Botulinum Toxin Type A Injection in the Treatment of Postparetic Facial Synkinesis: An Integrative Review.

ABSTRACT: This study aimed to review the recent literature about botulinum toxin type A treatment patterns, including muscle targets, doses, duration of effect, adverse effects, and clinical outcomes in patients with postparetic synkinesis. A bibliographic research of studies published in the last 10 yrs was carried out on PubMed database, using the medical subject heading terms: botulinum toxin and synkinesis. English-language cohort studies or randomized controlled trials about botulinum toxin type A treatment on patients with postparetic synkinesis were eligible for inclusion. Ten studies met the inclusion criteria, seven prospective studies, two retrospective studies, and one randomized controlled trial, involving 23-99 patients. The target facial muscles included frontalis, corrugator supercilli, orbicularis oculi, levator labii superioris, zygomaticus major, orbicularis oris, risorius, buccinator, depressor anguli oris, depressor labii inferioris, mentalis, and platysma. The dose of onabotulinumtoxinA administered per injection site ranged between 0.5 and 10 U. Adverse effects were rare and temporary. The mean duration of onabotulinumtoxinA effect ranges from 66 days to 4 mos. There was a statistically significant improvement in posttreatment evaluation, both in objective and subjective assessments. There is scientific evidence of the benefit of botulinum toxin type A treatment for postparetic synkinesis, but there is lack of standardized treatment protocols.

Facemasks during aerobic exercise: Implications for cardiac rehabilitation programs during the Covid-19 pandemic.

INTRODUCTION AND OBJECTIVES: During the COVID-19 pandemic, among the safety measures adopted, use of facemasks during exercise training sessions in cardiac rehabilitation programs raised concerns regarding possible detrimental effects on exercise capacity. Our study examined the cardiorespiratory impact of wearing two types of the most common facemasks during treadmill aerobic training. METHODS: Twelve healthy health professionals completed three trials of a symptom-limited Bruce treadmill protocol: Without a mask, with a surgical mask and with a respirator. Perceived exertion and dyspnea were evaluated with the Borg Scale of Perceived Exertion and the Borg Dyspnea Scale, respectively. Blood pressure, heart rate and arterial oxygen saturation (SpO2) were measured at each 3-minute stage. RESULTS: Using a surgical mask or a respirator resulted in a shorter duration of exercise testing. At peak capacity, using a respirator resulted in higher levels of dyspnea and perceived exertion compared to not wearing a facemask. A significant drop in SpO2 was present at the end of exercise testing only when using a respirator. There were no differences in either chronotropic or blood pressure responses between testing conditions. CONCLUSIONS: Professionals involved in cardiac rehabilitation should be aware of the cardiorespiratory impact of facemasks. Future studies should assess whether exposure to these conditions may impact on the overall results of contemporary cardiac rehabilitation programs.

Facemasks during aerobic exercise: Implications for cardiac rehabilitation programs during the Covid-19 pandemic.

INTRODUCTION AND OBJECTIVES: During the COVID-19 pandemic, among the safety measures adopted, use of facemasks during exercise training sessions in cardiac rehabilitation programs raised concerns regarding possible detrimental effects on exercise capacity. Our study examined the cardiorespiratory impact of wearing two types of the most common facemasks during treadmill aerobic training. METHODS: Twelve healthy health professionals completed three trials of a symptom-limited Bruce treadmill protocol: Without a mask, with a surgical mask and with a respirator. Perceived exertion and dyspnea were evaluated with the Borg Scale of Perceived Exertion and the Borg Dyspnea Scale, respectively. Blood pressure, heart rate and arterial oxygen saturation (SpO2) were measured at each 3-minute stage. RESULTS: Using a surgical mask or a respirator resulted in a shorter duration of exercise testing. At peak capacity, using a respirator resulted in higher levels of dyspnea and perceived exertion compared to not wearing a facemask. A significant drop in SpO2 was present at the end of exercise testing only when using a respirator. There were no differences in either chronotropic or blood pressure responses between testing conditions. CONCLUSIONS: Professionals involved in cardiac rehabilitation should be aware of the cardiorespiratory impact of facemasks. Future studies should assess whether exposure to these conditions may impact on the overall results of contemporary cardiac rehabilitation programs.

INTRODUÇÃO E OBJETIVOS: Durante a pandemia Covid-19 a utilização de máscaras faciais, incluindo durante o exercício terapêutico, faz parte das medidas de segurança adotadas. Este facto originou preocupação a nível das unidades de reabilitação cardíaca, uma vez que as máscaras faciais podem promover efeitos deletérios na capacidade de exercício. Este estudo avaliou o impacto da utilização das máscaras faciais durante o treino aeróbio em passadeira. MÉTODOS: Doze profissionais de saúde saudáveis completaram três provas em passadeira de acordo com o protocolo de Bruce: sem máscara, com máscara cirúrgica e com um respirador. A perceção de esforço e dispneia foi avaliada com a Escala de Perceção de Esforço de Borg e com a Escala de Dispneia de Borg, respetivamente. A pressão arterial, frequência cardíaca e saturação arterial de oxigénio (SpO2) foram registadas em cada estadio do protocolo. RESULTADOS: A utilização de máscara facial resultou numa menor duração da prova e, em determinados momentos, níveis de perceção de dispneia e de esforço mais elevados. Verificou-se uma descida significativa da SpO2 no final da prova com respirador. Não se verificaram diferenças na resposta cronotrópica ou da pressão arterial entre as diferentes condições de prova. CONCLUSÕES: Os profissionais envolvidos na reabilitação cardíaca devem reconhecer os impactos cardiorrespiratórios provocados pela utilização da máscara facial. São necessários mais estudos para determinar se a exposição a estas condições de treino pode ter impacto nos resultados dos programas de reabilitação cardíaca.

Emergency department interventions for adult patients with low back pain: a systematic review of randomised controlled trials.

BACKGROUND: Most low back pain trials have limited applicability to the emergency department (ED) because they provide treatment and measure outcomes after discharge from the ED. We investigated the efficacy and safety of pharmacological and non-pharmacological interventions delivered in the ED to patients with non-specific low back pain and/or sciatica on patient-relevant outcomes measured during the emergency visit. METHODS: Literature searches were performed in MEDLINE, EMBASE and CINAHL from inception to week 1 February 2020. We included all randomised controlled trials investigating adult patients (≥18 years) with non-specific low back pain and/or sciatica presenting to ED. The primary outcome of interest was pain intensity. Two reviewers independently screened the full texts, extracted the data and assessed risk of bias of each trial using the Physiotherapy Evidence Database (PEDro) scale. The overall quality of evidence, or certainty, provided by a set of trials evaluating the same treatment was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, which considers imprecision, inconsistency, indirectness and bias in the evidence. RESULTS: Fifteen trials (1802 participants) were included with 12 of 15 at low risk of bias (ie, PEDro score >6). Based on results from individual trials and moderate quality evidence, ketoprofen gel was more effective than placebo for non-specific low back pain at 30 min (mean difference (MD) -15.0, 95% confidence interval (CI) -21.0 to -9.0). For those with sciatica (moderate quality evidence), intravenous paracetamol (acetaminophen) (MD -15.7, 95% CI -19.8 to -11.6) and intravenous morphine (MD -11.4, 95% CI -21.6 to -1.2) were both superior to placebo at 30 min. Based on moderate quality of evidence, corticosteroids showed no benefits against placebo at emergency discharge for non-specific low back pain (MD 9.0, 95% CI -0.71 to 18.7) or sciatica (MD -6.8, 95% CI -24.2 to 10.6). There were conflicting results from trials comparing different pharmacological options (moderate quality evidence) or investigating non-pharmacological treatments (low quality evidence). CONCLUSION: Ketoprofen gel for non-specific low back pain and intravenous paracetamol or morphine for sciatica were superior to placebo, whereas corticosteroids were ineffective for both conditions. There was conflicting evidence for comparisons of different pharmacological options and those involving non-pharmacological treatments. Additional trials measuring important patient-related outcomes to EDs are needed.

How does completing an Ironman triathlon affect postural control? / Como a conclusão de um triatlo Ironman afeta o controle postural?

Abstract Despite the increase in the number of Ironman competitions worldwide, thousands of athletes have been joining Ironman experience but only a few studies have been published on the effects of this competition on postural control. This study aims to investigate the ability to maintain a static posture in three different positions before and after an Ironman competition and the blood glucose level behavior. Forty-nine volunteers underwent balance evaluation using the force plate VSRTM Sport. The area of the center of gravity (ACOG) was assessed pre- and post-competition in the bipodal, unipodal, and tandem postures. Glucose levels were also assessed concurrently. The ACOG findings showed a significant post-competition increase in the three postures assessed, with no significant interaction between the postures. The glucose test showed an increase in the post-competition glycemic levels. The findings showed reduced postural control, suggesting that prolonged exercise stimulation could lead to a disturbance in postural control.

Resumo Apesar do aumento no número de competições Ironman em todo o mundo e milhares de atletas se juntarem à experiência Ironman, apenas alguns estudos foram publicados sobre os efeitos dessa competição no controle postural. Este estudo tem como objetivo investigar a capacidade de manter uma postura estática em três posições diferentes antes e depois de uma competição de Ironman e o comportamento do nível de glicose no sangue. Quarenta e nove voluntários foram submetidos à avaliação do equilíbrio usando uma plataforma de força, VSRTM Sport. A área do centro de gravidade (ACOG) foi avaliada pré e pós-competição nas posturas bipodal, unipodal e tandem. Os níveis de glicose também foram avaliados simultaneamente. Os achados do ACOG mostraram um aumento significativo pós-competição nas três posturas avaliadas, sem interação significativa entre as posturas. O teste de glicose mostrou aumento nos níveis glicêmicos pós-competição. Os resultados mostraram decréscimo no controle postural, sugerindo que a estimulação prolongada ao exercício poderia levar a um distúrbio no controle postural.

Progression of aerobic exercise intensity in a cardiac rehabilitation program.

INTRODUCTION AND OBJECTIVES: To describe the progression of aerobic exercise intensity in patients on a cardiac rehabilitation (CR) program. METHODS: We conducted a retrospective analysis of a random sample of patients referred for CR after acute coronary syndrome between 2008 and 2016. The weekly peak exercise intensity achieved during aerobic exercise was estimated by treadmill speed and grade at peak effort and the corresponding perception of effort was assessed using the Borg scale. Initial exercise intensity was prescribed as 60-80% of reserve heart rate plus resting heart rate, and was modified according to perceived exertion. Peak heart rate/intensity and perceived exertion index were used as variables to characterize the response to the intensity achieved. Variables were compared at different time points: T1 (1st week), T2 (4th week) and T3 (8th week). RESULTS: Of the total of 868, 238 patients were randomly selected. At peak heart rate during the session, exercise intensity (in metabolic equivalents) was: T1: 7.2±2.0, T2: 9.0±2.2, and T3: 9.4±2.2 (p<0.01). The peak heart rate/intensity index was T1: 16.8±5.4, T2: 13.4±3.6 and T3: 13.1±3.8 (p<0.01) and the perceived exertion index was T1: 1.8±0.6; T2: 1.4±0.5; T3: 1.4±0.5 (p<0.01). CONCLUSIONS: Increasing exercise intensity during CR, associated with lower perception of effort and lower heart rate necessary to achieve such intensity, leads to significant improvement in functional capacity.

Tartamudez neurógena: revisión de la bibliografía / Neurogenic stuttering: a review of the literature

Introducción. La tartamudez neurógena es un trastorno del ritmo de habla de origen neurológico en el cual el paciente sabe perfectamente lo que quiere decir, pero es incapaz de articularlo a causa de la prolongación, el cese o la repetición involuntaria de un sonido. Objetivo. Reunir nuevos datos referentes a la epidemiología, la fisiopatología, el diagnóstico, la evaluación y el tratamiento de la tartamudez neurógena. Desarrollo. Se llevó a cabo una revisión de todos los artículos publicados en PubMed y Scopus entre enero de 2000 y septiembre de 2016. Se examinaron 33 publicaciones. La tartamudez neurógena es una entidad poco frecuente cuya incidencia epidemiológica no se ha definido completamente. Aparece en el marco de diversas enfermedades neurológicas y ligada a distintos lugares del sistema nervioso. A pesar de los avances recientes en el conocimiento del mecanismo subyacente, aún no ha sido posible determinar un único mecanismo fisiopatológico de este trastorno. El diagnóstico diferencial es complejo y requiere un buen conocimiento de otros trastornos del lenguaje. El tratamiento se basa actualmente en terapias logopédicas específicas. Conclusión. La tartamudez neurógena es un trastorno complejo que no se conoce con detalle. Nuevos estudios ayudarían a esclarecer los mecanismos fisiopatológicos que se ocultan tras ella y abrirían la puerta a nuevos métodos terapéuticos (AU)

Introduction. Neurogenic stuttering is a disorder of neurologic origin in the rhythm of speech during which the patient knows exactly what he wants to say but is unable to because of an involuntary prolongation, cessation or repetition of a sound. Aim. To assemble new insights regarding the epidemiology, pathophysiology, diagnosis, evaluation and treatment of neurogenic stuttering. Development. A review of all PubMed and Scopus published articles between January 2000 and September 2016 was performed. Thirty-three publications were analyzed. Neurogenic stuttering is a rare entity whose epidemiological incidence is yet not fully established. It is correlated with several neurological diseases and with several possible localizations within the nervous system. Notwithstanding the recent advances in the understanding of the underlying mechanism, it is not yet possible to establish a single pathophysiological mechanism of neurogenic stuttering. The differential diagnosis is complex and requires the detailed knowledge of other language disorders. The treatment is currently based on specific speech language therapy strategies. Conclusion. Neurogenic stuttering is a complex disorder which is not fully understood. Additional studies might help to better explain the underlying pathophysiological mechanism and to open doors to novel therapeutic methods (AU)

Botulinum toxin improves pain in chronic anal fissure.

HIGHLIGHTS: Chronic anal fissure is a common condition associated with intense pain.Local botulinum toxin injection is a valid option in its management.Pain intensity scores significantly improved after BoNT injection.Side effects were rare and mild.Our results support the inclusion of BoNT in the management algorithm of chronic anal fissure. INTRODUCTION: Chronic anal fissure is a common condition associated with intense pain. Local botulinum toxin injection is a valid option in its management. The purpose of this study was to evaluate the efficacy of botulinum toxin on pain relief in chronic anal fissure patients. METHODS: We conducted a retrospective cohort study, involving 81 consecutive patients referred to a chronic pain management unit due to a chronic anal fissure for treatment with botulinum toxin, during a 4 year period. Data were collected from hospital records regarding pre-treatment and post-treatment pain (numeric rating scale), side effects, need for botulinum toxin reinjection and need for surgical treatment. We used standard statistical methods for inter (t-test and qui2) and intra-group (paired sample t-test) comparisons, according to variables distribution. RESULTS: Pain intensity rest score significantly improved after BoNT injection [variation: -4.2 ± 2.9 (p < 0.001)], as did pain post-defecation score [variation: -5.1 ± 3.0 (p < 0.001)]. 8.6% needed botulinum toxin reinjection and 23.5% were submitted to surgery. Side effects were reported in 8.6%. DISCUSSION: The efficacy of botulinum toxin use on pain reduction along with its non-permanent and minor side effects support its role in the resolution of chronic anal fissure. However, treatment failure in the long term is still significant. CONCLUSION: Botulinum toxin is effective on pain relief in patients with chronic anal fissure, which supports its inclusion in the management algorithm of this condition.

Linfoma extranodal: aspectos por imagem dos principais sítios acometidos

"O linfoma, é uma doença relativamente comum, que pode acometer todas as faixa etárias, com especial predileção para idades mais avançadas. Assim como diversas outras condições, a exemplo da tuberculose, o linfoma é conhecido como o grande “mimetizador” e, frente ao surgimento de lesões sólidas em qualquer parte do corpo, esta hipótese deve sempre estar presente dentre os diagnósticos diferenciais"

Lymphoma is a relatively common disease, which can affect all age groups, with special predilection for more advanced ages. Like many other conditions, such as tuberculosis, lymphoma is known as the great "mimic" and, in the face of the appearance of solid lesions in any part of the body, this hypothesis must always be present among the differential diagnoses

Osiculoplastia con prótesis de titanio / Ossiculoplasty with titanium prosthesis

Objetivos: Revisión de los pacientes sometidos a una reconstrucción de la cadena osicular con prótesis de titanio durante un período de ocho años en nuestro Servicio. Métodos: Hemos revisado retrospectivamente las osiculoplastias realizadas durante un período de ocho años en un hospital público de distrito. La información se ha obtenido mediante consulta del proceso clínico. Entre 1999 y 2008, se realizaran 124 osiculoplastias usando la prótesis de titanio de Kurz® en casos de otitis media crónica (78 reconstrucciones parciales y 46 reconstrucciones totales de la cadena osicular). Se incluyeron en el análisis las reconstrucciones en un solo tiempo y dos tiempos quirúrgicos, así como las cirugías de revisión. Todos los pacientes tuvieron un seguimiento mínimo posquirúrgico de 6 meses (un promedio de 3 años y 4 meses). Se realizaron comparaciones del promedio de tonos puros óseo y aéreo pre y posquirúrgico. Se midieron los porcentajes de la brecha aérea-ósea y los casos de extrusión de la prótesis. Utilizamos como criterio de éxito la brecha aérea-ósea inferior o igual a 20 dB. Resultados: Se lograron osiculoplastias con éxito en el 73,1% de las reconstrucciones osiculares parciales y en el 30,4% de las reconstrucciones osiculares totales (p<0,05). El promedio de la brecha aérea-ósea posquirúrgica fue de 16 dB en las reconstrucciones parciales y de 26,7 dB en las reconstrucciones totales (p<0,05). Se produjeron cinco casos de extrusión de la prótesis. Conclusiones: La mayoría de las osiculoplastias mejoró satisfactoriamente la audición. No se produjo diferencia alguna en los resultados audiométricos de la reconstrucción de la cadena osicular parcial entre uno o dos tiempos quirúrgicos, aunque se obtuvieron mejores resultados audiométricos en los casos de reconstrucción de la cadena osicular total en dos tiempos quirúrgicos (AU)

Objectives: The goal of this study was to make a review of the patients who underwent ossicular chain reconstruction with titanium prosthesis during an eight-year period in our Department. Methods: A retrospective study was made on the ossiculoplasty cases over a period of eight years in a Public Hospital District. The information was extracted by clinical process consultation. Between 1999 and 2008, 124 ossiculoplasties using Kurz® titanium prosthesis for chronic otitis media were performed (78 partial ossicular chain reconstructions and 46 total ossicular chain reconstructions). The single stage, staged and revision ossicular chain reconstruction were included in the analysis. All patients had a minimum of 6 month postoperative follow up (mean 3 years and 4 months). Comparisons of preoperative and postoperative pure tone averages were performed. Air-bone gap and implant extrusion rates were measured. The success of the reconstruction was defined as a postoperative air-bone gap (ABG) of 20 dB or better. Results: Successful ossiculoplasty was obtained in 73,1% of partial ossicular reconstruction reconstructions and 30,4% of total ossicular chain reconstructions (P<0.05). The postoperative pure-tone average air-bone gaps was 16 dB in partial reconstructions and 26,7 dB in total reconstructions (P<0.05). There were five cases of prosthesis extrusion. Conclusions: The majority of the ossiculoplasties improved satisfactorily the hearing status. There was no difference in hearing results in one-stage and two-stage partial ossicular chain reconstruction, but there were better hearing results in the cases of two-stage total ossicular chain reconstruction (AU)

[Ossiculoplasty with titanium prosthesis]. / Osiculoplastia con prótesis de titanio.

OBJECTIVES: The goal of this study was to make a review of the patients who underwent ossicular chain reconstruction with titanium prosthesis during an eight-year period in our Department. METHODS: A retrospective study was made on the ossiculoplasty cases over a period of eight years in a Public Hospital District. The information was extracted by clinical process consultation. Between 1999 and 2008, 124 ossiculoplasties using Kurz(®) titanium prosthesis for chronic otitis media were performed (78 partial ossicular chain reconstructions and 46 total ossicular chain reconstructions). The single stage, staged and revision ossicular chain reconstruction were included in the analysis. All patients had a minimum of 6 month postoperative follow up (mean 3 years and 4 months). Comparisons of preoperative and postoperative pure tone averages were performed. Air-bone gap and implant extrusion rates were measured. The success of the reconstruction was defined as a postoperative air-bone gap (ABG) of 20 dB or better. RESULTS: Successful ossiculoplasty was obtained in 73,1% of partial ossicular reconstruction reconstructions and 30,4% of total ossicular chain reconstructions (P<.05). The postoperative pure-tone average air-bone gaps was 16 dB in partial reconstructions and 26,7 dB in total reconstructions (P<.05). There were five cases of prosthesis extrusion. CONCLUSIONS: The majority of the ossiculoplasties improved satisfactorily the hearing status. There was no difference in hearing results in one-stage and two-stage partial ossicular chain reconstruction, but there were better hearing results in the cases of two-stage total ossicular chain reconstruction.