Acute angle closure triggered by oral benzodiazepines / Fechamento angular agudo desencadeado por uso oral de benzodiazepínicos

ABSTRACT Benzodiazepines are psychoactive drugs that are prescribed worldwide with limited information on their ocular side effects. Acute angle closure glaucoma is an adverse event with a high risk of blinding, especially in the elderly. We report two patients under 45 years old who presented with bilateral acute angle closure secondary to use of two long half-life benzodiazepines (clonazepam and alprazolam). In addition to suspending the use of these medications and administering ocular hypotensive drugs, both patients were successfully treated with bilateral peripheral laser iridotomy. To the best of our knowledge, this is the first report of bilateral acute angle closure secondary to the use of clonazepam and alprazolam.(AU)

RESUMO Os benzodiazepínicos são medicamentos psicoativos prescritos em todo o mundo, mas com poucas informações sobre seus efeitos colaterais oculares. O glaucoma por fechamento agudo do ângulo iridocorneano é um dos eventos adversos com maior risco de cegueira, sendo descrito particularmente em idosos. Relatamos aqui dois pacientes com menos de 45 anos de idade, com fechamento agudo do ângulo bilateral secundário ao uso de dois diferentes benzodiazepínicos de meia-vida longa (clonazepam e alprazolam). Além da suspensão dessas medicações e do tratamento clínico com drogas hipotensoras oculares, ambos os casos alcançaram sucesso com iridotomias periféricas bilaterais à laser. Considerando o conhecimento atual, estes são os primeiros relatos de fechamento agudo do ângulo bilateral secundária ao uso de clonazepam e alprazolam.(AU)

Elaboração e validação do protocolo de desprescrição do clonazepam em idosos / Elaboration and validation of clonazepam deprescribing protocol for the elderly / Elaboración y validación del protocolo de desprescripción del clonazepam en ancianos

Introdução: Algumas alterações fisiológicas que ocorrem no indivíduo idoso favorecem o acúmulo e a intoxicação por medicamentos. Dentre estes, podemos citar a classe dos benzodiazepínicos, medicamentos que, apesar de amplamente prescritos, principalmente para tratamento de distúrbios do sono e ansiedade, são considerados potencialmente inapropriados para o uso em idosos. Portanto, a elaboração de protocolos para desprescrição desses medicamentos é estratégia necessária na gestão do cuidado dos pacientes geriátricos. Objetivo: Elaborar e validar um protocolo de desprescrição do clonazepam para idosos que fazem uso deste medicamento para ansiedade ou insônia. Métodos: Estudo metodológico, desenvolvido em duas etapas, sendo elas a elaboração e a validação do protocolo de desprescrição do clonazepam para idosos que fazem uso desse medicamento para ansiedade ou insônia, excetuando-se aqueles que preenchem os critérios de exclusão. A elaboração do protocolo resultou em três produtos: um fluxograma de desprescrição, um folheto sobre higiene do sono e um folheto contendo os benefícios da desprescrição do clonazepam sob supervisão médica. A validação do protocolo foi realizada por médicos especialistas, por meio da Técnica de Delphi. Já na validação dos folhetos, participaram, além dos especialistas, indivíduos com 60 anos ou mais, de ambos os sexos, que não fizessem uso do clonazepam. A partir dos resultados obtidos, foi analisada a concordância da avaliação por meio do Coeficiente de Validade de Conteúdo (CVC), uma vez que essa ferramenta objetiva medir o grau de concordância dos juízes participantes do processo de validação. Resultados: O fluxograma foi considerado validado após a segunda rodada de avaliação, pois todos os itens avaliados obtiveram CVC igual ou superior a 0,8 nesta rodada. Os folhetos foram considerados validados já na primeira rodada de avaliação, pois todos os itens também obtiveram CVC superior a 0,8 durante esta rodada. Conclusão: Considerando os resultados obtidos, o protocolo se apresenta como uma ferramenta importante ao guiar a conduta médica no processo de desprescrição do clonazepam.

Introduction: Some physiological changes that occur in the elderly individual favor the accumulation and intoxication by drugs. Among these, we can mention the class of benzodiazepines, medicines which, although widely prescribed mainly for the treatment of sleep disorders and anxiety, are considered potentially inappropriate for use in the elderly. Therefore, the elaboration of protocols for the deprescribing of those drugs is a necessary strategy in the management of the care of geriatric patient. Objective: To elaborate and validate a protocol for the Deprescribing of clonazepam for the elderly who use this medication for anxiety or insomnia. Methods: Methodological study, developed in two stages ­ elaboration and validation of the protocol of deprescribing of clonazepam for elderly people who use this medication for anxiety or insomnia, except those who meet the exclusion criteria. The elaboration of the protocol resulted in three products: a flowchart of deprescribing, a leaflet of sleep hygiene, and a leaflet containing the benefits of the clonazepam Deprescribing under medical supervision. The validation of the protocol was performed by medical specialists, through the Delphi Technique. In addition to the specialists, individuals of both sexes, aged 60 years or more who did not use clonazepam, took part in the validation of the leaflets. Based on the results obtained, the agreement of the evaluation was analyzed using the Content Validity Coefficient (CVC), since this tool aims to measure the degree of agreement of the judges participating in the validation process. Results: The flowchart was considered validated after the second round of evaluation, since all items assessed had a CVC equal to or greater than 0.8 in this round. The leaflets were considered validated in the first evaluation round, since all items also obtained CVC greater than 0.8 during this round. Conclusion: Considering the results obtained, the protocol presents itself as an important tool in guiding medical conduct in the process of Deprescribing of clonazepam

Introducción: Algunas alteraciones fisiológicas que ocurren en el individuo mayor favorecen el acumulación y la intoxicación por medicamentos. Entre estas, podemos citar la clase de los benzodiazepínicos, medicamentos que, a pesar de ampliamente prescritos, principalmente para el tratamiento de disturbios del sueño y de la ansiedad, son considerados potencialmente inapropiados si usados por personas mayores. Por lo tanto, la elaboración de protocolos para desprescripción de esos medicamentos son estrategias necesarias en la gestión al cuidado de los pacientes geriátricos. Objetivo: Elaborar y validar un protocolo de desprescripción de clonazepam para mayores que hacen uso de esta medicina para ansiedad o insomnio. Métodos: Estudio metodológico, desarrollado en dos etapas, siendo ellas la elaboración y la validación del protocolo de desprescripción del clonazepam para mayores que hacen uso de ese medicamento para ansiedad o insomnio, exceptuando aquellos que cumplen los criterios de exclusión. La elaboración del protocolo resultó en tres productos: un flujograma de desprescripción, un folleto sobre la higiene del sueño y un folleto conteniendo los beneficios de la desprescripción del clonazepam bajo supervisión médica. La validación del protocolo fue realizada por médicos especialistas, por medio de la Técnica de Delphi. Ya en la validación de los folletos, participaron, además de los especialistas, individuos con 60 años o más, de ambos sexos, que no hiciesen uso de clonazepam. A partir de los resultados obtenidos, fue analizada la concordancia de la evaluación por médio del Coeficiente de Validez de Contenido (CVC), una vez que esa herramienta objetiva medir el grado de concordancia de los jueces partícipes del proceso de validación. Resultados: El flujograma fue considerado validado después de la segunda ronda de evaluación, pues todos los ítems evaluados obtuvieron CVC igual o superior a 0,8 en esta rodada. Los folletos fueron considerados validados ya en la primera rodada de evaluación, pues todos los ítems también obtuvieron CVC superior a 0,8 durante esta rodada. Conclusión: Considerando los resultados obtenidos, el protocolo se presenta como una herramienta importante al guiar la conducta médica en el proceso de desprescripción del clonazepam.

Prevalência do uso de psicotrópicos na atenção primária à saúde em um município do interior de Minas Gerais / Prevalence of psychotropic drugs use in primary health care in a city in the interior of Minas Gerais

Introdução. Desde sua introdução no suporte à saúde mental, o uso de psicotrópicos tem representado uma parcela significativa do total de fármacos prescritos na Atenção Básica à Saúde. Geralmente, a maioria dos usuários de tais drogas não é avaliada por um psiquiatra, indicando que muitos usam sem real necessidade. Objetivo. Verificar a prevalência de uso de psicotrópicos nas áreas de abrangências de Unidades Básicas de Saúde (UBS) de Barbacena. Métodos. Estudo transversal em que foi verificada a prevalência de uso de psicotrópicos entre pacientes atendidos em quatro UBS no município de Barbacena, Minas Gerais. Foram entrevistados 400 usuários, por meio de questionário elaborado pelos autores. Os testes de associações estatísticas utilizados incluíram o teste do qui-quadrado e o teste de Fischer para variáveis categóricas, além do teste t de Student para variáveis contínuas. A força da associação entre as variáveis explicativas e o desfecho estudado foi verificada por meio do cálculo do Odds Ratio. Resultados. O uso de psicotrópicos foi informado por 212 (53%) entrevistados. Entre as mulheres entrevistadas, 163 (59,0%) referiram consumo desses. Dentre os medicamentos, a classe dos benzodiazepínicos foi a mais utilizada ­ 130 (61,3%), principalmente entre aqueles com idade menor que 60 anos, sendo o clonazepam o mais prescrito desta. Conclusão. A prevalência do uso de psicotrópicos nas UBS pesquisadas foi elevada, indicando a necessidade de melhorar os cuidados na atenção à saúde mental desses pacientes. É provável que muitos desses indivíduos não apresentassem transtorno mental que justificasse o uso de medicamentos psiquiátricos. (AU)

Introduction. Since its introduction in mental health support, the use of psychotropic drugs has represented a significant portion of the total drugs prescribed, mainly at the Basic Health Unit (BHU). Most users of these drugs are not evaluated by a psychiatrist, indicating that many of them use it with no real necessity. Objective. To verify the prevalence of psychotropic drug use in areas covered by Basic Health Unit in Barbacena. Methods. Cross-sectional study in which the prevalence of psychotropic drug use was verified among patients treated at four BHUs in the city of Barbacena, Minas Gerais. 400 users were interviewed through a questionnaire prepared by the authors. The statistical association tests used included the chi-square test and the Fischer test for categorical variables, as well as the Student t-test for continuous variables. The strength of the association between the explanatory variables and the studied outcome was verified by calculating the Odds Ratio. Results. The use of psychotropic drugs was reported by 212 (53%) respondents. Among the women interviewed, 161 (76.2%) reported to consume it. Among the drugs, the benzodiazepine class was the most used - 130 (61.3%), especially those under 60 years old, being clonazepam the most prescribed one. Conclusion. The prevalence of psychotropic drug use in Barbacena's BHU coverage areas was high, indicating the need to improve care in mental health for these patients. Probably, many of these individuals did not have a mental disorder that justified the use of psychiatric medications. (AU)

Polifarmácia e cognição em pacientes com idade avançada / Polypharmacy and cognition in elderly patients

Objetivo: Avaliar a prevalência da polifarmácia e da prescrição de medicações inapropriadas, bem como suas associações com a capacidade cognitiva e funcional do idoso. Métodos: Estudo observacional transversal, no qual foram analisadas as medicações prescritas em 141 prontuários para pacientes acima de 50 anos, em associação com testes que quantificaram a capacidade funcional e cognitiva deles. Resultados: Observou-se média de 4,41 medicamentos por paciente, sendo que 0,41 deles foram considerados inapropriado, segundo o critério de Beers. Verificou-se também relação estatisticamente significativa quanto ao número de medicações e testes que mediam a capacidade funcional e cognitiva dos idosos. Conclusão: O aumento da polifarmácia e da prescrição de medicações potencialmente inadequadas acarretou significativa piora da capacidade cognitiva e funcional do idoso

Objective: To evaluate the prevalence of polypharmacy and of the prescription of inappropriate medications, as well as their associations with the cognitive and functional capacity of the elderly. Methods: Cross-sectional observational study which analyzed the drugs prescribed in 141 medical records for patients over 50 years of age, associated with tests that quantified their functional and cognitive capacity. Results: An average of 4.41 medications per patient was observed, and 0.41 were considered inappropriate according to the Beers criteria. There was also a statistically significant relation regarding the number of medications and tests that measure the functional and cognitive capacity of the elderly. Conclusion: The increase in polypharmacy and in the prescription of potentially inappropriate medications led to a significant impairment of the cognitive and functional capacity of the elderly

Consumo do benzodiazepínico clonazepam (Rivotril®) no estado do Rio de Janeiro, Brasil, 2009-2013: estudo ecológico / Consumption of the benzodiazepine clonazepam (Rivotril®) in Rio de Janeiro State, Brazil, 2009-2013: an ecological study

Resumo O objetivo do estudo é estimar a prevalência do uso de clonazepam no Estado do Rio de Janeiro (RJ). Estudo ecológico e descritivo do consumo de clonazepam (2009-2013), com dados do Sistema Nacional de Gerenciamento de Produtos Controlados da Anvisa. O consumo foi medido pela Dose Diária Definida, com indicadores por população total e com 18 anos e mais utilizando a DDD padronizada de 8mg (anticonvulsivante) e a de 1mg (hipnosedativo). Os Municípios da Região Metropolitana foram agrupados segundo os Índices de Desenvolvimento Humano (IDH) e de GINI, submetidos à análise de conglomerados e apresentados segundo o consumo de clonazepam. No Estado do RJ, o consumo entre 2009 e 2013 aumentou de 0,35 para 1,97 DDD/1000 habitantes. Os valores são maiores para os indivíduos acima de 18 anos. Empregando-se 1mg ao invés de 8mg, chega-se a 21 DDD/1000 habitantes acima de 18 anos, em 2013. Rio de Janeiro e Niterói, com os maiores IDH, apresentaram em 2013 os maiores consumos, 3,38 e 4,52 DDD, respectivamente. Os dados sugerem que até 2% da população adulta é usuária de clonazepam, possivelmente como hipnosedativo. Deve-se atentar para o uso ampliado e fora de indicações terapêuticas, dados o potencial de abuso e as reações adversas ao clonazepam.

Abstract This descriptive, ecological study of clonazepam consumption in Rio de Janeiro State (RJ) estimated use prevalence from 2009 to 2013 using data from the National Controlled Product Management System operated by Brazil's health surveillance agency, Anvisa. Consumption was measured by total population and by population over 18 years old, using the standardised Daily Defined Doses of 8 mg (anticonvulsant) and 1 mg (sedative-hypnotic). The municipalities of the Rio de Janeiro Metropolitan Region were grouped by Human Development Index (HDI) and GINI index, subjected to cluster analysis and ranked by clonazepam consumption. From 2009 to 2013, consumption in the state rose from 0.35 to 1.97 DDD/1000 population, but the figures are higher for individuals over 18 years of age. A DDD of 1 mg instead of 8mg returns consumption in 2013 of 21 DDD/1000 population over 18 years of age. Consumption in 2013 was highest - 3.38 and 4.52 DDD, respectively - in Rio de Janeiro and Niterói, which have the highest HDIs. This suggests that up to 2% of the adult population uses clonazepam, possibly as a sedative-hypnotic. This broad use and use outside therapeutic indications deserves attention, given clonazepam's potential for abuse and adverse reactions.

Segurança do paciente: potenciais interações medicamentosas favorecidas pela sobreposição de medicamentos aprazados pelo enfermeiro / Patient safety: potential drug interactions favored by overlapping of medications scheduled by nurses

A terapêutica medicamentosa tem predomínio no ambiente hospitalar, apresenta-se em um contexto com inúmeras possibilidades para incidentes e assim, mais desafiador para interceptar situações que comprometam uma assistência de qualidade. O enfermeiro possui a responsabilidade sobre o processo de medicação e ocupam papel essencial na detecção e prevenção das interações medicamentosas ao adequar os horários durante o aprazamento. Este estudo teve por objetivo investigar as potenciais interações medicamentosas favorecidas pela sobreposição de medicamentos aprazados por enfermeiros nas prescrições de pacientes em unidade de internação clínica. Trata-se de um estudo descritivo, transversal, de análise documental com abordagem quantitativa com 260 prescrições medicamentosas. Foram selecionadas, por conveniência, prescrições de pacientes adultos de duas unidades de internação clínica de um hospital universitário localizado no Rio de Janeiro durante o mês de setembro de 2019. Os dados foram analisados por meio de estatística descritiva através do Microsoft Excel e as potenciais interações medicamentosas foram identificadas por meio da ferramenta Drug Interactions (Medscape®). Foi aprovado pelo Comitê de Ética em Pesquisa, da referida instituição sob o parecer: 3.556.571. Foram 3066 doses analisadas com concentração de quatro horários (10h, 18h, 22h e 06h) evidenciando aprazamento institucional padronizado. A via oral foi a mais predominante (74%). Os motivos para a omissão de dose foram: 60,3% sem justificativas, 22,8% não havia o medicamento ou não era padronizado e em 5,3% das doses, o horário estava ausente e as principais classes envolvidas foram: aparelho digestivo e metabolismo (38,6%), anti-infecciosos gerais para uso sistêmico (15,9%) e sistema nervoso (15,3%). A taxa de erros de medicação foi 5,44. Quanto ao tipo de prescrição, houve predomínio de prescrições pré-digitadas (n=194, 74,61%), apenas 3 (1,15%) foram escritas à mão e 63 (24,23%) foram mistas. As interações medicamentosas potenciais com menor gravidade foram ácido valproico/ isoniazida e carbonato de cálcio/ aspirina ambos com 19,7%, com gravidade moderada foram lopinavir/ clonazepam (11,9%) e diazepam/ tramadol (7,3%) e com risco grave foram isoniazida/ omeprazol (12,3%) e com 2,8% rifampicina/ dexametasona. A equipe de enfermagem deve considerar o cuidado centrado no paciente com aprazamento mais próximo às necessidades individuais, inclusive na preservação do sono e evitando a sobreposição medicamentosa, comunicação verbal e escrita adequada, a utilização de bases de dados como ferramenta de apoio à decisão clínica, realização da dupla checagem, elaboração de um guia de aprazamento, bem como um ambiente reservado para sua realização e a configuração do processo de trabalho quanto à organização, distribuição e acondicionamento dos medicamentos de forma adequada.

Drug therapy is predominant in the hospital environment, presenting itself as a context subject to numerous incidents possibilities, therefore, it's more challenging to intercept situations that compromise the quality of care. The nurse is responsible for the medication process and plays an essential role in detecting and preventing drug interactions by the adjustment of the schedules during the scheduling. The aim of this study was to investigate the potential drug interactions favored by overlapping of medications scheduled by nurses in patients' prescriptions at a clinical inpatient unit. This is a descriptive cross-sectional study of document analysis, through a quantitative approach with 260 drug prescriptions. For convenience, the prescriptions selected were those from adult patients from two inpatient units of a university hospital located in Rio de Janeiro, during September 2019. Data were analyzed through descriptive statistics using Microsoft Excel, and the potential drug interactions were identified using the Drug Interactions tool (Medscape®). The present work was approved by the Ethics and Research Committee of the mentioned institution under the peer review: 3,556,571. There were 3066 analyzed doses, with a concentration of four hours (10h, 18h, 22h and 06h) showing standardized institutional schedule. The oral route was the most predominant (74%). The reasons for dose omission were: 60.3% without justification; in 22.8%, there was no medication, or it was not standardized; and, in 5.3% of doses, the time was absent. The main classes involved were: digestive tract and metabolism (38.6%), general anti-infectives for systemic use (15.9%) and nervous system (15.3%). The medication error rate was 5.44. Regarding the type of prescription, there was a predominance of preset prescriptions (n=194, 74.61%); only 3 (1.15%) were handwritten, and 63 (24.23%) were mixed. The potential drug interactions with lower severity were valproic acid/ isoniazid and calcium carbonate/ aspirin, both with 19.7%; those with moderate severity were lopinavir/ clonazepam (11.9%) and diazepam/ tramadol (7.3%); and the ones with severe risk were isoniazid/ omeprazole (12.3%) and rifampicin/ dexamethasone (2.8%). Nursing staff must consider patient-centered care by adopting a medication schedule closer to the patient's individual needs, including sleep preservation and avoiding drug overlap; a proper verbal and written communication; the use of databases as a clinical decision support tool; double checking; the elaboration of a scheduling guide, as well as a reserved environment for its accomplishment; and the configuration of the work process regarding the organization, the distribution and a proper packaging of the medications.

Adjunctive Role of Bifrontal Transcranial Direct Current Stimulation in Distressed Patients with Severe Tinnitus

BACKGROUND: This study assessed the therapeutic effect of adjunctive bifrontal transcranial direct current stimulation (tDCS) in patients with tinnitus. METHODS: Forty-four patients who visited our university hospital with a complaint of non-pulsatile subjective tinnitus in January through December 2016 were enrolled. All patients received directive counseling and sound therapy, such as a sound generator or hearing aids, and/or oral clonazepam. Patients who agreed to undergo additional bifrontal tDCS were classified as the study group (n = 26). For tDCS, 1.5 mA of direct current was applied to the prefrontal cortex with a 10–20 EEG system for 20 minutes per session. RESULTS: The Tinnitus Handicap Inventory (THI), Beck Depression Inventory, and Visual Analog Scale (VAS) scores decreased significantly after treatment (P 0.05). Logistic regression analysis revealed that the initial THI score was independently associated with improvement in the THI. However, tDCS was not a significant determinant of recovery. CONCLUSION: tDCS can be used as an adjunctive treatment in patients with severe tinnitus. Although tDCS did not decrease the loudness of tinnitus, it could alleviate the distress associated with the condition in some patients with a moderate or catastrophic handicap.

A literature review on burning mouth syndrome

Burning mouth syndrome (BMS) is defined as the xerostomia, burning sensation and various discomfort of tongue and oral mucosa. BMS can occur in both men and women, but is more frequent in middle-aged menopausal women. Because exact cause can't be identified clearly and it is hard to make diagnosis in clinic, the purpose of the treatment have been to relieve symptoms. Etiology of BMS is divided into local, systemic, and psychological factors. α-lipoic acid, clonazepam, supplemental therapy and cognitive behavior therapy can be prescribed for BMS. Nowdays, many experts focus attention on effect of combination therapy. It is necessary to solve the symptoms of the patients by combination of pharmacological approach and psychotherapy with cognitive behavior therapy considering the factors in various aspects.

Pharmacological and Neuromodulatory Treatments for Panic Disorder: Clinical Trials from 2010 to 2018

OBJECTIVE: Treatment for panic disorder (PD) have evolved, although there is still a strong unmet need for more effective and tolerable options. The present study summarizes and discusses recent evidence regarding the pharmacological and neuromodulatory treatment of PD. METHODS: MEDLINE, Cochrane Library, PsycINFO and Thomson Reuters’s Web of Science were searched for clinical trials published between 2010 and 2018. We included all prospective experimental studies including randomized controlled trials (RCT) and other clinical trials with more than 10 patients. RESULTS: Only 11 articles met the inclusion criteria, including 4 RCT, 3 open clinical trials and 5 comparative clinical trials. RCT demonstrated efficacy of transcranial magnetic stimulation (TMS) in only one of two trials. Neither pindolol nor d-fenfluramine were effective in blocking flumazenil-induced panic attacks. Augmentation with quetiapine was not superior to placebo. Open trials indicated that escitalopram, vortioxetine and TMS may be effective. Comparative trials did not demonstrate superiority from any drug, but confirmed tranylcypromine, paroxetine, clonazepam and alprazolam as effective options. CONCLUSION: The current study confirmed the efficacy of tranylcypromine, paroxetine, clonazepam, alprazolam and escitalopram. Vortioxetine and TMS, with duration of 4 or more weeks, also seems to be effective. Quetiapine, pindolol and d-fenfluramine were not considered effective compounds.

Trasplante cardiaco en paciente bipolar: reporte de caso / Bipolar Disorder and Heart Transplantation: A Case Report

RESUMEN Introducción: El trastorno bipolar es una afección del estado de ánimo, crónico y recurrente, que cursa con síntomas que fluctúan entre la euforia y la depresión. El trasplante cardiaco es el tratamiento de elección para pacientes con insuficiencia cardiaca y arritmias que no responden al tratamiento convencional, pero este tipo de procedimiento está contraindicado de manera absoluta o relativa para pacientes con trastorno bipolar. Métodos: Reporte de caso y revisión narrativa de la literatura. Caso: Mujer de 34 arios con trastorno bipolar desde los 13, en tratamiento con litio y aripiprazol, que requirió un trasplante cardiaco como opción terapéutica por taquicardia ventricular refractaria al tratamiento convencional. La paciente no sufrió descompensación afectiva al retirársele el litio y el aripiprazol, que se debió suspender porque se asociaron con prolongación del intervalo QTc, y permaneció eutímica a lo largo del proceso con ácido valproico y clonazepam. Conclusiones: Este reporte de caso muestra un trasplante cardiaco exitoso en una paciente con trastorno afectivo bipolar en eutimia y sin otras contraindicaciones psicosociales para el injerto. Además, destaca la importancia del seguimiento por psiquiatría de enlace durante el proceso.

ABSTRACT Introduction: Bipolar disorder is a chronic and recurrent mood disease that includes symptoms that fluctuate from euphoria to depression. As a mood disorder, itis one of the main contraindications for transplantation procedures. The case is presented of a patient with bipolar disorder who had a heart transplant after a cardiac arrest. Heart transplantation is the treatment of choice in patients with heart failure and arrhythmias that do not respond to conventional treatment. Methods: Case report and narrative review of literature. Case report: A 34-year-old woman with bipolar disorder diagnosed when she was 13, treated with lithium and aripiprazole. She required a heart transplant as the only therapeutic option, after presenting with ventricular tachycardia refractory to conventional treatment. The patient did not suffer an emotional decompensation with the removal of the lithium and aripiprazole that were associated with prolonged QTc interval, and remained eurhythmic throughout the process. Discussion: Heart transplantation can be performed safely and successfully in patients with bipolar disorder, when suitably followed-up by a liaison psychiatry group. Conclusions: Bipolar disorder should not be considered as an absolute contraindication for heart transplantation.

Transtornos do sono: atualização (parte2/2) / Sleep disorders: up to date (2/2)

Este artigo (2/2) compõe uma revisão sobre fundamentos do sono e transtornos do sono (TS), sendo aqui considerados: 1-Incapacidade de dormir na hora desejada-atraso de fase, avanço de fase, ''jet lag'', ritmo sono-vigília irregular, sono/vigília de livre curso, transtornos dos trabalhadores em turnos; 2-Movimentos ou comportamentos anormais durante o sono. Este segundo grupo é aqui subdividido em: A1-Parassonias relacionadas ao sono NREM (Non-rapid eye movement) ­ despertar confusional, sonambulismo, terror noturno, síndrome da cabeça explosiva, alucinações relacionadas ao sono, enurese noturna e parassonias causadas por doenças e medicações; A2-Parassonias relacionadas ao sono REM (rapid eye movement) - transtorno comportamental do sono REM, pesadelos, paralisias recorrentes isoladas do sono, promulgação sono ''dream enactment behavior"; B-Transtornos do movimento relacionados ao sono-bruxismo, síndrome das pernas inquietas, movimentos periódicos das pernas, câimbras do sono, movimentos rítmicos relacionados ao sono, mioclonias proprioespinhais do início do sono, movimentos relacionados à medicação, mioclonias em doenças sistêmicas e mioclonias benignas do sono em bebês.(AU)

This is the second part (2/2) of an article that intends to review major topics regarding sleep fundamentals and sleep disorders (SD), now considering: 1-Circadian rhythm disorders-delayed onset sleep phase disorder, advanced onset sleep phase disorder, jet lag, irregular sleep-wake rhythm, free-running type, shift work type; 2-Abnormal movements or behaviours during sleep. This second category is divided in two groups: A1-NREM (Non-rapid eye movement) parasomnias ­ confusional awakening, sleepwalking, night terrors, explosive head syndrome, sleep-related hallucinations, nocturnal enuresis and parasomnias related to diseases or medications; A2-REM (Rapid eye movement) parasomnias-REM sleep behaviour disorder, nightmares, recurrent isolated sleep paralysis, dream enactment behaviour; B-Sleep related movement disorders-bruxism, restless legs syndrome, periodical limb movement disorders, nocturnal leg cramps, sleep related rhythmic movement disorder, propriospinal myoclonus, movements related to medication use, myoclonus related to systemic diseases and benign myoclonus of sleep.(AU)

Postmenopausal Burning Mouth Syndrome Relieved by Clonazepam

Burning mouth syndrome (BMS) is an intraoral chronic pain disorder characterized by continuous burning sensations. BMS occurs particularly in postmenopausal women, and its etiology is not definite and considered idiopathic. Various treatments such as analgesics, anticonvulsants, and antidepressants are found to be effective, but the definitive treatment has not been established. We report two cases of postmenopausal BMS that were relieved by clonazepam, and review the literature about the various possible etiologies and treatment modalities of BMS.

Sedación en la oficina del odontólogo: ¿Midazolam o Clonazepam? / Midazolam or Clonazepam for sedation at the dentistry office?

Introducción: Con frecuencia anestesiólogos son requeridos para trabajar fuera de pabellón quirúrgico intrahospitalario. Un campo interesante es la sedación en la consulta odontológica. Esto plantea un desafío dada la lejanía de un hospital, que le impide contar con ayuda inmediata en caso de una situación de emergencia y a la angustia que genera al paciente el procedimiento, por lo que debe lograrse un perfecto balance entre seguridad y ansiolisis. Material y Método: Se estudiaron pacientes sometidos a instalación de implantes dentales. Se comparó el uso de midazolam (M) y clonazepam (C) evaluando la satisfacción del implantólogo y del paciente. Resultados: Se estudiaron 67 pacientes y al evaluar su satisfacción, ésta se catalogó como buena y muy buena con ambos fármacos. Sin embargo en la evaluación del odontólogo se encontraron diferencias, ya que en el grupo M, tres casos fueron evaluados como regulares y ningún caso en el grupo C (p < 0.05). La causa de esta mala evaluación, fue explicada por el operador debido a que estos enfermos no fueron capaces de abrir la boca de manera satisfactoria. No se registraron episodios de desaturación, hipotensión, ni crisis hipertensiva. Discusión: Se demostró que la sedación con benzodiacepinas fue útil y segura. Sin embargo, la utilización de midazolam llevaría a un estado de hipnosis más profundo que impediría al paciente abrir bien su boca, hecho que dificultó el procedimiento dental. En conclusión el clonazepam podría tener la ventaja de lograr altos niveles de satisfacción tanto del profesional como del paciente.

Background: Increasingly, anesthesiologists are often required to perform procedures outside the operating room. An interesting field is sedation in the dental office. This poses a major challenge given the remoteness of a hospital and the anxiety generated in the patient. Therefore a perfect balance must be achieved between anxiolysis and safety for each case. Materials and Methods: We prospectively studied patients undergoing dental implants. We compared the use of two benzodiazepines, midazolam (M) and clonazepam (C) and evaluated the satisfaction of both the dental surgeon and the patient. Results: We studied 67 patients. When assessing patient satisfaction the patients were classified as good and very good with both drugs. However dentists in the evaluation some differences were found between the two groups, in the M group, three cases were evaluated as fair and no cases in group C (p <0.05). The cause of this poor assessment was explained by the operator, as a result of these three patients not being able to open their mouths during the procedure. There were no episodes of desaturation, hypotension or hypertensive crisis in any of the patients. Discussion: We demonstrated that sedation with benzodiazepines in the dentist's office as a useful and safe alternative with either midazolam or clonazepam. However, the use of midazolam leads to a deeper state of hypnosis that would prevent the patient to open the mouth suffuciently, making it difficult a dental procedure. In conclusion clonazepam could have the advantage of achieving high levels of satisfaction from both the dentist and the patient.

Clinical characteristics and therapeutic response in patients with Burning Mouth Syndrome: accompanying 2 years / Características clínicas e resposta terapêutica em pacientes portadores da Síndrome de Ardência Bucal: acompanhamento de 2 anos

Introduction: Burning Mouth Syndrome (BMS) is a condition characterized by burning symptom of the oral mucosa in the absence of clinical signs. Its etiology is still unknown and, and to date there is no effective treatment. Purpose: The aim of this study was to evaluate patients with BMS profile and the therapies results in a retrospective study. Material and method: Clinical and therapeutic data were collected from records of patients with BMS diagnosed between January 2013 to April 2015 at the Clinic of Stomatology Clinic, Faculdade de Odontologia of Universidade de São Paulo, according to the criteria established by the International Headache Society in 2013. The therapies used for BMS control were also evaluated. Result: Twelve patients were diagnosed with BMS at this period. All of them were women with a mean age of 61.18 years and the apex of the tongue was the most common affected site and the duration of the burning sensation ranged from 6 months to 25 years. Many therapies were prescribed for BMS control, such as topical capsaicin, topical clonazepan, low level laser therapy and homeopathy. Among the established therapies, capsaicin has immediate effect in reducing symptoms. Conclusion: The present study showed that the challenges towards an effective treatment for BMS are varied and are mainly related to the lack knowing of the pathogenesis of this disease. The demographic profile of patients studied here was similar to that described in the available literature, however, the variables represented by secondary symptoms (medical history, anxiety and depression levels) may be modifying factors of therapeutic response and the pathogenesis of the disease itself.

Introdução: A Síndrome de Ardência Bucal (SAB) é uma condição caracterizada pelo sintoma de ardência na mucosa oral na ausência de qualquer sinal clínico. Sua etiologia ainda é desconhecida e, até o momento, não dispõe de tratamento efetivo. Objetivo: Avaliar o perfil do paciente portador de SAB, as terapias instituídas e seus resultados em estudo retrospectivo. Material e método: Foram coletados os dados clínicos e terapêuticos dos prontuários de pacientes diagnosticados com SAB, no período de janeiro de 2013 a abril de 2015, no Ambulatório da Disciplina de Estomatologia Clínica da Faculdade de Odontologia da Universidade de São Paulo. Os critérios para o diagnóstico utilizados se basearam nos estabelecidos pela International Headache Society em 2013 e foram observadas as terapêuticas empregadas e seus resultados. Resultado: Doze pacientes foram diagnosticadas com SAB neste período, todas do sexo feminino, média de idade 61,18 anos, e a principal região acometida pelo sintoma de ardor foi o ápice de língua. O tempo de duração deste sintoma variou de 6 meses a 25 anos. As terapias utilizadas para o controle de sintomas da SAB foram capsaicina, clonazepan tópico, laserterapia e homeopatia. Dentre as terapias instituídas, a capsaicina apresentou efeito imediato na redução dos sintomas. Conclusão: O presente estudo demonstrou que os desafios que circundam a obtenção de um tratamento efetivo para a SAB são diversos e estão principalmente relacionados ao desconhecimento da etiopatogenia da doença. O perfil demográfico dos pacientes aqui estudados foi semelhante ao descrito na literatura disponível, entretanto, as variáveis representadas por sintomas secundários (história médica, níveis de ansiedade e depressão) podem constituir fatores modificadores da resposta terapêutica e da própria etiopatogenia da doença.

The prevalence of potentially inappropriate medications prescribed in elderly patients admitted in a tertiary teaching hospital: A retrospective cross-sectional study

BACKGROUND:The number of elderly people (aged 60 years or over) is expected to double in the next 35 years as a result of decreasing mortality and declining fertility worldwide. The elderly population is at increased risk of being prescribed potentially inappropriate medications (PIM).OBJECTIVES:To determine the prevalence of PIM prescribed among the geriatric patients admitted in a tertiary teaching hospital in Valenzuela City in 2014.METHODS:This is a retrospective cross-sectional study on patients who are 65 years and older admitted under Internal Medicine between January 2014 to December 2014. Medical records were reviewed for PIM prescription according to the updated 2012 Beers Criteria.RESULTS: PIMs were noted in 303 out of of 618 patients.The most common PIMs were insulin sliding scale, digoxin,orphenadrine, ipratropium, ketorolac, clonazepam, clonidine, hydroxyzine, amiodarone and spironolactone.CONCLUSION:The prevalence of PIM prescription is 49% among geriatric patients admitted in a tertiary teaching hospital in Valenzuela City in 2014. It is recommended to determineprevalence of PIM use in other geriatric care settings, the predictors for PIM use, and the economic burden of PIM use.

Familiar Hyperekplexia, a Potential Cause of Cautious Gait: A New Korean Case and a Systematic Review of Phenotypes

Familial hyperekplexia, also called startle disease, is a rare neurological disorder characterized by excessive startle responses to noise or touch. It can be associated with serious injury from frequent falls, apnea spells, and aspiration pneumonia. Familial hyperekplexia has a heterogeneous genetic background with several identified causative genes; it demonstrates both dominant and recessive inheritance in the α1 subunit of the glycine receptor (GLRA1), the β subunit of the glycine receptor and the presynaptic sodium and chloride-dependent glycine transporter 2 genes. Clonazepam is an effective medical treatment for hyperekplexia. Here, we report genetically confirmed familial hyperekplexia patients presenting early adult cautious gait. Additionally, we review clinical features, mode of inheritance, ethnicity and the types and locations of mutations of previously reported hyperekplexia cases with a GLRA1 gene mutation.

The Role of Segmental Analysis of Clonazepam in Hair in Drug Facilitated Cases / 法医学杂志

OBJECTIVES@#To infer the frequency of dosage and medication history investigate of the victims in drug facilitated cases by the segmental analysis of clonazepam in hair.@*METHODS@#Freezing milling under liquid nitrogen environment combined with ultrasonic bath was used as sample pretreatment in this study, and liquid chromatography-tandem mass spectrometry was used for the segmental analysis of the hair samples collected from 6 victims in different cases. The concentrations of clonazepam and 7-aminoclonazepam were detected in each hair section.@*RESULTS@#Clonazepam and its metabolite 7-aminoclonazepam were detected in parts of hair sections from the 6 victims. The occurrence time of drug peak concentration was consistent with the intake timing provided by victims.@*CONCLUSIONS@#Segmental analysis of hair can provide the information of frequency of dosage and intake timing, which shows an unique evidential value in drug facilitated crimes.

The prevalence of potentially inappropriate medications prescribed in elderly patients admitted in a tertiary teaching hospital: A retrospective cross-sectional study

@#<p style="text-align: justify;"><strong>BACKGROUND:</strong>The number of elderly people (aged 60 years or over) is expected to double in the next 35 years as a result of decreasing mortality and declining fertility worldwide. The elderly population is at increased risk of being prescribed potentially inappropriate medications (PIM).<br /><strong>OBJECTIVES:</strong>To determine the prevalence of PIM prescribed among the geriatric patients admitted in a tertiary teaching hospital in Valenzuela City in 2014.<br /><strong>METHODS:</strong>This is a retrospective cross-sectional study on patients who are 65 years and older admitted under Internal Medicine between January 2014 to December 2014. Medical records were reviewed for PIM prescription according to the updated 2012 Beers Criteria.<br /><strong>RESULTS:</strong> PIMs were noted in 303 out of of 618 patients.The most common PIMs were insulin sliding scale, digoxin,orphenadrine, ipratropium, ketorolac, clonazepam, clonidine, hydroxyzine, amiodarone and spironolactone.<br /><strong>CONCLUSION:</strong>The prevalence of PIM prescription is 49% among geriatric patients admitted in a tertiary teaching hospital in Valenzuela City in 2014. It is recommended to determineprevalence of PIM use in other geriatric care settings, the predictors for PIM use, and the economic burden of PIM use.</p>

The prevalence of potentially inappropriate medications prescribed in elderly patients admitted in a tertiary teaching hospital: A retrospective cross-sectional study

BACKGROUND:The number of elderly people (aged 60 years or over) is expected to double in the next 35 years as a result of decreasing mortality and declining fertility worldwide. The elderly population is at increased risk of being prescribed potentially inappropriate medications (PIM).OBJECTIVES:To determine the prevalence of PIM prescribed among the geriatric patients admitted in a tertiary teaching hospital in Valenzuela City in 2014.METHODS:This is a retrospective cross-sectional study on patients who are 65 years and older admitted under Internal Medicine between January 2014 to December 2014. Medical records were reviewed for PIM prescription according to the updated 2012 Beers Criteria.RESULTS: PIMs were noted in 303 out of of 618 patients.The most common PIMs were insulin sliding scale, digoxin,orphenadrine, ipratropium, ketorolac, clonazepam, clonidine, hydroxyzine, amiodarone and spironolactone.CONCLUSION:The prevalence of PIM prescription is 49% among geriatric patients admitted in a tertiary teaching hospital in Valenzuela City in 2014. It is recommended to determineprevalence of PIM use in other geriatric care settings, the predictors for PIM use, and the economic burden of PIM use.

Tratamientos farmacológicos en pacientes con síndrome de boca urente: revisión sistemática / Pharmacologic treatment of burning mouth syndrome: a systematic review

El objetivo fue determinar mediante una revisión sistemática, cuáles tratamientos farmacológicos para el Síndrome de Boca Urente (SBU) logran una reducción de síntomas, según Escala Visual Análoga (EVA). Se realizó una búsqueda bibliográfica en la bases de datos PubMed y SciELO, Trip Database, Scopus Database, EBSCO host y LILACS entre el 2005 y 2015. De 72 artículos, se seleccionaron un total de 11. Los tratamientos sistémicos usados fueron, Hipericum perforatum, Catuama, Clonazepam, Ácido alfa lipoico y Lafutidina. Entre los tratamientos tópicos, Aceite de oliva virgen enriquecido con licopeno, Lisozima lactoperoxidasa, Clonazepam y Capsaicina. Los fármacos que obtuvieron mejores resultados para el tratamiento del SBU fueron Lafutidina, Catuama, Clonazepam tópico y sistémico, y en menor grado Capsaicina.

The aim of this study was to determine through a systematic review, which is the best drug treatment for burning mouth syndrome (SBU), measured on a Visual Analogue Scale. A scientific literature search was conducted in PubMed and SciELO, Trip Database, Database Scopus, EBSCO host and LILACS data between 2005 and 2015. Of a total of 72 articles, 11 were included for analysis. Systemic treatments were Lycopene-enriched virgin olive oil, Hypericum perforatum, Catuama, Clonazepam, Alpha lipoic acid; topical treatments were Lysozyme lactoperoxidase, Clonazepam, Capsaicin and Lafutidine. The best results obtained were with Lafutidine, Catuama, topical and systemic Clonazepam, and to a lesser degree Capsaicin.