Migraine preventive treatment failure: A cross-sectional study in a tertiary center in Brazil / Falha no tratamento preventivo da enxaqueca: um estudo transversal em um centro terciário no Brasil

BACKGROUND: In Brazil, there is a scarcity of evidence on migraine burden in patients who have experienced previous preventive treatment failure (PPTF). OBJECTIVE: To evaluate the associations between ≥ 3 PPTF and clinical, psychiatric, and medical history data. METHODS: In a retrospective, cross-sectional study, the medical records of migraine patients who first visited a tertiary specialized clinic were examined. We selected adults of both sexes aged ≥ 18 who attended their first appointment between March and July 2017. Ordinal logistic regression models estimated the associations between number of PPTF (no previous treatment, 1 PPTF, 2, and ≥ 3 PPTF) and chronic migraine, the number of diagnosis exams performed, abortive drugs classes used, and non-pharmacological treatments tried (all categorized as none, 1- 3, and ≥ 4), and severe depression (PHQ-9 ≥ 15) and anxiety (GAD-7 ≥ 15), adjusted for sex, age, and years with disease. RESULTS: Data from 440 patients (72.1 % female) with a mean (SD) age of 37.3 (13.0) years were analyzed. The frequency of no previous treatment was 37.7 % (166/440), while 31.8 % (140/440) showed ≥ 3 PPTF. In patients with ≥ 3 PPTF, 35.7 % (50/140) had episodic, and 64.3 % (90/140) had chronic migraine. Compared to no previous treatment, patients with ≥ 3 PPTF showed higher odds (95 % confidence interval) for chronic migraine [2.10 (1.47, 2.98)], ≥ 4 diagnosis exams [6.59 (3.38, 12.84)], ≥ 4 abortive drug classes [16.03 (9.53, 26.94)], ≥ 4 non-pharmacological treatments [5.91 (3.07,11.35)], and severe depression [1.75 (1.07, 2.88)] and anxiety [1.73 (1.05, 2.85)]. CONCLUSION: Patients first visiting a headache specialist had a high frequency of non-response treatment associated with higher migraine burden in terms of chronification, psychiatric comorbidity, acute medication and non-pharmacological treatment inefficacy, and unnecessary exams.

FUNDAMENTO: No Brasil, há escassez de evidências sobre a carga da enxaqueca em pacientes que apresentaram falha prévia no tratamento preventivo (FTPP). OBJETIVO: Avaliar as associações entre ≥ 3 PPTF e dados clínicos, psiquiátricos e de história médica. MÉTODOS: Em um estudo retrospectivo e transversal, foram examinados os prontuários de pacientes com enxaqueca que visitaram pela primeira vez uma clínica especializada terciária. Foram selecionados adultos de ambos os sexos com idade ≥ 18 anos que compareceram à primeira consulta entre março e julho de 2017. Modelos de regressão logística ordinal estimaram as associações entre número de PPTF (sem tratamento prévio, 1 PPTF, 2 e ≥ 3 PPTF) e enxaqueca crônica, o número de exames de diagnóstico realizados, classes de medicamentos abortivos utilizados e tratamentos não farmacológicos tentados (todos categorizados como nenhum, 1-3 e ≥ 4) e depressão grave (PHQ-9 ≥ 15) e ansiedade (GAD-7 ≥ 15), ajustado por sexo, idade e anos de doença. RESULTADOS: Foram analisados ​​dados de 440 pacientes (72,1% mulheres) com idade média (DP) de 37,3 (13,0) anos. A frequência de nenhum tratamento prévio foi de 37,7% (166/440), enquanto 31,8% (140/440) apresentaram ≥ 3 PPTF. Em doentes com ≥ 3 PPTF, 35,7% (50/140) tiveram enxaqueca episódica e 64,3% (90/140) tiveram enxaqueca crónica. Em comparação com nenhum tratamento anterior, pacientes com ≥ 3 PPTF apresentaram chances mais altas (intervalo de confiança de 95%) para enxaqueca crônica [2,10 (1,47, 2,98)], ≥ 4 exames de diagnóstico [6,59 (3,38, 12,84)], ≥ 4 classes de medicamentos abortivos [16,03 (9,53; 26,94)], ≥ 4 tratamentos não farmacológicos [5,91 (3,07;11,35)] e depressão grave [1,75 (1,07; 2,88)] e ansiedade [1,73 (1,05; 2,85)]. CONCLUSÃO: Os pacientes que consultaram pela primeira vez um especialista em dor de cabeça tiveram uma alta frequência de não resposta ao tratamento associada a maior carga de enxaqueca em termos de cronificação, comorbidade psiquiátrica, medicação aguda e ineficácia do tratamento não farmacológico e exames desnecessários.

Migraine review for general practice / Revisión de la migraña para la práctica habitual

Migraine continues second among the world's causes of disability. Diagnosis is based on the history and clinical examination and imaging is usually not necessary. Migraine can be subdivided depending on whether there is an aura or not and based on the frequency of the headaches. The number of headache days determines whether the patient has episodic migraine or chronic migraine. Treating migraines can be done to treatment the migraine itself and to prevent its appearance. In this review we approach the migraine from a practical point of view with updated information.

La migraña continúa siendo la segunda causa a nivel mundial de discapacidad. El diagnóstico se basa en la historia clínica y el examen clínico y las imágenes no suelen ser necesarias. La migraña se puede subdividir dependiendo de si hay un aura o no y según la frecuencia de la cefalea. El número de días con cefalea determina si el paciente tiene migraña episódica o migraña crónica. El tratamiento de las migrañas se puede realizar para tratar la migraña en sí y para prevenir su aparición. En esta revisión abordamos la migraña desde un punto de vista práctico con las últimas novedades.

Migraine review for general practice.

Migraine continues second among the world's causes of disability. Diagnosis is based on the history and clinical examination and imaging is usually not necessary. Migraine can be subdivided depending on whether there is an aura or not and based on the frequency of the headaches. The number of headache days determines whether the patient has episodic migraine or chronic migraine. Treating migraines can be done to treatment the migraine itself and to prevent its appearance. In this review we approach the migraine from a practical point of view with updated information.

Rehabilitación oral de hipomineralización incisivo molar

El Objetivo es conocer e investigar el manejo odontológico y las posibles opciones de rehabilitación en los casos de Hipomineralización Incisivo Molar. Como metodología se usó el Reporte Clínico de un caso de Hipomineralización Incisivo Molar, en un paciente masculino de 8 años de edad con Diagnostico Sistémico de: Comunicación Interauricular, Retraso Psicomotor Global, Síndrome de Brown, Enfermedad por Reflujo Esofágico, TBC Latente; y Diagnostico Estomatológico de: Hipomineralización Incisivo Molar; atendido en el Instituto Nacional de Salud del Niño, en el servicio de Odontología de Pacientes Medicamente Comprometidos. El paciente presenta Hipomineralización en primeras molares y en incisivos centrales inferiores permanentes; debido a la complejidad de las lesiones a restaurar y la poca capacidad del paciente para mantener la apertura bucal por mucho tiempo se opta por rehabilitar al paciente en sala de operaciones, colocándose coronas de acero preformadas en molares más afectados y restaurando con Resina Composite los molares e incisivos menos afectados. Como resultados, en los controles realizados al paciente se puede observar que ha mejorado la calidad de vida, ya que no presenta más sensibilidad dentinaria, tampoco molestias al comer, encontrando a un paciente y sus padres muy satisfechos con los tratamientos realizados, considerando hasta ahora el tratamiento exitoso, tanto clínico como radiográfico. Conclusión: La ejecución de medidas preventivas individuales puede posponer el inicio del tratamiento restaurador y reducir la incomodidad del paciente a largo plazo. El diagnóstico precoz permite el seguimiento y la instauración de dichas medidas preventivas tan pronto las superficies afectadas sean accesibles.

[Are domiciliary care patients receiving adequate thromboprophylaxis?]. / ¿Hacemos profilaxis antitrombótica adecuadamente en los pacientes crónicos domiciliarios?

INTRODUCTION: The study aims to determine the percentage of patients treated at home with an indication of prophylaxis of thromboembolic disease (TED) according to the PRETEMED guidelines and whether they receive such prophylaxis. MATERIALS AND METHODS: A cross-sectional descriptive study was conducted in Segovia Palace Health Centre (Madrid). INCLUSION CRITERIA: to be included in the domiciliary care protocol. EXCLUSION CRITERIA: terminal patient, hospitalised or surgery in the last 3 months. The variables used include, age, sex, duration of domiciliary care, mobility, anticoagulant or antiplatelet treatment and reason, and associated and precipitating factors to calculate the risk of TED according to the PRETEMED guidelines, and if they receive such prophylaxis, by reviewing computerised medical records and meeting with the staff responsible. RESULTS: The study included a total of 187 patients, of whom 81% were women There was a significant differences in mean age by sex (men, 76.91 years, 95% CI; 72.59-81.24, and women, 86.72 years, 95% CI; 72.59-81.24, P<.05). Almost two-thirds (65%) walked in the home. There were 3.7% patients who had an indication for receiving prophylaxis, but did not receive it, although 85.8% of them were on anticoagulants or antiplatelet therapy for other reasons. CONCLUSIONS: Most patients in domiciliary care have a low baseline risk of developing a TED episode in our study. There should be more emphasis placed on the prophylaxis of TED in acute medical episodes in which patients with slightly elevated risk may increase the likelihood of TED. Observational studies should be conducted to study the baseline risk and the subsequent development of TED in the population receiving home care.

Preventive therapy in children exposed to Mycobacterium tuberculosis: problems and solutions.

Young children living with a tuberculosis patient are at high risk of Mycobacterium tuberculosis infection and disease. WHO guidelines promote active screening and isoniazid (INH) preventive therapy (PT) for such children under 5 years, yet this well-established intervention is seldom used in endemic countries. We review the literature regarding barriers to implementation of PT and find that they are multifactorial, including difficulties in screening, poor adherence, fear of increasing INH resistance and poor acceptability among primary caregivers and healthcare workers. These barriers are largely resolvable, and proposed solutions such as the adoption of symptom-based screening and shorter drug regimens are discussed. Integrated multicomponent and site-specific solutions need to be developed and evaluated within a public health framework to overcome the policy-practice gap and provide functional PT programmes for children in endemic settings.

Abordagem profilática contra tuberculose em pacientes infectados pelo HIV em serviço ambulatorial de hospital filantrópico / Prophylactic app roach against tuberculosis in HIV-infected patients in the outpatient service of philanthropic hospital

Introdução: a tuberculose é uma das principais doenças oportunistas que acometem pacientes com HIV/aids. Para reduzir o risco de adoecimento por tuberculose nestes pacientes, o Ministério da Saúde recomenda a realização anual de teste tuberculínico, visando a instituição oportuna de terapia preventiva (TP). Esta abordagem pode ser considerada um parâmetro de avaliação de qualidade de um serviço. Objetivo: analisar a abordagem profilática contra tuberculose em pacientes infectados pelo HIV em serviço ambulatorial de hospital filantrópico. Métodos: estudo retrospectivo de prontuários dos pacientes com HIV/aids que estavam em acompanhamento no Ambulatório de Doenças Infecciosas e Parasitárias da Santa Casa de Misericórdia de Vitória, em dezembro de 2007. Foram explorados fatores que pudessem condicionar a solicitação de PPD e fez-se análise descritiva dos casos em que se realizou TP, bem como dos casos de tuberculose. Resultados: da população de estudo, de 361 pacientes, foram excluídos os que tiveram tuberculose antes ou até os primeiros 3 meses do início do acompanhamento e selecionou-se uma amostra de 334 pacientes. A média de tempo de acompanhamento foi de 5,77 anos e o número médio de PPD por paciente foi de 1,42, observando-se 23,35% dos pacientes sem nenhuma solicitação de PPD. De 178 resultados do primeiro PPD registrados em prontuário, houve 22 exames positivos. Foi instituída TP em 37 casos e ocorreram 15 casos de tuberculose pós-seguimento, correspondendo a uma incidência de 4,5%. Conclusão: foram observadas falhas na abordagem preventiva contra tuberculose, bem como precariedade de registro em prontuário, afetando diretamente a qualidade do atendimento. É importante aprimorar a abordagem médica dirigida à redução do risco de tuberculose nos pacientes com HIV/aids.

Introduction: tuberculosis is one of the main opportunistic diseases which affect HIV/aids patients. In order to reduce the risk of developing tuberculosis in these patients, the Brazilian Health Ministry recommends an annual tuberculin skin test, aimed at establishing oportune preventive therapy (PT). This approach can be considered a parameter of evaluation of the quality of a health service. Objective: analysing the prophylactic approach against tuberculosis in HIV-infected patients in an outpatient clinic of philanthropic hospital. Methods: retrospective study of HIV/aids patients' medical records which were monitored in the Infectious and Parasitary Diseases Ambulatory of the Santa Casa da Misericordia in the city of Vitoria, in December, 2007. Factors that could condition the solicitation of PPD were explored and descriptive analisys was made of the cases in which PT was done, and of tuberculosis cases as well. Results: within the study population of 361, those that had tuberculosis before or up until the first three months from the beginning of themonitoring were excluded and 334 patients were selected. The average monitoring time was 5.77 years and the average number of PPD per patient was 1.42, considering that 23.35% of the patients had no solicitation for PPD. Out of 178 results of the first PPD recorded, 22 were positive. PT was established in 37 cases and there was an occurrence of 15 cases of tuberculosis post-monitoring, corresponding to an incidence of 4.5%. Conclusion: failures in the preventive approach against tuberculosis were observed, as well as the precariousness of medical record keeping, affecting the quality of care directly. Improving the medical approach in reducing the risk of tuberculosis in HIV/aids patients is important.