Evaluation of the classifications of severity in acute respiratory distress syndrome in childhood by the Berlin Consensus and the Pediatric Acute Lung Injury Consensus Conference / Avaliação das classificações de gravidade na síndrome do desconforto respiratório agudo na infância pelo Consenso de Berlim e pelo Pediatric Acute Lung Injury Consensus Conference

ABSTRACT Objective To compare two methods for defining and classifying the severity of pediatric acute respiratory distress syndrome: the Berlin classification, which uses the relationship between the partial pressure of oxygen and the fraction of inspired oxygen, and the classification of the Pediatric Acute Lung Injury Consensus Conference, which uses the oxygenation index. Methods This was a prospective study of patients aged 0 - 18 years with a diagnosis of acute respiratory distress syndrome who were invasively mechanically ventilated and provided one to three arterial blood gas samples, totaling 140 valid measurements. These measures were evaluated for correlation using the Spearman test and agreement using the kappa coefficient between the two classifications, initially using the general population of the study and then subdividing it into patients with and without bronchospasm and those with and without the use of neuromuscular blockers. The effect of these two factors (bronchospasm and neuromuscular blocking agent) separately and together on both classifications was also assessed using two-way analysis of variance. Results In the general population, who were 54 patients aged 0 - 18 years a strong negative correlation was found by Spearman's test (ρ -0.91; p < 0.001), and strong agreement was found by the kappa coefficient (0.62; p < 0.001) in the comparison between Berlin and Pediatric Acute Lung Injury Consensus Conference. In the populations with and without bronchospasm and who did and did not use neuromuscular blockers, the correlation coefficients were similar to those of the general population, though among patients not using neuromuscular blockers, there was greater agreement between the classifications than for patients using neuromuscular blockers (kappa 0.67 versus 0.56, p < 0.001 for both). Neuromuscular blockers had a significant effect on the relationship between the partial pressure of oxygen and the fraction of inspired oxygen (analysis of variance; F: 12.9; p < 0.001) and the oxygenation index (analysis of variance; F: 8.3; p = 0.004). Conclusion There was a strong correlation and agreement between the two classifications in the general population and in the subgroups studied. Use of neuromuscular blockers had a significant effect on the severity of acute respiratory distress syndrome.

RESUMO Objetivo Comparar dois métodos para definição e classificação de gravidade na síndrome do desconforto respiratório agudo pediátrica: a classificação de Berlim, que utiliza a relação entre pressão parcial de oxigênio e fração inspirada de oxigênio e a classificação do Pediatric Acute Lung Injury Consensus Conference, que utiliza o índice de oxigenação. Métodos Estudo prospectivo com pacientes de 0 - 18 anos com diagnóstico de síndrome do desconforto respiratório agudo e ventilados mecanicamente de forma invasiva, que forneceram de uma a três amostras de gasometria arterial, totalizando 140 medidas válidas. Essas medidas foram avaliadas quanto à correlação pelo teste de Spearman e à concordância pelo coeficiente kappa entre as duas classificações, inicialmente usando a população geral do estudo e, depois, subdividindo-a em pacientes com e sem broncoespasmo e com e sem o uso do bloqueador neuromuscular. Também foi verificado o efeito desses dois fatores (broncoespasmo e bloqueador neuromuscular) de forma separada e conjunta sobre ambas as classificações por meio da análise de variância para dois fatores. Resultados Na população geral, composta de 54 pacientes com idades de 0 - 18 anos, foi encontrada forte correlação negativa pelo teste de Spearman (ρ -0,91; p < 0,001) e forte concordância pelo coeficiente kappa (0,62; p < 0,001) na comparação entre Berlim e Pediatric Acute Lung Injury Consensus Conference. Nas populações com e sem broncoespasmo e com e sem o uso do bloqueador neuromuscular, os coeficientes de correlação mantiveram valores semelhantes aos da população geral. Entretanto, para os pacientes sem uso do bloqueador neuromuscular, houve maior concordância entre as classificações em relação aos pacientes com uso do bloqueador neuromuscular (kappa 0,67 versus 0,56 com p < 0,001 em ambos). Acrescenta-se ainda o efeito significativo do uso do bloqueador neuromuscular sobre a relação entre pressão parcial de oxigênio e fração inspirada de oxigênio (análise de variância; F: 12,9; p < 0,001) e o índice de oxigenação (análise de variância; F: 8,3; p = 0,004). Conclusão Houve forte correlação e concordância entre as duas classificações na população geral e nos subgrupos estudados, entretanto, há efeito significativo do uso do bloqueador neuromuscular sobre as classificações de gravidade da síndrome do desconforto respiratório agudo.

Profile of patients with essential blepharospasm and hemifacial spasm in the two largest ophthalmology reference centers in Brazil / Perfil dos pacientes com blefaroespasmo essencial e espasmo hemifacial nos dois maiores centros de referência em oftalmologia no Brasil

ABSTRACT Purpose: Information is scarce regarding the comprehensive profile of patients with essential blepharospasm and hemifacial spasm in Brazil. The present study aimed to assess the clinical features of patients with these conditions, followed up in two reference centers in Brazil. Methods: The study included patients with essential blepharospasm and hemifacial spasm, followed up at the Departments of Ophthalmology at Universidade Federal de São Paulo and Universidade de São Paulo. Apart from demographic and clinical features, past stressful events related to the first symptoms (triggering event), aggravating factors, sensory tricks, and other ameliorating factors for the eyelid spasms were assessed. Results: A total of 102 patients were included in this study. Most patients were female (67.7%). Essential blepharospasm was the most frequent movement disorder [51/102 patients (50%)], followed by hemifacial spasm (45%) and Meige's syndrome (5%). In 63.5% of the patients, the onset of the disorder was associated with a past stressful event. Ameliorating factors were reported by 76.5% of patients; 47% of patients reported sensory tricks. In addition, 87% of the patients reported the presence of an aggravating factor for the spasms; stress (51%) was the most frequent. Conclusion: Our study provides information regarding the clinical features of patients treated in the two largest ophthalmology reference centers in Brazil.

RESUMO Objetivo: Há poucos dados sobre o perfil de pacientes com blefaroespasmo essencial e espasmo hemifacial no Brasil. O objetivo deste estudo é avaliar de forma mais abrangente as características clínicas dos pacientes portadores dessas doenças acompanhados em dois centros de referência em oftalmologia no Brasil. Métodos: Pacientes com blefaroespasmo essencial e espasmo hemifacial, acompanhados nos Departamentos de Oftalmologia da Universidade Federal de São Paulo e da Universidade de São Paulo foram incluídos neste estudo. Além dos dados clínicos e demográficos, foram avaliados também a presença de eventos estressantes relacionados ao início dos sintomas (evento desencadeante), fatores agravantes, truques sensoriais, e outros fatores de melhora. Resultados: Cento e dois pacientes foram incluídos no estudo. A maior parte dos pacientes era do sexo feminino (67,7%). Blefaroespasmo essencial foi a condição mais frequente, observada em 51 (50%) dos pacientes. Espasmo hemifacial correspondia a 45% dos casos, enquanto 5% dos pacientes apresentavam a Síndrome de Meige. 63,5% dos pacientes associaram o início dos sintomas com um evento estressante prévio. 76,5% dos pacientes relataram fatores de melhora para os espasmos; 47% relataram truques sensoriais. Além disso, 87% dos pacientes relataram fatores de piora; estresse (51%) foi o mais frequente. Conclusão: Este estudo fornece informações a respeito das características clínicas dos pacientes com blefaroespasmo essencial e espasmo hemifacial acompanhados nos dois maiores centros de referência em oftalmologia do Brasil.

Facial phantom model: a low-cost and safe tool for teaching botulinum toxin application in neurology residencies / Modelo de manequim facial: uma ferramenta segura e de baixo custo para o ensino da aplicação de toxina botulínica nas residências em neurologia

Abstract Background The application of botulinum toxin (BoNT) in the treatment of blepharospasm and hemifacial spasm (HS) is a well-established practice. However, neurology residency programs often rely on real patients for training, which has limitations in terms of patient availability and skill acquisition. Objective Assess the efficacy of a new facial phantom model for acquiring motor skills in BoNT application. Methods An anthropomorphic facial phantom model was developed in collaboration with a medical training simulator start-up. A group of seven neurologists and one ophthalmologist with expertise in BoNT application evaluated the model using an adapted learning object review instrument (LORI). The instrument assessed aspects such as: content quality, alignment of learning objectives, feedback and adaptation, motivation, presentation design, and accessibility. Results The facial phantom model received high scores in the LORI evaluation, with the highest ratings given to alignment with learning objectives and motivation. The model also scored well in terms of accessibility, content quality, and presentation design. However, feedback and adaptation received a lower score due to the static nature of the model. Conclusion The facial phantom model shows promise as a valuable tool for teaching and developing competence in BoNT application for HS and blepharospasm. The model reduces the reliance on real patients for training, providing a broader and safer learning experience for neurology residents. It also provides a realistic learning experience and offers portability, cost-effectiveness, and ease of manufacturing for use in various medical training scenarios. It is an effective and accessible tool for teaching BoNT application.

Resumo Antecedentes A aplicação de toxina botulínica (TxB) no tratamento do blefaroespasmo e do espasmo hemifacial (EH) é uma prática bem estabelecida. No entanto, os programas de residência em neurologia frequentemente dependem de pacientes reais para treinamento, o que apresenta limitações em termos de disponibilidade de pacientes e aquisição de habilidades. Objetivo Avaliar a eficácia de um novo modelo de manequim facial para aquisição de habilidades motoras na aplicação de TxB. Métodos Foi desenvolvido um modelo antropomórfico de manequim facial em coloboração com uma empresa de simuladores de treinamento médico. Um grupo constituído por sete neurologistas e um oftalmologista com experiência em aplicação de TxB avaliou o modelo utilizando um instrumento adaptado de revisão de objeto de aprendizagem (LORI). O instrumento analisou aspectos como: qualidade do conteúdo, alinhamento dos objetivos de aprendizagem, feedback e adaptação, motivação, concepção da apresentação e acessibilidade. Resultados O modelo de manequim facial obteve pontuações altas na avaliação do LORI com os maiores escores em alinhamento com os objetivos de aprendizagem e motivação. O modelo também obteve boas pontuações em termos de acessibilidade, qualidade do conteúdo e concepção da apresentação. No entanto, o item feedback e adaptação recebeu uma pontuação média mais baixa, devido à natureza estática. Conclusão O modelo manequim facial mostra-se promissor como uma EH e blefaroespasmo. O modelo reduz a dependência de pacientes reais para treinamento portátil, de baixo custo e de fácil fabricação para uso em diversos cenários de treinamento, proporcionando uma experiência de aprendizagem mais ampla e segura para residentes de neurologia. Além disso, fornece uma experiência de aprendizagem realista e oferece portabilidade, economia e facilidade de fabricação para uso em vários cenários de treinamento médico. É uma ferramenta eficaz e acessível para o ensino da aplicação de TxB.

Intervención mediante imaginería motora tras una encefalopatía post-hipóxica. A propósito de un caso / Motor imagery intervention after hipoxic brain injury. A case study

Objetivos: valorar las diferencias pre y post intervención en la motricidad fina, funcionalidad de miembros superiores y control de espasmos a través de la imaginería motora en una persona que ha sufrido una encefalopatía post-hipoxia. Métodos: el paciente es un varón de 52 años que sufrió una encefalopatía post-hipoxia que cursó con una alteración de la respuesta motora en forma de espasmos incontrolados ante estímulos inesperados que provocaba una imposibilidad de manipulación o uso funcional de objetos. Se realizó una intervención a través de imaginería motora con el fin de reducir el número de espasmos y aumentar la funcionalidad de miembros superiores. Se estructuró en sesiones de 45 minutos, dos sesiones semanales durante tres meses. Se realizó una valoración a través de las escalas Motor Assessment Scale, Purdue Pegboard Test y Nine Hole Peg Test, además de una serie de tareas funcionales para medir el número de espasmos durante la ejecución de cada actividad. Conclusión: al finalizar la intervención se evidenció una mejoría tanto en motricidad fina como en funcionalidad de miembros superiores. Por lo tanto, la imaginería motora podría suponer una herramienta eficaz a la hora de abordar este tipo de clínica tan específica.(AU)

Objective: An intervention was designed and carried out to increase To assess pre- and post-intervention differences in fine motor skills, upper limb functionality and spasm control through motor imagery in a person who has suffered post-hypoxic encephalopathy. Methods: The patient is a 52-year-old male who has suffered post-hypoxic encephalopathy with an altered motor response in the form of uncontrolled spasms to unexpected stimuli that made it impossible to manipulate or functionally use objects. An intervention was carried out through motor imagery to reduce the number of spasms and increase the functionality of the upper limbs. It was structured in 45-minute sessions, twice a week for three months. An assessment was performed using the Motor Assessment Scale, Purdue Pegboard Test and Nine Hole Peg Test, as well as a series of functional tasks to measure the number of spasms during the execution of each activity. Conclusion: At the end of the intervention there was an improvement in both fine motor skills and upper limb function. Therefore, motor imagery could be an effective tool when dealing with this type of very specific clinical condition.(AU)

Fenótipos MINOCA - Um Desafio para o Manejo Específico do Paciente / MINOCA Phenotypes - A Challenge for Patient-Specific Management

Resumo O infarto do miocárdio com artérias coronárias não obstrutivas (MINOCA) é um fenômeno clínico intrigante e de prognóstico incerto, caracterizado pela evidência de infarto do miocárdio (IM) com artérias coronárias normais ou quase normais na angiografia1. Atualmente, não há diretrizes para o manejo e muitos pacientes recebem alta sem uma etiologia determinada, significando muitas vezes que o tratamento ideal é adiado.Relatamos três estudos de caso MINOCA com as principais causas fisiopatológicas cardíacas, particularmente epicárdicas, microvasculares e não isquêmicas, levando ao tratamento diferencial. Os pacientes apresentavam dor torácica aguda, aumento da troponina e nenhuma doença coronariana angiograficamente significativa.Neste estudo, analisamos a etiologia, diagnóstico clínico e tratamento da MINOCA em relação à literatura relevante.MINOCA é considerado um diagnóstico de trabalho dinâmico, incluindo distúrbios coronários, miocárdicos e não coronários. Estudos prospectivos e registros são necessários para melhorar o atendimento e o resultado do paciente.

Abstract Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a puzzling clinical phenomenon with an unclear prognosis, characterized by evidence of myocardial infarction (MI) with normal or near-normal coronary arteries on angiography1. Currently, there are no guidelines for management, and many patients are discharged without a determined etiology, often meaning that optimal treatment gets postponed.We report three MINOCA case studies with main pathophysiological cardiac causes, particularly epicardial, microvascular, and non-ischemic, prompting differential management. The patients presented with acute chest pain, troponin raise, and no angiographically significant coronary disease.In this study, we analyzed the etiology, clinical diagnosis, and treatment of MINOCA concerning the relevant literature.MINOCA is considered to be a dynamic working diagnosis, including coronary, myocardial, and non-coronary disorders. Prospective studies and registries are needed to improve patient care and outcome.

Efeito da nitroglicerina no espasmo e na oclusão da artéria radial em cateterismos transradiais realizados em mulheres / Effect of nitroglycerin on radial artery spasm and occlusion in transradial catheterizations performed in women

Introdução: O benefício do cateterismo transradial já foi confirmado em pacientes do sexo feminino. Mulheres submetidas a exames por cateterismo transradial apresentam desafios únicos. A ocorrência de espasmo e oclusão da artéria radial após o procedimento é maior em mulheres. Objetivamos avaliar o benefício da nitroglicerina na redução de espasmo e oclusão da artéria radial em mulheres submetidas a cateterismo transradial. Métodos: Estudo multicêntrico, prospectivo, randomizado 2x2 fatorial, duplo-cego. Participantes foram randomizados para nitroglicerina 500mcg ou placebo em dois momentos: após colocação do introdutor hemostático e antes da retirada. A avaliação de espasmo da artéria radial foi clínica, por meio de escala dor. A avaliação da oclusão da artéria radial foi realizada com Doppler, nas primeiras 12 horas. Resultados: Foram incluídos 2.040 pacientes, sendo 774 (37,5%) mulheres. A média de idade foi similar entre os sexos (62,2 anos versus 61,5 anos; p=0,27). A incidência de espasmo da artéria radial foi maior nas mulheres (21,2% versus 6,6%; p<0,01), bem como a incidência de oclusão da artéria radial (3,4% versus 1,8%; p=0,03). O uso da nitroglicerina no início do procedimento não reduziu a incidência de espasmo da artéria radial em mulheres quando comparado com o placebo (19,7% versus 22,6%; p=0,34), tampouco as taxas de oclusão da artéria radial (4,3% versus 2,5%; p=0,17). O uso da nitroglicerina ao fim do procedimento não reduziu a incidência de oclusão da artéria em mulheres (2,8% versus 3,9%; p=0,37). Conclusões: O espasmo e a oclusão da artéria radial são mais frequentes em mulheres submetidas a cateterismo transradial quando comparadas aos homens. O uso da nitroglicerina não apresenta efeito benéfico na redução dessas incidências.

Background: The benefit of transradial catheterization is well established in female patients. Women undergoing transradial catheterization exams present with unique challenges. The occurrence of radial artery spasm and occlusion after the procedure is higher in women. The objective of this study was to evaluate the benefit of nitroglycerin in reducing radial artery spasm and occlusion in women undergoing transradial catheterization. Methods: This was a 2x2 factorial randomized, multicenter, prospective, double-blinded study. Participants were randomized to nitroglycerin 500mcg or placebo at two time points: after placement of the hemostatic introducer and before its removal. The evaluation of the radial artery spasm was clinical, using a pain scale The evaluation of the radial artery occlusion was performed with Doppler, in the first 12 hours. Results: A total of 2,040 patients were included, of which 774 (37.5%) were female. Mean age was similar between sexes (62.2 years versus 61.5 years; p=0.27). The incidence of radial artery spasm was higher in women (21.2% versus 6.6%; p<0.01), as well as the incidence of radial artery occlusion (3.4% versus 1.8%; p=0.03). The use of nitroglycerin at the beginning of the procedure did not reduce the incidence of radial artery spasm in women when compared with placebo (19.7% versus 22.6%; p=0.34), nor did the rates of radial artery occlusion (4.3% versus 2.5%; p=0.17). The use of nitroglycerin at the end of the procedure did not reduce the incidence of artery occlusion in women (2.8% versus 3.9%; p=0.37). Conclusions: Radial artery spasm and occlusion are more frequent in women undergoing transradial catheterization when compared to men. The use of nitroglycerin does not have a beneficial effect in reducing these incidences.

Epiteliopatía en limpiaparabrisas en pacientes con blefaroespasmo o espasmo hemifacial / Lid wiper epitheliopathy in patients with blepharospasm and/or hemifacial spasm

Objetivo Evaluar la presencia de epiteliopatía en limpiaparabrisas en pacientes con blefaroespasmo o espasmo hemifacial antes del tratamiento habitual con toxina botulínica y 4 semanas después. Métodos Estudio prospectivo compuesto por 31 ojos de 20 pacientes con diagnóstico neurológico de espasmo hemifacial (9 ojos de 9 pacientes) y blefaroespasmo esencial (22 ojos de 11 pacientes). Se evaluaron antes y 4 semanas después de la infiltración con toxina botulínica diversos parámetros de superficie ocular con el cuestionario OSDI, test de Schirmer, tiempo de rotura lagrimal y tinciones de fluoresceína y verde de lisamina valoradas con el test de Oxford y el grado de afectación del limpiaparabrisas palpebral. Resultados El 100% de los pacientes presentaron afectación del limpiaparabrisas palpebral antes (30% grado leve y 70% moderado) y después del tratamiento con toxina (100% grado leve). El 75% de los pacientes presentaron un OSDI normal-leve antes del tratamiento; después del tratamiento fue del 80%. El tiempo de rotura lagrimal fue de 7,2±0,2 s antes y de 7,5±0,7 s después del tratamiento. El test de Schirmer fue de 11,4±5,5 y 12,5±5,5mm antes y después del tratamiento. El test de Oxford resultó patológico inicialmente en el 69,3% de los pacientes; tras 4 semanas solo fue patológico en el 54%. Conclusión La epiteliopatía en limpiaparabrisas está presente en el 100% de los pacientes con blefaroespasmo o espasmo hemifacial. El principal mecanismo fisiopatológico que la desencadena en estos pacientes es el aumento en el coeficiente de fricción, ya que el volumen y la estabilidad lagrimal son normales (AU)

Objective To evaluate the presence of wiper epitheliopathy in patients with blepharospasm and/or hemifacial spasm before and 4 weeks after routine treatment with botulinum toxin. Methods Prospective study comprising 31 eyes of 20 patients with neurological diagnosis of hemifacial spasm (9 eyes of 9 patients) and essential blepharospasm (22 eyes of 11 patients). Various ocular surface parameters were assessed before and 4 weeks after infiltration with botulinum toxin using the OSDI questionnaire, Schirmer's test, tear break-up time, fluorescein and lissamine green staining assessed with the Oxford test and the degree of involvement of the palpebral wiper. Results 100% of the patients had palpebral wiper involvement before (30% mild and 70% moderate) and after toxin treatment (100% mild). 75% of patients had mild-normal OSDI before treatment, after treatment it was 80%. The tear break-up time was 7.2±0.2 sg before and 7.5±0.7 sg after treatment. Schirmer's test was 11.4±5.5 and 12.5±5.5mm before and after treatment. The Oxford test was initially pathological in 69.3% of patients, after 4 weeks it was pathological in only 54%. Conclusion Wiper epitheliopathy is present in 100% of patients with blepharospasm and/or hemifacial spasm. The main pathophysiological mechanism that triggers it in these patients is the increase in the coefficient of friction, as tear volume and stability are norma (AU)

Lid wiper epitheliopathy in patients with blepharospasm and/or hemifacial spasm.

OBJECTIVE: To evaluate the presence of wiper epitheliopathy in patients with blepharospasm and/or hemifacial spasm before and 4 weeks after routine treatment with botulinum toxin. METHODS: Prospective study comprising 31 eyes of 20 patients with neurological diagnosis of hemifacial spasm (9 eyes of 9 patients) and essential blepharospasm (22 eyes of 11 patients). Various ocular surface parameters were assessed before and 4 weeks after infiltration with botulinum toxin using the OSDI questionnaire, Schirmer's test, tear break-up time (BUT), fluorescein and lissamine green staining assessed with the Oxford test and the degree of involvement of the palpebral wiper. RESULTS: 100% of the patients had palpebral wiper involvement before (30% mild and 70% moderate) and after toxin treatment (100% mild). 75% of patients had mild-normal OSDI before treatment, after treatment it was 80%. The BUT was 7.2 ±â€¯0.2 sg before and 7.5 ±â€¯0.7 sg after treatment. Schirmer's test was 11.4 ±â€¯5.5 and 12.5 ±â€¯5.5 mm before and after treatment. The Oxford test was initially pathological in 69.3% of patients, after 4 weeks it was pathological in only 54%. CONCLUSION: Wiper epitheliopathy is present in 100% of patients with blepharospasm and/or hemifacial spasm. The main pathophysiological mechanism that triggers it in these patients is the increase in the coefficient of friction, as tear volume and stability are normal.

Trastornos paroxísticos del movimiento de carácter benigno y transitorio en la infancia / Transient benign paroxysmal movement disorders in infancy

Introducción: Los trastornos paroxísticos del movimiento de carácter benigno y transitorio en la infancia engloban un grupo de trastornos que aparecen durante el período neonatal y en los primeros años de vida, y que desaparecen espontáneamente sin dejar secuelas. El objetivo de este artículo fue revisar los principales trastornos paroxísticos del movimiento de carácter benigno y transitorio en la infancia, centrándose principalmente en el enfoque utilizado para su reconocimiento y diagnóstico. Desarrollo: En general, estos trastornos presentan entidades como temblores, mioclonías neonatales benignas del sueño, estremecimientos, mioclonías benignas de la infancia temprana, distonía transitoria idiopática del lactante, espasmo nutans, desviación tónica paroxística de la mirada hacia arriba en la infancia y tortícolis paroxística benigna. Conclusiones: Los trastornos paroxísticos del movimiento de carácter benigno y transitorio son episodios paroxísticos no epilépticos, cuyo diagnóstico es eminentemente clínico. Es crucial reconocer correctamente estas entidades para evitar los estados de ansiedad y la necesidad de realizar exámenes complementarios y tratamientos innecesarios.(AU)

Introduction: Transient benign paroxysmal movement disorders in infancy encompass a group of disorders that appear during the neonatal period and in the first years of life, and that spontaneously disappear without leaving consequences. This article aimed to review the main transient benign paroxysmal movement disorders in infancy, focusing on recognition and diagnostic approach. Development: Overall, it includes entities such as: jitteriness, benign neonatal sleep myoclonus, shuddering, benign myoclonus of early infancy, transient idiopathic dystonia in infancy, spasmus nutans, paroxysmal tonic upgaze of infancy, and benign paroxysmal torticollis. Conclusion: Transient benign paroxysmal movement disorders are non-epileptic paroxysmal episodes, and their diagnosis is eminently clinical. The correct recognition of these entities is crucial to avoid anxiety, unnecessary complementary exams, and treatments.(AU)

Riesgos y complicaciones durante la sedación para endoscopía diagnóstica del tubo digestivo sin enfermedad concomitante / Risks and complications during sedation for diagnostic endoscopy of the gastrointestinal tract without concomitant disease

Resumen: Durante la sedación en procedimientos endoscópicos del tubo digestivo alto y bajo, es frecuente que se susciten complicaciones ventilatorias y hemodinámicas. Se presenta una revisión de las estrategias para prevenir y tratar las complicaciones ventilatorias más frecuentes: espasmo laríngeo, apnea por fármacos anestésicos endovenosos y broncoespasmo. También se revisan las complicaciones hemodinámicas: reflejo vagal e hipotensión aguda. Se propone un algoritmo de manejo que sintetiza y esquematiza las medidas profilácticas y terapéuticas descritas en la literatura, ordenándolas de acuerdo a su prioridad y eficacia, permitiendo identificar con claridad el nivel de tratamiento necesario y la viabilidad del procedimiento endoscópico.

Abstract: During sedation in endoscopic procedures of the lower and upper digestive tract, it is common for ventilatory and hemodynamic complications to arise. This article presents a review of the strategies to treat and prevent the most common ventilatory complications: laryngeal spasm, apnea due to intravenous anesthetic drugs and bronchospasm. Hemodynamic complications are also reviewed: vagal reflex and acute hypotension. A management algorithm is proposed which synthesizes and schematizes the prophylactic and therapeutic measures described in the bibliography, ordering them by their priority and effectiveness, allowing to clearly identify the degree of treatment necessary and the viability of the endoscopic procedure.

Espasmo hemifacial: experiencia en un centro terciario

Resumen El espasmo hemifacial consiste en un infrecuente trastorno del movimiento que afecta a la musculatura inervada por el nervio facial, en especial la de la hemicara superior. Existen dos formas clínicas, una primaria en la que la causa subyacente está representada por un conflicto neurovascular, y una secundaria, en la que la alteración del nervio facial es producida por algún tipo de lesión ocupante de espacio. Resulta de especial interés para el otorrinolaringólogo conocer esta entidad y ser capaz de diferenciar ambas formas clínicas dado el diferente enfoque terapéutico que pueden requerir. Aportamos una visión general de esta patología repasando su epidemiología y fisiopatología, además, de nuestra experiencia en forma de una serie de cuatro casos que ilustran las variadas formas de presentación de esta entidad, así como los signos y síntomas de alarma que pueden ayudar a realizar un correcto diagnóstico y manejo.

Abstract Hemifacial spasm consists of an unfrecuent movement disorder involving facial muscles, especially those from the upper half of the face. Two different clinical presentations are described. Primary hemifacial spasm is defined by a neurovascular conflict, and secondary occurs when facial nerve is damaged by a space occupying lesion. It is of special interest for the otorhinolaryngologist to get to know about this condition and to be able to acknowledge its clinical presentations due to the different therapeutical approach that may be needed for each of them. We contribute with a general vision of this entity reviewing its epidemiology and patophysiology. Furthermore, we show our experience by sharing a four-case series which we believe to illustrate the different ways of presentation as well as the alarm signs and symptoms that may be helpful in order to accomplish an accurate diagnose and treatment.

Tétanos generalizado en un adolescente / Spread tetanus in an adolescent

Se presenta el caso clínico de un adolescente de 13 años de edad, con antecedentes de buena salud, quien solo recibió inmunización durante la etapa neonatal, el cual sufrió una herida causada por un clavo enmohecido en el dorso del pie derecho y acudió al Hospital Wete de Zanzíbar, Tanzania, por presentar dolores musculares, espasmos generalizados, risa sardónica y trismo, por lo cual se le diagnosticó tétanos generalizado. Se prescribió tratamiento médico con hidratación parenteral, toxina antitetánica, toxoide tetánico, antibióticos, sedantes y curación local de dicha herida. Luego de 2 meses de hospitalización el paciente tuvo una evolución satisfactoria.

The case report of a 13 years adolescent, with history of good health who just received immunization during the neonatal period is presented. He suffered from a wound caused by a rusty nail in the back of the right foot and he went to the Wete Hospital in Zanzibar, Tanzania, presenting muscular pains, spread spasms, sardonic laugh and trismus, reason why he was diagnosed spread tetanus. Treatment was prescribed with parenteral hydration, anti-tetanus toxin, anti-tetanus toxoide, antibiotics, sedative and total cure of this wound. After 2 months of hospitalization the patient had a favorable clinical course.

Descompresión Microvascular para el Tratamiento del Espasmo Hemifacial

Resumen El espasmo hemifacial se caracteriza por contracciones tonicoclónicas en los músculos inervados por el nervio facial, causado por la compresión del nervio facial por una arteria, generalmente la arteria cerebelosa anteroinferior o venas del ángulo pontocerebeloso. Suelen aparecer espontáneamente, debido a la tensión emocional, fatiga, y disminuyen durante el reposo. Se presenta entre los 13 a 77 años con una duración de los síntomas aproximadamente de ocho años. La inyección local de toxina botulínica puede ser efectiva en el tratamiento, y la descompresión microvascular está reservada para casos refractarios al tratamiento médico, con resolución completa entre el 85 al 93%. En este artículo, se resumen las principales características anatomo-clínicas, fisiopatológicas, y una descripción detallada de la descompresión microvascular como mejor opción terapéutica.

Abstract Hemifacial spasm is characterized by tonic-clonic contractions of the muscles innervated by the facial nerve. It is caused by compression of the facial nerve by a blood vessel, which usually is the anterior inferior cerebellar artery or the veins of the cerebello-pontine angle. It typically appears spontaneously, caused by emotional tension and fatigue, and it's reduced during rest. Likewise, it presents between the ages of 13 and 77 years, with a median duration of symptoms of eight years. Treatment with local botulinum toxin injection can be effective, and the Microvascular decompression is reserved for cases that are refractory to medical treatment, resulting in full spasm resolution in 85 to 93% of patients. This article summarizes the main anatomic-clinical and physio-pathological characteristics of hemifacial spasms. Additionally, a detailed description of microvascular decompression as the best therapeutic option is described in detail.

Comparison of one-catheter strategy versus conventional two-catheter strategy on the volume of radiological contrast and diagnostic coronary catheterization performance by transradial access: A systematic review and meta-analysis of randomized clinical trials.

Background: One-catheter strategy, based in multipurpose catheters, allows exploring both coronary arteries with a single catheter. This strategy could simplify coronary catheterization and reduce the volume of contrast administration, by reducing radial spasm. To date, observational studies showed greater benefits regarding contrast consumption and catheterization performance than controlled trials. The aim of this work is to perform the first systematic review and meta-analysis of randomized clinical trials (RCT) to adequately quantify the benefits of one-catheter strategy, with multipurpose catheters, over conventional two-catheter strategy on contrast consumption, and catheterization performance. Methods: A search in PubMed, CINALH, and CENTRAL databases was conducted to identify randomized trials comparing one-catheter and two-catheter strategies. The primary outcome was volume of iodinated contrast administrated. Secondary endpoints, evaluating coronary catheterization performance included: arterial spasm, fluoroscopy time, and procedural time. Results: Five RCT were included for the final analysis, with a total of 1599 patients (802 patients with one-catheter strategy and 797 patients with two-catheter strategy). One-catheter strategy required less administration of radiological contrast (difference in means [DiM] [95% confidence interval (CI)]; -3.831 mL [-6.165 mL to -1.496 mL], p = 0.001) as compared to two-catheter strategy. Furthermore, less radial spasm (odds ratio [95% CI], 0.484 [0.363 to 0.644], p < 0.001) and less procedural time (DiM [95% CI], -72.471 s [-99.694 s to -45.249 s], p < 0.001) were observed in one-catheter strategy. No differences on fluoroscopy time were observed. Conclusions: One-catheter strategy induces a minimal reduction on radiological contrast administration but improves coronary catheterization performance by reducing arterial spasm and procedural time as compared to conventional two-catheter strategy.

Antecedentes: La estrategia de catéter único permite explorar ambas coronarias con un solo catéter. Nuestro objetivo es realizar la primera revisión sistemática y meta-análisis de ensayos clínicos aleatorizados para cuantificar adecuadamente los beneficios de la estrategia de catéter único, con catéteres multipropósito, sobre la estrategia convencional de dos catéteres. Métodos: Se realizó una búsqueda en PubMed, CINALH y CENTRAL, identificando ensayos aleatorizados que compararan estrategias de un catéter y dos catéteres. El resultado primario fue volumen de contraste administrado. Los secundarios, que evaluaron el rendimiento del cateterismo, incluyeron: espasmo radial, tiempo de fluoroscopia y de procedimiento. Resultados: Se incluyeron cinco ensayos, totalizando 1,599 pacientes (802 con estrategia de un catéter y 797 con estrategia de dos catéteres). La estrategia de catéter único requirió menos contraste (diferencia-de-medias; −3.831 mL [−6.165 mL a −1.496 mL], p = 0.001), presentando menos espasmo radial (odds ratio, 0.484 [0.363 a 0.644], p < 0.001) y menos tiempo de procedimiento (diferencia-de-medias; −72.471 s [−99.694 s a −45.249 s], p < 0.001). No hubo diferencias en el tiempo de fluoroscopia. Conclusiones: La estrategia de catéter único induce una reducción mínima en la administración de contraste, pero mejora el rendimiento del cateterismo al reducir el espasmo radial y el tiempo de procedimiento en comparación con la estrategia convencional.

Comparison of one-catheter strategy versus conventional two-catheter strategy on the volume of radiological contrast and diagnostic coronary catheterization performance by transradial access: A systematic review and meta-analysis of randomized clinical trials / Comparación de la estrategia de catéter único versus la estrategia convencional de dos catéteres sobre el volumen de contraste radiológico y el rendimiento del cateterismo coronario diagnóstico por acceso transradial: una revisión sistemática y meta-análisis de ensayos clínicos aleatorizados

Abstract Background: One-catheter strategy, based in multipurpose catheters, allows exploring both coronary arteries with a single catheter. This strategy could simplify coronary catheterization and reduce the volume of contrast administration, by reducing radial spasm. To date, observational studies showed greater benefits regarding contrast consumption and catheterization performance than controlled trials. The aim of this work is to perform the first systematic review and meta-analysis of randomized clinical trials (RCT) to adequately quantify the benefits of one-catheter strategy, with multipurpose catheters, over conventional two-catheter strategy on contrast consumption, and catheterization performance. Methods: A search in PubMed, CINALH, and CENTRAL databases was conducted to identify randomized trials comparing one-catheter and two-catheter strategies. The primary outcome was volume of iodinated contrast administrated. Secondary endpoints, evaluating coronary catheterization performance included: arterial spasm, fluoroscopy time, and procedural time. Results: Five RCT were included for the final analysis, with a total of 1599 patients (802 patients with one-catheter strategy and 797 patients with two-catheter strategy). One-catheter strategy required less administration of radiological contrast (difference in means [DiM] [95% confidence interval (CI)]; −3.831 mL [−6.165 mL to −1.496 mL], p = 0.001) as compared to two-catheter strategy. Furthermore, less radial spasm (odds ratio [95% CI], 0.484 [0.363 to 0.644], p < 0.001) and less procedural time (DiM [95% CI], −72.471 s [−99.694 s to −45.249 s], p < 0.001) were observed in one-catheter strategy. No differences on fluoroscopy time were observed. Conclusions: One-catheter strategy induces a minimal reduction on radiological contrast administration but improves coronary catheterization performance by reducing arterial spasm and procedural time as compared to conventional two-catheter strategy.

Resumen Antecedentes: La estrategia de catéter único permite explorar ambas coronarias con un solo catéter. Nuestro objetivo es realizar la primera revisión sistemática y meta-análisis de ensayos clínicos aleatorizados para cuantificar adecuadamente los beneficios de la estrategia de catéter único, con catéteres multipropósito, sobre la estrategia convencional de dos catéteres. Métodos: Se realizó una búsqueda en PubMed, CINALH y CENTRAL, identificando ensayos aleatorizados que compararan estrategias de un catéter y dos catéteres. El resultado primario fue volumen de contraste administrado. Los secundarios, que evaluaron el rendimiento del cateterismo, incluyeron: espasmo radial, tiempo de fluoroscopia y de procedimiento. Resultados: Se incluyeron cinco ensayos, totalizando 1,599 pacientes (802 con estrategia de un catéter y 797 con estrategia de dos catéteres). La estrategia de catéter único requirió menos contraste (diferencia-de-medias; −3.831 mL [−6.165 mL a −1.496 mL], p = 0.001), presentando menos espasmo radial (odds ratio, 0.484 [0.363 a 0.644], p < 0.001) y menos tiempo de procedimiento (diferencia-de-medias; −72.471 s [−99.694 s a −45.249 s], p < 0.001). No hubo diferencias en el tiempo de fluoroscopia. Conclusiones: La estrategia de catéter único induce una reducción mínima en la administración de contraste, pero mejora el rendimiento del cateterismo al reducir el espasmo radial y el tiempo de procedimiento en comparación con la estrategia convencional.

Tratamiento efectivo de la toxina botulínica tipo A en el espasmo hemifacial, Guantánamo 2018-2019 / Botulinum toxin type A efficient treatment in patients with hemifacial spasm, Guantanamo 2018-2019

RESUMEN Introducción: No se encuentran antecedentes de investigaciones que aborden resultados de la aplicación de toxina botulínica tipo A en pacientes con espasmo hemifacial en la provincia Guantánamo. Objetivo: Evaluar los resultados terapéuticos de la aplicación de toxina botulínica tipo A en pacientes con espasmo hemifacial atendidos en consulta de Neurología. Método: Se realizó un estudio descriptivo longitudinal de 21 pacientes atendidos en servicio de Neurología con espasmo hemifacial y tratamiento con toxina botulínica tipo A, desde enero 2018 hasta enero 2019. Las variables estudiadas fueron: edad, sexo, hemicara afectada, periodo de latencia, duración, desaparición del efecto clínico de toxina botulínica tipo A, y porciento de incapacidad funcional en pacientes al aplicar la escala de discapacidad antes y después de la aplicación del tratamiento. Resultados: Predominó el sexo femenino con 57,1%, edad mayor de 55 años con 57,14 %, lado afectado predominante el izquierdo con 57,14 %, el periodo de latencia de la toxina botulínica tipo A fue entre el tercer y décimo día con 14 pacientes para un 66,67 %, el tiempo máximo de duración del tratamiento fue de uno a dos meses con un 57,14 %, y la desaparición del efecto terapéutico de la toxina fue entre el tercer y cuarto mes con un 52,38%. Luego de la aplicación de la escala de evaluación clínica del espasmo hemifacial se evidenció disminución del porcentaje de pacientes con incapacidad funcional. Conclusiones: La toxina botulínica tipo A es efectiva en el tratamiento del espasmo hemifacial.

ABSTRACT Introduction: No research records were founded dressing the results of the application of botulinum toxin type A in patients with hemifacial spasm in Guantanamo province. Objective: to evaluate the therapeutic results of the application of botulinum toxin type A in patients with hemifacial spasm treated in a Neurology consultation. Method: a descriptive and longitudinal study was carried out in 21 patients attended in Neurology service with hemifacial spasm and botulinum toxin type A treatment, fromJanuary 2018 to January 2019. The variables studied were: age, gender, hemiface affected, latency period, duration, disappearance of the clinical effects of botulinum toxin type A, and percentage of functional disability in patients when applying the disability scale before and after the treatment. Results: Female cases predominated (57.1%), agesover 55 years (57.14 %), the most common affected side of the face was the left, with 57.14 %, the latency period of botulinum toxin type A was between the third to the tenth day in 14 of the patients (66.67 %), the maximum time of duration of treatment ranged from one to two months (57.14 %), and the disappearance of the therapeutic effect of the toxin in the patients was between the third to the fourth month (52.38%). After the application of the clinical assessment scale of hemifacial spasm, a decrease in the percentage of patients with functional disability was evidenced. Conclusions: Botulinum toxin type A is effective in the treatment of hemifacial spasm.

La rigidez cadavérica, el espasmo cadavérico y tipos de fibras musculares / The cadaveric rigidity, the cadaveric spasm and types of muscle fibers

La rigidez cadavérica (rigor mortis) es un proceso no muy bien comprendido por la mayoría de los médicos. El conocimiento de la intimidad del proceso de la rigidez cadavérica es de vital importancia ya que es una de las variables que junto con las livideces (livor mortis) y la temperatura (algor mortis) del cadáver ayudan a determinar el cronotanatodiagnóstico, tanatocronodiagnóstico o intervalo postmortal del período inmediato de la muerte. Para entender el mecanismo de la rigidez y el espasmo cadavérico es preciso hacer un repaso de la contracción muscular fisiológica en el vivo. Hay que tener presente que el tipo de fibra muscular predominante modificará las características de la contracción muscular fisiológica en el vivo, y también la rigidez y el espasmo cadavérico. (AU)

The cadaveric rigidity (rigor mortis) is a process which is not very well understood by the majority of the doctors. The knowledge of the intimacy of the cadaveric stiffness process is of vital importance since it is one of the variables that, as well as the postmortem lividity (livor mortis) and the body temperature post mortem (algor mortis) help determine the chronotanatodiagnostic, tanatochronodiagnostic or postmortal interval of the immediate period of death. In order to understand the mechanism of stiffness and cadaveric spasm, it is necessary to review the physiological muscle contraction in vivo. We should keep in mind that the predominant type of muscle fiber will modify the characteristics of physiological muscle contraction in vivo, as well as stiffness and cadaveric spasm. (AU)

Endoscope-assisted retrosigmoid approach in hemifacial spasm: our experience / Abordagem retrosigmóidea assistida por endoscopia em espasmo hemifacial: nossa experiência

Abstract Introduction: The use of surgical decompression of facial hemispasm due to the loop in the internal auditory canal is not always accepted due to the risk related to the surgical procedure. Currently a new surgical technique allows surgeons to work in safer conditions. Objective: To report the results with endoscope-assisted retrosigmoid approach for facial nerve microvascular decompression in hemifacial spasm due to neurovascular conflict. The surgical technique is described. Methods: We carried out a prospective study in a tertiary referral center observing 12 (5 male, 7 female) patients, mean age 57.5 years (range 49-71) affected by hemifacial spasm, that underwent to an endoscope assisted retrosigmoid approach for microvascular decompression. We evaluated intra-operative findings, postoperative HFS resolution and complication rates. Results: Hemifacial spasm resolution was noticed in 9/12 (75%) cases within 24 h after surgery and in 12/12 (100%) subjects within 45 days. A significant (p < 0.001) correlation between preoperative historical duration of hemifacial spasm and postoperative recovery timing was recorded. Only 1 patient had a complication (meningitis), which resolved after intravenous antibiotics with no sequelae. No cases of cerebrospinal fluid leak, facial palsy or hearing impairment were recorded. Hemifacial spasm recurrence was noticed in the only subject where the neurovascular conflict was due to a vein within the internal auditory canal. Conclusions: The endoscope assisted retrosigmoid approach technique offers an optimal visualization of the neurovascular conflict thorough a minimally invasive approach, thus allowing an accurate decompression of the facial nerve with low complication rates. Due to the less invasive nature, the procedure should be considered in functional surgery of the cerebellar pontine angle as hemifacial spasm treatment, specially when the procedure is performed by an otolaryngologist.

Resumo Introdução: O uso de descompressão cirúrgica do espasmo hemifacial devido ao loop no canal auditivo interno nem sempre é aceito devido ao risco relacionado ao procedimento cirúrgico. Atualmente, uma nova técnica cirúrgica permite trabalhar em condições seguras. Objetivo: Relatar os resultados que obtivemos com a abordagem retrosigmóidea assistida por endoscopia para a descompressão microvascular do nervo facial em casos de espasmo hemifacial devido a conflito neurovascular. A técnica cirúrgica é descrita. Método: Realizamos um estudo prospectivo em um centro de referência terciária observando 12 pacientes (5M, 7F), com média de idade de 57,5 (intervalo 49-71) anos com espasmo hemifacial submetidos a uma abordagem retrosigmóide assistida por endoscopia para descompressão microvascular. Foram avaliados os achados intraoperatórios, a resolução pós-operatória do espasmo hemifacial e as taxas de complicações. Resultados: A resolução do espasmo hemifacial foi observada em 9/12 (75%) dos casos nas 24 horas após a cirurgia e em 12/12 (100%) dos indivíduos até 45 dias. Uma correlação significativa (p < 0,001) entre a duração do histórico pré-operatório de espasmo hemifacial e o tempo de recuperação pós-operatório foi registrado. Apenas um paciente apresentou uma complicação (meningite), que foi resolvida após administração de antibióticos por via intravenosa sem sequelas. Nenhum caso fístula liquórica, paralisia facial ou deficiência auditiva foi registrado. A recorrência do espasmo hemifacial foi observada em único indivíduo em quem o conflito neurovascular foi causado por um vaso no interior do canal auditivo interno. Conclusões: A técnica da abordagem retrosigmóidea assistida por endoscopia oferece uma ótima visualização do conflito neurovascular através de uma abordagem minimamente invasiva, permite assim uma descompressão precisa do nervo facial com baixas taxas de complicações. Por ser menos invasivo, o procedimento deve ser considerado na cirurgia funcional do ângulo pontocerebelar como tratamento de espasmo hemifacial, especialmente quando o procedimento é feito por um otorrinolaringologista.

Consensus of the Iberoamerican Oculoplastic Society for diagnosis and management of facial dystonia. / Consenso de la Sociedad Iberoamericana de Oculoplástica para el diagnóstico y manejo de las distonías faciales.

OBJECTIVE: To propose guidelines for the diagnosis and treatment of facial dystonia prepared by a group of experts in orbit and oculoplastics from the Iberoamerican Oculoplastic Society. MATERIAL AND METHODS: An interactive discussion between the expert panel and those attending the 6th Iberoamerican Society of Oculoplastics Congress, which took place at the Hospital Nuestra Señora de la Luz in Mexico City on 22 October 2018, providing their personal experience based on evidence for diagnosis and treatment of facial dystonia. Around 200 ophthalmologists specialised in oculoplastics from North, Central and South America, Spain, and Portugal were involved. Discussion was focused on the following themes: pathophysiology, diagnosis, medical management, and surgical management. CONCLUSIONS: Facial dystonia diagnosis is clinical; therefore, image studies are rarely needed. The ophthalmologist is generally the first physician to be consulted, and is able to be the treating physician, with the exception of specific cases of hemifacial spasm where management with neurosurgery may be beneficial. Botulinum toxin is the treatment of choice. Treatment with oral neuroleptics and myectomy of the orbicularis oculi muscle are reserved for refractory cases, since these do not have an adequate clinical response as first choice treatments. Persistent use of botulinum toxin does not modify the natural course of the disease.