Cirugía de desfuncionalización de glándulas salivales mayores en sialorrea masiva / Major salivary gland defunctionalization surgery in massive sialorrhea

Introducción: La sialorrea es la pérdida involuntaria de saliva de la boca, ya sea debido a la producción excesiva de saliva o disminución de la frecuencia de deglución. Se habla de sialorrea patológica cuando persiste más allá de los 4 años de edad. Además de las implicaciones sociales, cambios de ropa frecuentes, puede provocar neumonías por aspiración y deshidratación. El manejo de la sialorrea requiere una evaluación completa con un enfoque de equipo multidisciplinario para el tratamiento, que incluye terapias no farmacológicas, farmacológicas y quirúrgicas. Objetivo: Presentar resultados quirúrgicos y farmacológicos en el tratamiento de sialorrea masiva. Material y Método: Se realizó revisión de historias clínicas de 7 pacientes portadores de sialorrea masiva. Todos los pacientes incluidos fueron refractarios a tratamiento médico. El diagnóstico fue obtenido por un equipo multidisciplinario. Se les realizó desfuncionalización quirúrgica y farmacológica de glándulas salivales. Se les aplicó Escala de Severidad (DSS) y escala de frecuencia (DFS), previo a cirugía y posterior a procedimiento hasta el año. Resultados: Mejoría clínica subjetiva posterior a desfuncionalización quirúrgica con disminución de DSS y DFS. Disminución promedio de baberos a 10/día. Conclusión: Los resultados obtenidos son buenos, si se consideran las escalas DSS, DFS y el número de baberos al día, que son mediciones tanto subjetivas y objetivas respectivamente.

Introduction: Massive Sialorrhea is the involuntary loss of saliva from the mouth, either due to excessive saliva production or decreased swallowing frequency. We speak of pathological sialorrhea when it persists beyond 4 years old. In addition to the social implications and frequent clothing changes. It can cause aspiration pneumonia and dehydration. Treatment for sialorrhea requires a comprehensive evaluation with a multidisciplinary team approach. Including non-pharmacological, pharmacological, and surgical therapies. Aim: Presentation of the results of surgical defunctionalization of the salivary glands plus injection of Botulinum Toxin in the treatment of massive sialorrhea. Material and Method: A review of the clinical records of 7 patients with massive sialorrhea was carried out. All included patients were refractory to medical treatment. The diagnosis was obtained by a multidisciplinary team. Surgical and pharmacological dysfunctionalization of salivary glands was performed. Severity Scale (DSS) and Frequency Scale (DFS) were applied before surgery and after the procedure up to a year. Results: Subjective clinical improvement after surgical defunctionalization with decreased SHD and DFS. Average decrease in bibs to 10/day. Conclusion: The evaluated strategy presented similar benefits with respect to the literature. The SHD and DFS scales and the number of bibs per day are both subjective and objective measurements, respectively, and allow the clinical improvement and quality of life of patients undergoing surgery to be evaluated individually.

Relationship between anticholinergic load and self-perceived health in a population aged 44 years or older / Relação entre carga anticolinérgica e autopercepção de saúde em população com mais de 44 anos

OBJECTIVE: To investigate the relationship between anticholinergic load (ACL) and self-perceived general health in adults in a medium-sized municipality in southern Brazil. METHODS: This cross-sectional study was based on 2015 data from a medium-sized municipality in southern Brazil. All respondents aged 44 years or older who reported using drugs in the 2 weeks before the interview were included (n = 662). The Anticholinergic Drug Scale was used to measure the ACL. Self-perceived health was categorized as positive self-perception (PSP) or negative self-perception (NSP). Crude and adjusted Poisson regression analyses were conducted to investigate the association between ACL and self-perceived health. RESULTS: NSP was found in 50.91% of 662 respondents. Significant ACL, older age, lower economic status, lower education, polypharmacy, and depression correlated with a higher frequency of NSP. Individuals with significant ACL had a prevalence of NSP of 1.27 (95% confidence interval: 1.02 ­ 1.58), and each additional ACL level represented a 6.10% higher chance of worse self-perceived health, regardless of confounding factors. CONCLUSIONS: An association was found between significant ACL and NSP, with an effect dependent on ACL level

OBJETIVO: Investigar a relação entre carga anticolinérgica (CAC) e autopercepção de saúde em adultos de um município de médio porte do sul do Brasil. METODOLOGIA: Trata-se de um estudo transversal com dados de 2015, realizado em um município de médio porte do sul do Brasil. Todos os entrevistados com 44 anos ou mais que relataram uso de drogas nas duas semanas anteriores à entrevista foram incluídos (n = 662). A Anticholinergic Drug Scale (ADS) foi utilizada para medir a CAC. A autopercepção da saúde foi categorizada em autopercepção positiva (APP) ou autopercepção negativa (APN). Análises de regressão de Poisson bruta e ajustada foram realizadas para investigar a associação entre CAC e autopercepção de saúde. RESULTADOS: Entre os 662 participantes, a CAC foi encontrada em 50,91% dos respondentes. CAC significativa, idade avançada, situação econômica mais baixa, menor escolaridade, polifarmácia e depressão foram correlacionados com maior frequência de APN. Indivíduos com CAC significativo apresentaram prevalência de APN de 1,27 (intervalo de confiança de 95%: 1,02 ­ 1,58), e cada nível adicional de CAC representou uma chance 6,10% maior de pior autopercepção de saúde, independentemente de fatores de confusão. CONCLUSÕES: Encontrou-se associação entre ACL significativo e APN, com efeito dependente do valor do CAC

Tratamiento de la enfermedad de Parkinson temprana / Treatment of early Parkinson's disease

RESUMEN La enfermedad de Parkinson (EP) es principalmente una enfermedad de pacientes ancianos. Es un trastorno multifacético que comprende síntomas motores y no motores en todas las etapas de la enfermedad. Esta revisión busca integrar los datos de las opciones de tratamiento más recientes con los datos de las terapias establecidas, a fin de proporcionar una referencia actualizada basada en la evidencia para los médicos que tratan la EP temprana, con medicamentos que puedan usarse como alternativa a la levodopa. El enfoque de los médicos para el tratamiento de la enfermedad de Parkinson (EP) temprana debe tener en cuenta numerosos aspectos, entre ellos, cómo informar al paciente sobre el diagnóstico y la decisión crítica de qué terapia adoptar y cuándo iniciarla. El tratamiento del trastorno motor asociado con la EP temprana debe considerar varios factores cruciales, como la edad de inicio, las comorbilidades y los requisitos funcionales del paciente, y no se puede resumir en una fórmula simple. En pacientes más jóvenes (es decir, antes de la edad de 70 años) y en aquellos sin altos requisitos funcionales, el tratamiento generalmente se inicia con agonistas de dopamina y / o inhibidores de la enzima monoaminooxidasa-B (MAO- B I). En pacientes más jóvenes, la levodopa se debe agregar a los agonistas de la dopamina y / o MAO-B I, según lo requiera la progresión de la enfermedad, mientras que en los pacientes mayores, cuando la respuesta a la levodopa sola no es satisfactoria, los agonistas de la dopamina o los inhibidores de la catecol-O- metiltransferasa pueden posteriormente ser agregados.

SUMMARY Parkinson's disease (PD) is primarily a disease of elderly patients. Is a multifaceted disorder comprised of both motor and non-motor symptoms at all stages of the disease. This review seeks to integrate data from the newest treatment options with data from established therapies, so as to provide an up-to- date evidence-based reference for clinicians treating early PD, with medications that can be used as an alternative to levodopa. The clinicians' approach to the treatment of early Parkinson's disease (PD) should take into account numerous aspects, including how to inform a patient upon diagnosis and the critical decision of what therapy to adopt and when to start it. The treatment of the motor disorder associated with early PD needs to consider several crucial factors, such as age at onset, comorbidities, and the patient's functional requirements, and cannot be summarized in a simple formula. In younger patients (i.e., before the age of 70) and in those without high functional requirements, treatment is usually initiated with dopamine agonists and/or monoamine oxidase-B enzyme inhibitors (MAO-B I). In younger patients, levodopa should be added to dopamine agonists and/or MAO-B I, as required by disease progression, whereas in older patients, when response to levodopa alone is not satisfactory, dopamine agonists or catechol-O- methyltransferase inhibitors may subsequently be added.

Development of a Brazilian anticholinergic activity drug scale / Desenvolvimento de uma escala brasileira de medicamentos com atividade anticolinérgica

ABSTRACT Objective To develop a scale of anticholinergic activity drugs used in Brazil, to be applied in health care and pharmacoepidemiology research. Methods We performed a literature review on PubMed/MEDLINE® to identify previously published scales of anticholinergic drugs. This scale started with anticholinergic drugs, and those with known anticholinergic activity as per the 4th level, chemical-therapeutic subgroup, of the Anatomical Therapeutic Chemical classification. We also included drugs with high anticholinergic activity, as described in a list of potentially inappropriate medications for use in older adults, according to the 2015 American Geriatrics Society Beers Criteria. Drugs listed in at least two anticholinergic scales were added. Then we verified which drugs in the previous steps were marketed in Brazil. We assigned a score of 1, 2 and 3, based on their anticholinergic action. Results A total of 273 anticholinergic drugs were identified, of which 125 were included in the scale. We identified 45 (36.0%) drugs with a score of 3, 13 (10.4%) with a score of 2, and 67 (53.6%) with a score of 1. Drugs for the nervous and respiratory systems were the most frequent in the scale. Eight drugs were not present in previous scales. Conclusion The methodology used for development of the Brazilian anticholinergic activity scale is simple, systematized, reproducible and easy to update. The scale allows evaluating the impact of anticholinergic burden on health outcomes, and can potentially contribute to pharmacoepidemiology research, leading to more accurate measurements of anticholinergic activity.

RESUMO Objetivo Desenvolver uma escala de atividade anticolinérgica abrangendo os medicamentos utilizados no Brasil, para aplicação no cuidado em saúde e em pesquisas farmacoepidemiológicas. Métodos Realizou-se revisão da literatura no PubMed/MEDLINE®para identificação das escalas de mensuração da atividade anticolinérgica. Iniciou-se a escala com os fármacos anticolinérgicos e aqueles com atividade anticolinérgica conhecida, relacionados segundo o nível 4, subgrupo químico, na classificação da Anatomical Therapeutic Chemical . Incluíram-se os fármacos com atividade anticolinérgica alta, descritos na lista de medicamentos potencialmente inapropriados para idosos, segundo o 2015 American Geriatrics Society Beers Criteria . Adicionaram-se os medicamentos que constavam em, no mínimo, duas escalas anticolinérgicas. Em seguida, verificaram-se os medicamentos constantes nas etapas anteriores comercializados no Brasil. A magnitude da atividade anticolinérgica foi estabelecida em escores com os valores de 1, 2 e 3. Resultados Foram identificados 273 medicamentos com atividade anticolinérgica, sendo 125 incluídos na escala. Destes, 45 (36,0%) receberam pontuação 3, 13 (10,4%) tiveram pontuação 2, e 67 (53,6%) pontuação 1. A maioria dos medicamentos da escala atuava nos sistemas nervoso e respiratório. Oito fármacos não constavam em escalas prévias. Conclusão A metodologia de desenvolvimento da escala brasileira de atividade anticolinérgica é simples, sistematizada, reprodutível e de fácil atualização. A escala permite avaliar o impacto da carga anticolinérgica nos resultados em saúde e pode contribuir com as pesquisas farmacoepidemiológicas, propiciando mensurações mais exatas da atividade anticolinérgica.

Use of onabotulinum toxin A in patients with idiopathic overactive bladder and a lack of efficacy, intolerance or contraindication with anticholinergics / Uso de la onabotulinumtoxina A en pacientes con vejiga hiperactiva idiopática con falta de eficacia, intolerancia o contraindicación para los anticolinérgicos

Objective To assess the efficacy and safety of onabotulinum toxin A in patients with idiopathic overactive bladder inadequately managed with anticholinergics. Materials and Methods A prospective, open-label, single centre, and interventional study was conducted, from 2008 to 2013, on consecutive patients with idiophatic overactive bladder that showed lack of efficacy or intolerance to anticholinergic agents. Results The study included 73 female patients aged 58.9 ± 12.9 years. A dose of 100 and 200 units of toxin were administered in 89 and 5 cases, respectively. Nineteen patients received a second injection, 8 patients received 3, and one patient was treated 4 times. Clinically, it was observed that 98% patients had urge urinary incontinence at baseline, as compared with 42% under treatment. Similar results were obtained regarding the number of pads used per day, from 2.8 at baseline to 0.5 after treatment as regards the urodynamic parameters, the first desire to void volume improved from 97 ± 63 mL to 139 ± 81 mL. Similar results were obtained as regards cystometric capacity and the volume of the first involuntary detrusor contraction. One patient had a positive urine culture resolved using a conventional oral antibiotic regimen. Intermittent catheterisation was required in 5 patients during the first week. Conclusions Onabotulinum toxin A injections significantly improved, not only the clinical symptoms, but also the urodynamic parameters in patients with idiopathic overactive bladder inadequately managed with anticholinergic drugs. This is a simple technique with minimal adverse effects and generally well tolerated.

Objetivo Evaluar la eficacia y seguridad de onabotulinumtoxina A en pacientes con vejiga hiperactiva idiopática con falta de eficacia, intolerancia o contraindicación para el uso de anticolinérgicos. Material and Métodos Se realizó un estudio observacional, prospectivo, abierto en un único centro entre 2008 y 2013, en pacientes consecutivos con vejiga hiperactiva idiopática con falta de eficacia o intolerancia a los anticolinérgicos. Resultados Las 73 pacientes fueron mujeres con edad de 58,9 ± 12,9 años. Se administraron 100 y 200 unidades de toxina en 89 y 5 casos, respectivamente. Diecinueve pacientes recibieron una segunda inyección, 8 pacientes 3 inyecciones y un paciente 4. Clínicamente se observó que inicialmente un 98% de las pacientes tenían incontinencia urinaria de urgencia y después del tratamiento solo un 42%; el número de absorbentes por día, pasó de 2,8 al inicio a 0,5 después del tratamiento. Respecto a los parámetros urodinámicos, el volumen del primer deseo miccional mejoró de 97 ± 63 mL a 139 ± 81 mL. Se obtuvieron resultados similares en capacidad cistométrica y el volumen de la primera contracción involuntaria del detrusor. Una paciente tuvo urocultivo positivo, resolviéndose con un régimen de antibiótico oral convencional. El cateterismo intermitente fue necesario en 5 pacientes durante la primera semana. Conclusiones Las inyecciones de onabotulinumtoxina A mejoraron significativamente no solo los síntomas clínicos, sino también los parámetros urodinámicos en pacientes con vejiga hiperactiva idiopática inadecuadamente manejados con anticolinérgicos. Esta es una técnica simple, con efectos adversos mínimos y generalmente bien tolerada.