Effect of onabotulinum toxin type a intraprostatic injection on the outcome of benign prostatic hyperplasia patients refractory to medical therapy: a 2-year follow-up study / Efecto de la inyección intraprostática de Toxina botulínica tipo A en la evolución de los pacientes con Hiperplasia Prostática Benigna refractarios a tratamiento medico: Estudio de seguimiento a dos años

OBJECTIVES: To determine the outcome of Benign Prostatic Hyperplasia patients refractory to standard medical therapy and with significant comorbidities submitted to intraprostatic injection of onabotulinum toxin A. METHODS: Thirty-seven patients with symptomatic Benign Prostatic Hyperplasia refractory to medical therapy who were poor candidates for surgical treatment were enrolled. All patients voided spontaneously. They received one single transrectal application of 200 U of onabotulinum toxin A. All medical therapy was discontinued. The primary objective was to evaluate the percentage of patients that were still accepting to postpone the surgery at 2 years. As secondary objectives the variation of International Prostate Symptom Score and maximum urinary flow rate were also investigated. RESULTS: From the initial cohort, 2 patients developed severe cognitive impairment and eight patients abandoned the study and opted for surgery, due to acute urinary retention or lack of symptomatic improvement. Four patients were lost to follow-up. In the non-failure cohort, baseline International Prostate Symptom Score and Quality of Life and Postvoid Residual Volume decreased significantly and Maximum urinary flow rate increased significantly after injection. Prostate-Specific Antigen values showed no statistically significant variation. We did not find any statistically significant differences between the 2 cohorts regarding basal parameters. CONCLUSIONS: Intraprostatic onabotulinum toxin A injection can be an option for treatment of Benign Prostatic Hyperplasia/Lower Urinary Tract Symptoms refractory to medical treatment in poor surgical candidates, preventing surgery in at least two thirds of the patients. Side effects are limited to acute prostatitis

OBJETIVOS: Determinar la evolución de los pacientes con hiperplasia benigna de próstata refractarios al tratamiento médico estándar y con comorbilidad significativa sometidos a inyección intraprostática de toxina botulínica tipo A. MÉTODOS: Se incluyeron treinta y siete pacientes con HBP sintomática refractaria a tratamiento médico que eran malos candidatos para tratamiento quirúrgico. Todos los pacientes orinaban espontáneamente. Recibieron una única aplicación de 200 U de toxina botulínica A por vía transrectal. Se suspendió toda la medicación oral. El objetivo primario era evaluar el porcentaje de pacientes que a los dos años continuaban aceptando posponer la cirugía. Cómo objetivos secundarios también se investigaron las variaciones del IPSS (Índice internacional de síntomas prostáticos) y el flujo urinario máximo. RESULTADOS: De la cohorte inicial, 2 pacientes desarrollaron un empeoramiento cognitivo severo y ocho pacientes abandonaron el estudio y optaron por cirugía, por retención aguda de orina o falta de mejoría sintomática. Cuatro pacientes se perdieron en el seguimiento. En la cohorte que no fracasó, el IPSS basal, la calidad de vida y el volumen residual disminuyeron significativamente y el flujo urinario máximo aumentó de forma significativa después de la inyección. Los valores de PSA no mostraron una variación significativa. No encontramos diferencias estadísticamente significativas entre las dos cohortes en relación con los parámetros basales. CONCLUSIONES: La inyección intraprostática de toxina botulínica A puede ser una opción en el tratamiento de los STUI/HBP refractarios a tratamiento médico en malos candidatos para cirugía, evitando la operación en al menos dos tercios de los pacientes. Los efectos secundarios se limitan a prostatitis aguda

Cómo convencer al jefe de servicio y al gerente de la importancia de las unidades/consultas especializadas de cefaleas / How to convince the head of department and managing director of the importance of specialised headache clinics

A pesar de que la cefalea es, con diferencia, el principal motivo neurológico de consulta, y de la complejidad diagnóstica y terapéutica de algunos pacientes, el número de consultas monográficas de cefalea (CC) y de unidades de cefalea (UC) es muy reducido en nuestro país. En este artículo pasaremos revista a los principales argumentos que nos permitan, como neurólogos, defender la necesidad de la implementación de una CC/UC, dependiendo de la población que se debe atender, en todos nuestros servicios de neurología. Para ello deberemos, en primer lugar, vencer las reticencias internas, que hacen que la cefalea sea aún poco apreciada y atractiva dentro de nuestra especialidad. El hecho de que la cefalea justifique más de un cuarto de las consultas a un servicio de neurología estándar de nuestro país y de que existan más de 200 cefaleas diferentes, algunas de ellas realmente invalidantes, y las nuevas opciones de tratamiento para pacientes crónicos, como la OnabotulinumtoxinA para la migraña crónica o las técnicas de neuromodulación, obligan a introducir dentro de nuestras carteras de servicios la asistencia especializada en cefaleas. Aunque no disponemos de datos incontrovertibles, existen ya datos suficientes en la literatura que indican que esta atención es eficiente en pacientes con cefaleas crónicas no sólo en términos de salud, sino también desde el punto de vista económico (AU)

In spite that headache is, by far, the most frequent reason for neurological consultation and that the diagnosis and treatment of some patients with headache is difficult, the number of headache clinics is scarce in our country. In this paper the main arguments which should allow us, as neurologists, to defend the necessity of implementing headache clinics are reviewed. To get this aim we should first overcome our internal reluctances, which still make headache as scarcely appreciated within our specialty. The facts that more than a quarter of consultations to our Neurology Services are due to headache, that there are more than 200 different headaches, some of them actually invalidating, and the new therapeutic options for chronic patients, such as OnabotulinumtoxinA or neuromodulation techniques, oblige us to introduce specialised headache attendance in our current neurological offer. Even though there are no definite data, available results indicate that headache clinics are efficient in patients with chronic headaches, not only in terms of health benefit but also from an economical point of view (AU)

Aplicaciones de la toxina botulínica en glándulas salivales / Application of botulinum toxin in salivary glands

Botulinum toxin is a neuromodulator produced by Clostridium botulinum, a gram-negative, anaerobic bacterium responsible for botulism. The clinical utility of botulinum toxin initially became evident in the treatment of strabismus. Subsequently, botulinum toxin has been used for a variety of other medical conditions such as muscular hyperactivity, including blepharospasm, hemifacial spasm, and cervical dystonia. In addition to its well-known applications, within the properties of botulinum toxin are those that make possible the treatment of various diseases affecting salivary glands and oral cavity. Recently there has been an important development in research and finding new applications in otolaryngology. Recent studies have demonstrated the advantages of botulinum toxin injected into the salivary glands of patients who present drooling, reducing the salivary flow and improving their quality of life. In the same way it has proven to be effective as a treatment of sialocele in patients with parotid gland surgery. In parotid and pharyngocutaneous fistula it has proven effective in reducing the salivary flow, facilitating the closure of the defect. Moreover, in patients with Frey’s syndrome it has been effective reducing symptoms and improving quality of life. It has also been histologically demonstrated its protective effect on the glandular damage in patients undergoing radiotherapy.

East-west differences in the organization of botulinum toxin use in nine Central European countries.

Availability and quality of expensive treatment modalities such as botulinum toxin (BTX) largely depend on organizational aspects such as costs, reimbursement by insurance companies, expertise and facilities for expert training, and the propagation of research. To investigate which determinants influence the organization of BTX' use throughout nine Central European countries (Austria, Croatia, Czech Republic, Germany, Hungary, Italy, Slovakia, Slovenia and Switzerland) we sent out questionnaires to leading BTX experts and consulted data banks of manufacturers and bulletins of international organizations. In Western European countries, there is a tendency for users to organize themselves in formal groups and to concentrate on research whereas the way how BTX is provided is diverse regarding qualifications of specialists and institutions. In the post-communist Eastern European countries, we found a tendency towards a centralized system of reimbursement and BTX treatment seems to be more in the hands of neurologists than any other specialists. Strong correlations were observed between the number of BTX centres, degree of organization of user groups and number of scientific publications, on the one hand, and parameters of healthcare performance and socioeconomic determinants, on the other. Our study suggests that in the nine countries surveyed, organizational aspects of BTX use vary considerably, whilst similarities are based mainly on socioeconomic rather than socio-demographic determinants.