.8%). Dry mouth was the most common adverse in patients with oral oxybutynin (72%) and transient macroscopic hematuria in patients with onabotulinumtoxinA (28%). Only one patient with oral oxybutynin dropped out the study because of adverse effects. Conclusion The comparison of the two study drugs showed that onabotulinumtoxinA was significantly more efficacious than oral oxybutynin with regard to continence, urodynamic parameters and quality of life. Clinicaltrials.gov: NCT:01477736.

RESUMO Objetivo Comparar prospectivamente os resultados de injeções intradetrusoras de onabotulinumtoxinA e oxibutinina oral em pacientes com hiperatividade neurogênica do detrusor devido à lesão da medula espinhal, para avaliar a continência urinária, os parâmetros urodinâmicos e a qualidade de vida. Métodos Pacientes adultos em cateterismo intermitente foram randomizados 1:1 para tratamento com uma injeção de onabotulinumtoxinA 300U ou oxibutinina 5mg via oral, três vezes por dia. O desfecho primário foi alteração nos episódios de incontinência urinária em 24 horas, e os secundários foram capacidade cistométrica máxima, pressão máxima do detrusor, complacência vesical e qualidade de vida antes da randomização e na 24ª semana. Resultados Participaram do estudo 68 pacientes. Observou-se melhora significativa na incontinência urinária por 24 horas em todos os parâmetros urodinâmicos investigados e na qualidade de vida em ambos os grupos. Em comparação com a oxibutinina oral, a onabotulinumtoxinA foi significativamente mais eficaz para todos os parâmetros investigados. A falha no tratamento foi maior para oxibutinina oral (23,5%) em comparação com onabotulinumtoxinA (11,8%). A boca seca foi o evento adverso mais comum em pacientes tratados com oxibutinina oral (72%), e a hematúria macroscópica transitória naqueles tratados com onabotulinumtoxinA (28%). Apenas um paciente tratado com oxibutinina oral interrompeu o estudo por conta dos efeitos adversos. Conclusão A comparação dos dois fármacos do estudo mostrou que onabotulinumtoxinA foi significativamente mais eficaz que oxibutinina oral em relação a continência, parâmetros urodinâmicos e qualidade de vida. Clinicaltrials.gov: NCT:01477736.

Primary treatment of early fistula of parotid duct with botulinum toxin type A injection

Abstract: Salivary duct injury can be idiopathic, iatrogenic, or post-trauma and may result in sialocele or fistula. Most injuries regress spontaneously and botulinum toxin A is one of several therapeutic possibilities. We report a case of iatrogenic injury to the parotid duct after Mohs' micographic surgery for a squamous cell carcinoma excision in the left jaw region, treated by injection of botulinum toxin type A. Although the fistula by duct injury can be self-limiting, botulinum toxin injection by promoting the inactivity of the salivary gland allows rapid healing of the fistula.

Abobotulinum - a toxin injection in patients with refractory idiopathic detrusor overactivity: injections in detrusor, trigone and bladder neck or prostatic urethra, versus detrusor - only injections

ABSTRACT Purpose: To evaluate if the injections of abobotulinum-A toxin in trigone and bladder neck/prostatic urethra in addition to detrusor provides better symptoms relief and urodynamic findings in patients with idiopathic detrusor overactivity (IDO) refractory to medical treatment. Materials and Methods: A total of 74 patients with IDO refractory to anticholinergics received injections in detrusor, trigone and bladder neck/prostatic urethra (Group A, N=36) versus detrusor only injections (Group B, N=38) of abobotulinum-A toxin. All patients were evaluated by a standard overactive bladder symptom score (OABSS) questionnaire and cystometrography before and 6 weeks after the operation. OABSS questionnaire was also completed 20 weeks after the operation. Results: The magnitude of OABSS reduction from baseline to 6 weeks after operation in groups A and B patients was 13.4±2.2 versus 11.7±2.1 (p=0.001). Cystometry results were similar in both groups except for higher volume at urgent desire to void in Group B patients (p <0.001). The mean±SD change in residual volume in Group A at 6 weeks after the operation was −4.8±28.6mL (p=0.33) compared to 21.3±16.9mL in Group B patients (p <0.001). Conclusions: In patients with IDO, adding trigone, and bladder neck/prostatic urethra as sites of abobotulinum- A toxin injection produces greater reductions in OABSS score and less residual urine volume but a lower volume at urgent desire to void in comparison with detrusor only injections.

Long-term response of different Botulinum toxins in refractory neurogenic detrusor overactivity due to spinal cord injury

ABSTRACT Purpose To assess the response in spinal cord injured patients alternatively treated with different types and dosages of Botulinum neurotoxin type A (BoNT/A) over 15 years. Material and methods Patients who underwent first BoNT/A from 1999-2001 and practiced intermittent catheterization were included. Baseline 3-day bladder diary (BD) and urodynamics were collected. BoNT/A failure was defined when patients asked for re-injection ≤ 3 months post-treatment. Criteria for re-injection was at least one daily episode of urinary incontinence at BD. Before re-injection, patients were asked if they had reached 6 months of dryness without antimuscarinics (YES response). Results Overall, 32/60 (53.4%) "No failure" (NF) group; 16 (26.6%) "occasional failure" (OF) and 12 (20%) "consecutive failure" (CF) were included. A total of 822 BoNT/A infiltrations were performed. The mean interval from previous injection to treatment re-scheduling was 8 months. No significant differences between treatments were found within the three groups (p>0.05). The percentage of YES responses increased from 19% (AboBoNT/A 500IU) to 29 % (OnaBoNT/A 300IU) in NF, and from 18% (AboBoNT/A 500IU) to 25% (OnaBoNT/A 300IU) for OF. Five NF cases (15.6%) maintained 6 months of dryness after each injection. Among the baseline variables, only low compliance (< 20mL/cmH2O) was found as predictor for failure (p=0.006). Conclusions Long term BoNT/A for NDO did not increase failures, independent of the types of treatments and switching. Definition of failure and other criteria for continuing repetitive BoNT/A treatment is mandatory. CF was predictable for no response in earlier follow-up.

Keratoconus progression is not inhibited by reducing eyelid muscular force with botulinum toxin A treatment: a randomized trial / A progressão do ceratocone não é inibida reduzindo a força palpebral com o uso da toxina botulínica tipo A: ensaio clínico randomizado

ABSTRACT Purpose: To evaluate whether reducing eyelid muscular force through the administration of botulinum toxin type A (BTX-A) to the orbicularis oculi muscles of patients with keratoconus affected corneal parameters indicative of disease progression. Methods: In this prospective parallel randomized clinical trial, 40 eyes of 40 patients with keratoconus were randomized into equally sized control and BTX-A groups. Patients in the BTX-A group received subcutaneous BTX-A injections into the orbicularis muscle. The control group received no intervention. Palpebral fissure height, best spectacle-corrected visual acuity (BSCVA), and corneal topographic parameters were evaluated at baseline and at 3-, 6-, 12-, and 18-month follow-ups. Results: The mean ± standard deviation vertical palpebral fissure heights were 9.74 ± 1.87 mm and 9.45 ± 1.47 mm at baseline in the control and BTX-A groups, respectively, and 10.0 ± 1.49 mm and 9.62 ± 1.73 mm at 18 months, with no significant difference between the groups (p=0.337). BSCVA values were 0.63 ± 0.56 and 0.60 ± 0.27 at baseline in the control and BTX-A groups (p=0.643), and 0.52 ± 0.59 and 0.45 ± 0.26 at 18 months, again with no significant difference between the groups (p=0.452). In addition, there were no statistical differences between the groups at 18 months for the three keratometry topographic parameters: flattest (K1), steepest (K2), and mean (Km) keratometry (p=0.562). Conclusion: BTX-A inhibition of eyelid force generation did not result in detectable changes in corneal parameters in keratoconic patients during 18 months of follow-up.

RESUMO Objetivo: Avaliar se a administração da toxina botulínica tipo A (BTX-A) no músculo orbicular de pacientes com ceratocone a fim de reduzir a força muscular palpebral pode alterar os parâmetros corneanos indicativos de progressão da doença. Métodos: Ensaio clínico randomizado paralelo prospectivo. Quarenta olhos de 40 pacientes, randomizados em grupo controle ou grupo BTX-A na razão de 1:1. Pacientes do grupo BTX-A foram submetidos à injeção subcutânea da toxina botulínica tipo A no músculo orbicular. Os pacientes do grupo controle não sofreram nenhuma intervenção. Foram avaliados a medida da fenda palpebral, melhor acuidade visual corrigida, e topografia corneana nos momentos pré-operatório, e aos 3-,6-,12-, e 18 meses de seguimento. Resultados: Média ± DP (desvio padrão) da fenda palpebral no pré-operatório nos grupos controle e BTX-A foram 9,74 ± 187 e 9,45 ± 1,47 mm, respectivamente; aos 18 meses, a média da altura da fenda palpebral vertical nos grupos controle e BTX-A foram 10,0 ± 1,49 mm e 9,62 ± 1,73 mm, respectivamente, sem diferença significante entre os grupos (p=0,337). A média pré-operatória da melhor acuidade visual corrigida nos grupos controle e BTX-A foram 0,63 ± 0,56 e 0,60 ± 0,27, respectivamente (p=0,643); aos 18 meses, a média nos grupos controle e BTX-A foram 0,52 ± 0,59 e 0,45 ± 0,26, respectivamente, sem diferença significante entre os grupos (p=0,452). Não houve diferença estatística entre os grupos aos 18 meses para todos os parâmetros topográficos ceratométricos avaliados, mais plano-(K1), mais curvo-(K2), e ceratometria média Km (p≥0,562). Conclusão: A inibição da força muscular palpebral pela toxina botulínica tipo A não causou alterações detectáveis nos parâmetros corneanos em pacientes com ceratocone, com 18 meses de seguimento.

Toxina botulínica tipo A nas DTM musculares: há eficácia? / Botulinum toxin type A in muscle TMD: There's effectiveness?

Os objetivos dessa revisão da literatura foram verificar a eficácia da toxina botulínica tipo A (BTX-A) na diminuição da dor em indivíduos com DTM e identificar os parâmetros ideais para o local, número de aplicações, dosagens e tempo de duração. Foram selecionados 19 artigos das bases de dados do Google Acadêmico e PubMed, que incluíram 14 artigos de pesquisa clínica e 5 de revisão sistemática. Foi possível concluir a respeito da toxina botulínica que os músculos indicados para a aplicação são principalmente os masseteres e os temporais, podendo ser aplicado também nos músculos pterigoideos, lateral e medial, digástrico e platisma. Os locais de escolha são os que apresentam maior volume e sensibilidade à palpação (pontos-gatilho) ou maior atividade eletromiográfica em repouso. As dosagens variam de um total de 10U a 400U de BTX-A por indivíduo, sendo distribuídas pelos músculos indicados. A BTX-A, em geral, é aplicada em dose única, porem alguns autores preconizam uma segunda aplicação se a primeira não fez o efeito esperado. O efeito da toxina botulínica sobre os músculos e a dor, em geral, tem duração variada, sendo relatado desde 3 a 4 semanas até 3 a 5 meses. A maioria dos estudos observou à eficácia da BTX-A na diminuição da dor de indivíduos com DTM. Porém é necessário que mais estudos clínicos randomizados, duplo cegos, multicêntricos e controlados sejam realizados para que a eficácia da BTX-A seja comprovada e para que um protocolo de atendimento seja realizado.(AU)

The objectives of this literature review were to verify the efficacy of botulinum toxin type A (BTX-A) in reducing pain of TMD patients and to identify the optimal parameters for the location, number of applications, dosages and duration. We selected 19 articles from Google Scholar and PubMed databases that included 14 articles of clinical research and 5 systematic reviews. It was concluded about BTX-A that the muscles appropriate to the application are mostly masseter and temporal and can also be applied in the pterygoid muscle lateral and medial, digastric and platysma. The choices of locations are those who have higher volume and sensitivity to palpation (trigger points) or higher EMG activity at rest. Dosages vary from a total of 10U to 400U of BTX-A by individual, being distributed by the indicated muscles. BTX-A in general is applied in a single dose, but some authors recommend a second application if the first did not make the expected effect. The effect of BTX-A on muscle and pain in general has varying duration, being reported from 3 to 4 weeks for 3 to 5 months. Most studies have noted at the effectiveness of BTX-A in patient pain reduction DTM. However more randomized, double-blind, multicenter, controlled clinical trials needs to be carried out so that the effectiveness of BTX-A could be confirmed and a management protocol, stabilished.(AU)

Uso de abobotulintoxina a para dolor neuropático intratable: reporte de 9 casos / Experience with abobotulintoxin a for intractable neuropathic pain: a nine-nases report

INTRODUCCIÓN: el uso de toxina botulínica tipo A por vía subcutánea ha sido reportado en la literatura durante la última década. el mecanismo de acción para este uso no ha sido del todo aclarado, y los pacientes con más probabilidades de beneficiarse de las inyecciones de toxina botulínica tipo a, son aquéllos con dolor periférico caracterizado por existencia de alodinia, hiperalgesia y dolor paroxístico. el reporte en literatura ha sido con uso de onabotulintoxina a. MATERIAL Y MÉTODO: el presente estudio descriptivo-observacional tuvo por fin analizar los resultados en alivio del dolor de 9 pacientes con dolor neuropático, tratados con inyecciones de preparado abobotulintoxina a en la unidad de alivio del dolor de hospital público de región metropolitana de Chile, considerados refractarios a tratamiento farmacológico combinado para dolor neuropático a dosis máximas, que tenían componente de alodinia y dolor paroxístico como característica de dolor neuropático y que recibieron inyección de abobotulintoxina a subcutánea. RESULTADOS: 7 de 9 pacientes obtuvieron resultados esperados según lo reportado por la literatura, con alivio del dolor medido en escala numérica: 50% de alodinia, tras primera dosis; y del 80% de dolor paroxístico incidental, tras segunda dosis; tres meses después de la primera dosis, disminución en escala numérica de alodinia en un 80%. de ellos, 5 lograron disminuir requerimiento de opioides potentes. 2 pacientes de los 9 no tuvieron resultados satisfactorios: 1 no tuvo ningún resultado y 1 tuvo resultado favorable, pero con breve duración del efecto.CONCLUSIONES: la inyección subcutánea de abobotulintoxina A puede constituir una herramienta terapéutica eficaz en pacientes con dolor neuropático, tal como ha demostrado ser onabotulintoxina a.

BACKGROUND: the use of botulinum toxin type a subcutaneously has been reported in the literature in the last decade. the mechanism of action for this use has not been fully elucidated, given the effect reported in relief of allodynia, paroxysmal pain and hyperalgesia. the report in the literature is with the use of onabotulintoxin a. MATERIAL AND METHOD: to analyze results in pain relief in 9 patients with intractable neuropathic pain treated with abobotulintoxin a injections, in the pain relief unit of a public hospital in the metropolitan region of Chile, with an observational, retrospective and descriptive study. clinical record analysis of 9 individuals with neuropathic pain considered refractory to combined pharmacological treatment for neuropathic pain at maximal doses, who had allodynia component and paroxysmal pain as a characeristic of neuropathic pain, and who received injection of subcutaneous or intradermal abobotulintoxin A in the area of persistent allodynia. RESULTS 7 patients out of 9 had expected outcomes, allodynia relief of at least 50% after the first dose, and 80% relief of incidental paroxysmal pain and with relief of 80% allodynia after the second dose three months after the first. of these, 5 were able to decrease the requirement of potent opioids. 2 patients out of 9 had no satisfactory results: 1 had no results, and 1 had a favorable outcome but with a short duration of effect. CONCLUSIONS: subcutaneous injection of abobotulintoxin a may be an effective therapeutic tool in patients with neuropathic pain characterized by allodynia and paroxysmal pain.

The positive effect of Botulinum toxin type A on the viability of random flap in tobacco exposed in rats

ABSTRACT PURPOSE: To evaluate the effect of Botulinum Toxin A in different time of tobacco exposure. METHODS: 60 male, Wistar rats were divided into two tobacco exposure groups: a 2- month or a 4-month regimen. After this period, these two groups were subdivided as two: saline solution(SS) or botulinum toxin A(Bonta), at the time of the surgery. Seven days before the SS or Bonta injection, the animals were submitted to a random flap (3x10cm). On the seventh postoperative day, all animals were assessed for total flap area, viable area, and the viable/ total area ratio. RESULTS: This study showed a difference between groups 2-month saline vs. BontA injection (p=0.04); groups 4-month saline vs. BontA injection (p=0.001); groups 2-month saline vs. 4-month BontA (p=0.003), and, between groups 2- month BontA vs. 4-month saline(p=0.03). CONCLUSIONS: Botulinum Toxin A increased random flap viability in tobacco-exposed rats. Two months of tobacco exposure had the same effect as exposure for four months.

Botulinum Toxin Type A Injection for Spastic Equinovarus Foot in Children with Spastic Cerebral Palsy: Effects on Gait and Foot Pressure Distribution

PURPOSE: To investigate the effect of intramuscular Botulinum toxin type A (BoNT-A) injection on gait and dynamic foot pressure distribution in children with spastic cerebral palsy (CP) with dynamic equinovarus foot. MATERIALS AND METHODS: Twenty-five legs of 25 children with CP were investigated in this study. BoNT-A was injected into the gastrocnemius (GCM) and tibialis posterior (TP) muscles under the guidance of ultrasonography. The effects of the toxin were clinically assessed using the modified Ashworth scale (MAS) and modified Tardieu scale (MTS), and a computerized gait analysis and dynamic foot pressure measurements using the F-scan system were also performed before injection and at 1 and 4 months after injection. RESULTS: Spasticity of the ankle plantar-flexor in both the MAS and MTS was significantly reduced at both 1 and 4 months after injection. On dynamic foot pressure measurements, the center of pressure index and coronal index, which represent the asymmetrical weight-bearing of the medial and lateral columns of the foot, significantly improved at both 1 and 4 months after injection. The dynamic foot pressure index, total contact area, contact length and hind foot contact width all increased at 1 month after injection, suggesting better heel contact. Ankle kinematic data were significantly improved at both 1 and 4 months after injection, and ankle power generation was significantly increased at 4 months after injection compared to baseline data. CONCLUSION: Using a computerized gait analysis and foot scan, this study revealed significant benefits of BoNT-A injection into the GCM and TP muscles for dynamic equinovarus foot in children with spastic CP.

Efficacy of botulinum toxin type A 100 units versus 200 units for treatment of refractory idiopathic overactive bladder

Objective: To evaluate the efficacy and safety of a single intra detrusor injection of BoNTA comparing two different doses (100 U or 200 U) in patients with idiopathic overactive bladder. Materials and Methods: A randomized prospective study evaluated the efficacy of BoNTA in management of refractory idiopathic overactive bladder and included 80 patients. All patients were assessed initially by taking a history, a physical examination, overactive bladder symptom score, urine analysis, routine laboratory investigations, KUB and pelviabdominal. OABSS was adjusted on all patients postoperative at 1,3,6,9 months also Urodynamic was done for all patients preoperative and postoperative at 3, 6, 9 months. Results: The mean age was 30.22±8.37 and 31.35±7.61 in group I and II respectively. There was no statistically difference between both groups in all parameters all over the study except at 9 months after treatment. Hematuria was observed 6 and 9 patients in group I and II respectively. Dysuria was observed in 6 and 15 patients in group I and II respectively. UTI was detected in 3 and 7 patients in group I and II respectively. Conclusion: A single-injection procedure of 100 U or 200 U BoNTA is an effective and safe treatment for patients with IOAB who failed anticholinergic regimens. OABSS and QoL were improved for 6 months; 100 U injections seemed to have comparable results with 200 U. There was a significant difference at month 9 towards 200 U with more incidences of adverse events.

Yesos seriados en niños con parálisis cerebral espástica con pie y marcha en equino previamente infiltrados con toxina botulínica tipo A: estudio de 8 casos / Serial casts in children with spastic cerebral palsy and equinus foot previously treated with botulinum toxin type A: study of 8 cases

Introducción: Los yesos seriados son una estrategia de tratamiento para prevenir, corregir o disminuir alteraciones del pie equino, sin embargo, los resultados no son concluyentes cuando se usan combinados con toxina botulínica para mejorar funcionalidad. Objetivo: Evaluar los efectos de yesos seriados en el rango de movimiento (ROM) de tobillo y en la función motora gruesa, de pacientes con parálisis cerebral (PC) espástica ingresados al programa de yesos seriados del Instituto Teletón (IT) Coquimbo, entre junio y septiembre de 2014. Método: Se evaluó el ROM de tobillo mediante test de Silfverskiold y el control motor selectivo (CMS) acorde al protocolo de yesos seriados del IT Coquimbo en 8 niños con PC espástica, Gross Motor Function Classification System (GMFCS) I, infiltrados con toxina botulínica tipo A, en dosis 3U por kg/peso. Anterior al primer yeso y una semana posterior a la última aplicación, fueron evaluados en la función motora gruesa con Gross Motor Function Measure-66 (GMFM-66) en sus dimensiones D y E. Se utilizó test de Wilcoxon para comparar las medianas de las diferencias de los puntajes de las pruebas aplicadas. Se consideró un valor p < 0,05 como estadísticamente significativo. Resultados: Los 8 niños presentaron mejoría significativa en el ROM de tobillo con rodilla en extensión (p = 0,011), con rodilla en flexión (p = 0,011), en la GMFM-66 (p = 0,034) y GMFM-66-D (p = 0,038) de la misma evaluación. La dimensión E no presentó una variación estadísticamente significativa. Conclusión: La terapia con yesos seriados en pacientes con PC espástica, GMFCS I previamente infiltrados con toxina botulínica tipo A, produce incremento en el ROM de tobillo y en GMFM-66-D.

Introduction: Serial casting is a treatment strategy to prevent, correct or reduce alterations of equinus foot; however, the results are not conclusive when used in combination with botulinum toxin to improve function. Objective: To evaluate the effects of serial casting on the range of motion (ROM) of the ankle, and the gross motor function of patients with spastic cerebral palsy (CP) admitted into the serial casting program at Coquimbo Telethon Institute between June and September 2014. Method: The ROM of the ankle was evaluated using the Silfverskiold Test and the selective motor control (CMS), according to the serial casting program at Coquimbo Telethon Institute in 8 children with spastic CP, Gross Motor Function Classification System (GMFCS) level I, and injected with botulinum toxin type A, at a dose of 3U per kg of body weight. Children were evaluated before the first cast and after the last one with the Gross Motor Function Measure, version 66 (GMFM-66), dimensions D and E. Wilcoxon test was used to compare the medians of the differences in all the tests applied. A p-value < 0.05 was considered statistically significant. Results: All children showed significant improvement in ROM of the ankle with extended knee (p = 0.011), and flexed knee (p = 0.011). Similarly, all children showed significant improvement in the GMFM-66 (p = 0.034) and GMFM-66-D (p = 0.038). The GMFM- E did not show significant changes. Conclusion: Serial casting in patients with spastic CP, GMFCS I and previously injected with botulinum toxin type A improved ROM of the ankle and the GMFM-D.

OnabotulinumtoxinA for neurogenic detrusor overactivity and dose differences: a systematic review

Purpose To evaluate the efficacy and safety of onabotulinumtoxinA for patients with neurogenic detrusor overactivity (NDO). Materials and Methods We searched the Cochrane Library, PUBMED, EMBASE, Chinese Bio-medicine database, China Journal Full-text Database, VIP database, Wanfang database for randomized controlled trials (from inception to September 2012). Two authors independently selected studies, extracted data and assessed the methodological and evidence quality using the Cochrane Risk of Bias Table and GRADE (Grading of Recommendations, Assessment, Development and Evaluation) respectively. Data analysis was performed by RevMan 5.1 and descriptive analysis was employed if necessary. Results Eight studies were selected (n=1879 participants). OnabotulinumtoxinA was more related to urinary tract infection (UTI) (200U: OR 1.72, CI: 1.18-2.52; 300U: OR 1.88, CI: 1.31-2.69) versus placebo. Also, OnabotulinumtoxinA was superior to placebo in improving maximum cystometric capacity (MCC) (200U: OR 138.80, CI: 112.45-165.15; 300U: OR 152.09, CI: 125.25-178.93) and decreasing maximum detrusor pressure (MDP) (200U: MD -29.61, CI: -36.52--22.69; 300U: MD-28.92, CI: -39.59--18.25). However, there were no statistical differences between 200U and 300U onabotulinumtoxinA in UTI (OR 0.84, CI: 0.58-1.22), MCC (OR-12.72, CI: -43.36-17.92) and MDP (MD 2.21, CI: -6.80-11.22). Conclusions OnabotulinumtoxinA may provide superior clinical and urodynamic benefit for populations with NDO. High-quality studies are required for evaluating the optimal dose, long-term application and when to perform repeated injections. .

Clinical Outcomes of Individualized Botulinum Neurotoxin Type A Injection Techniques in Patients with Essential Blepharospasm

PURPOSE: To assess the clinical outcomes following botulinum neurotoxin type A (BoNT-A) treatment with an individualized injection technique based on the types of spasms and to compare the results of the individualized injection technique with those of the conventional injection technique in the same patients. METHODS: From November 2011 to July 2013, 77 BoNT-A injections were performed in 38 patients. Eighteen patients were treated with conventional BoNT-A injections before 2011, and 20 patients were referred to our hospital for unsatisfactory results after a conventional injection technique. We classified the patients by spasm-dominant sites: the lateral orbital area, representing the orbital orbicularis-dominant group (ODG); the glabella, representing the corrugator-dominant group (CDG); and the ptosis, representing the palpebral part of the orbicularis-dominant group (PDG). We increased the injection dose into the spasm-dominant sites of the blepharospasm groups. We assessed subjective symptom scores (functional disability score, FDS) after treatment. RESULTS: This study included 38 patients (26 women, 12 men; mean age, 60.6 +/- 10.9 years). There were 21 patients in the ODG, 10 patients in the CDG, and 7 patients in the PDG. Mean ages were 59.7 +/- 12.6, 59.8 +/- 8.5, and 66.8 +/- 9.0 years, and mean BoNT-A injection dose was 38.8 +/- 11.2, 38.8 +/- 11.2, and 38.8 +/- 10.8 U in each group, respectively (p = 0.44, 0.82 Kruskal-Wallis test). Mean FDS after injection was 1.7 +/- 0.7 in the ODG, 1.4 +/- 0.8 in the CDG, and 1.2 +/- 0.3 in the PDG. There were significant differences in reading and job scale among the three groups. In a comparison between the conventional and individualized injection techniques, there was a significant improvement in mean FDS and in the reading scale in the PDG with the individualized injection technique. The success rate was 92.1% in the conventional injection group and 94.1% in the individualized injection group. CONCLUSIONS: The individualized injection technique of BoNT-A according to the spasm-dominant site is an effective and safe treatment method for essential blepharospasm patients.

Change of Distribution and Timing of Bite Force after Botulinum Toxin Type A Injection Evaluated by a Computerized Occlusion Analysis System

PURPOSE: The aim of this study was to determine the force distribution and pattern of mastication after injection of botulinum toxin type A (BTX-A) into both masseter muscles. The hypothesis to be tested was that the difference between right and left balance of occlusal force diminishes over time following BTX-A injection. MATERIALS AND METHODS: Fifteen patients were submitted to BTX-A injection therapy for subjective masseter hypertrophy. A total of 25 U of BTX-A (50 U in total) was injected into two points located 1 cm apart at the center of the lower one-third of both masseter muscles. All patients were examined using the T-Scan occlusion analysis system before and 4, 8, 12, and 24 weeks after BTX-A injection. RESULTS: A significant change in force balance was found between the right and left sides over time and the difference between the two sides decreased with the time post-injection, reaching a minimum at 12 weeks. Comparison of the force balance between the anterior and posterior occlusions revealed no significant difference at any of the time points. The occlusion and disclusion times (right and left sides) did not differ significantly with time since BTX-A injection. CONCLUSION: A decline in the difference in the clenching force between the left and right sides was found with increasing time up to 12 weeks following BTX-A injection.