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Original article
Evaluation of the effect of botulinum toxin A on the physical and mental health of patients with hemifacial spasm
Evaluación del efecto de la toxina botulínica A en la salud física y mental de pacientes con espasmo hemifacial
J.S. Weia,1, X. Hub,1, L. Xiac, J. Shangc, Q. Hanc,
Corresponding author
dahuihui19830809@163.com

Corresponding authors.
, D.Y. Zhangd,
Corresponding author
1347218117@qq.com

Corresponding authors.
a Department of Neurology, Hongze Huaian District People's Hospital, Huaian 223100, China
b Department of Neurology, The Second People's Hospital of Huai’an, The Affiliated Huai’an Hospital of Xuzhou Medical University, Huai’an 223002, China
c Department of Neurology, Huai’an First People's Hospital, the Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Huaian 223300, China
d Department of Radiology, Huai’an First People's Hospital, the Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Huaian 223300, China
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Compared to the average population&#44; depression and anxiety are more prevalent among people with HFS&#44; of which symptoms also adversely affect their quality of life&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">HFS not only brings physical discomfort to patients but also causes severe social and psychological dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0013"><span class="elsevierStyleSup">3</span></a> In recent years&#44; several lines of studies have revealed that most HFS patients experience fear and tension&#44; thus initiating emotional problems like anxiety and depression&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">4&#44;5</span></a> These emotional problems would further increase the incidence of HFS&#44; causing a vicious cycle&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">6&#44;7</span></a> A case of psychological HFS with depression was first reported in 2001&#46; Clinical findings showed that some HFS patients had subjective depressive symptoms during the consultation&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Botulinum toxin A &#40;BTX-A&#41; is a promising biotoxin that functions on the presynaptic area of the neuromuscular junction and impedes the release of acetylcholine&#44; which ultimately brings about functional reversible paralysis of the associated muscles&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">9</span></a> Regarding the symptomatic treatment of HFS&#44; it has been proved that BTX injection is effective&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">10</span></a> Repeated injections have demonstrated a better ameliorative outcome on patients&#8217; quality of life&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">9&#44;11</span></a> BTX-A is regarded as the most popular treatment method for HFS&#46; However&#44; the alleviation of anxiety and depression in HFS patients after injection of BTX-A is still inadequately understood&#46; Therefore&#44; this study attempted to investigate the effect of BTX-A on the physical and mental health of patients with HFS&#46; 65 patients with HFS were treated with BTX-A&#44; and the Cornell Medical Index &#40;CMI&#41; self-assessment questionnaire was used for self-determination of health levels before and 2 months after BTX-A treatment&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Subjects and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Participants</span><p id="par0020" class="elsevierStylePara elsevierViewall">A total of 65 patients with HFS&#44; who were first diagnosed in our hospital from April 2018 to December 2019&#44; were selected for the HFS group&#46; The group included 27 males and 38 females with an average age of &#40;54&#46;71<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;80&#41; years&#46; Accordingly&#44; 65 healthy people were recruited as the control group during the same period&#46; This group included 31 males and 34 females with an average age of &#40;55&#46;20<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;05&#41; years&#46; There was no significant difference in gender and age between the two groups &#40;<span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;498&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;480&#59; <span class="elsevierStyleItalic">t</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;235&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;814&#41;&#46; The participants were diagnosed with HFS using the Consensus of Chinese Experts on Diagnosis and Treatment of Hemifacial Spasm&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">12</span></a> Except for patients with other related diseases that affect physical and mental health&#44; all patients signed an informed consent form for BTX-A injection and participation in this study&#46; All participants voluntarily took part in the self-assessment of the scale&#44; except those who could not communicate or complete the assessment&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a> shows the workflow of this study&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">CMI self-assessment</span><p id="par0025" class="elsevierStylePara elsevierViewall">The factors such as somatization&#44; fatigue and habit&#44; previous health status and medical history&#44; depression&#44; anxiety&#44; maladjustment&#44; sensitivity&#44; anger&#44; tension&#44; M-R value&#44; and CMI total scores were statistically analyzed&#46; Before BTX-A treatment&#44; the CMI self-assessment questionnaire was used to conduct a preliminary evaluation of the participants and the factors of HFS group were compared with those of the control group&#46; At two months after-treatment&#44; patients in the HFS group were re-evaluated using the same CMI self-assessment questionnaire&#44; and the factors were compared between before and after treatment&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Local injection of BTX-A</span><p id="par0030" class="elsevierStylePara elsevierViewall">All patients were injected with BTX-A developed by Lanzhou Institute of Biological Products &#40;Hengli&#44; 100<span class="elsevierStyleHsp" style=""></span>U&#47;bottle&#41; and diluted with sterile saline to 40<span class="elsevierStyleHsp" style=""></span>U&#47;ml before use&#46; The injection of BTX-A was performed using a 1<span class="elsevierStyleHsp" style=""></span>ml disposable sterile insulin syringe &#40;Shurui&#41; produced by BD Medical Instruments &#40;Shanghai&#41; Co&#46;&#44; Ltd&#46; Orbicularis oculi muscle&#44; zygomatic muscle&#44; orbicularis oris muscle&#44; and mental muscle of the affected side were selected for injection according to the site and degree of spasm of the patient&#44; as shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46; Each point was 2&#8212;4 U&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Evaluation of grading and curative effects of HFS</span><p id="par0035" class="elsevierStylePara elsevierViewall">According to the Cohen et al&#46;&#8217;s grading standard&#44; the degree of spasticity is graded as follows&#58; 0&#58; normal&#59; I&#58; external stimulation to increase blinking&#59; II&#58; mild&#44; no external stimulation&#44; slight tremor of facial muscles and eyelids&#44; no dysfunction&#59; III&#58; moderate&#44; obvious spasticity accompanied by mild dysfunction&#59; IV&#58; severe&#44; severe spasticity and dysfunction&#44; affecting work and life&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">13</span></a> Curative effect is evaluated using the following criteria&#58; &#40;1&#41; After treatment&#44; the spasticity of patients was reduced from grade II&#8211;IV to grade as complete remission&#46; &#40;2&#41; The spasticity was reduced from grade II&#8211;III to grade I or from grade IV to grade I&#8211;II as significant relief&#46; &#40;3&#41; The spasticity was reduced from grade III to grade II or from grade IV to grade III as partial relief&#46; &#40;4&#41; No change in the grade of spasticity was considered invalid&#46; Total effective rate<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#40;number of complete remission cases&#43; number of obvious remission cases&#41;&#47;total number of treatment cases&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical analyses</span><p id="par0040" class="elsevierStylePara elsevierViewall">The measurement data conforming to the normal distribution were represented as x&#175;&#177;s&#46; Student&#39;s <span class="elsevierStyleItalic">t</span>-tests were employed to evaluate differences between outcomes for each variable&#46; Independent sample <span class="elsevierStyleItalic">t</span>-test was used to compare the means between the two groups&#44; and the comparison before and after BTX-A treatment was determined by paired <span class="elsevierStyleItalic">t</span>-test&#46; The measurement data inconsistent with the normal distribution were determined by Wilcox test&#46; The counting data were expressed as a percentage &#40;&#37;&#41;&#44; and the difference between the groups was measured by the <span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span> test&#46; Spearman correlation coefficients were calculated for the correlation&#46; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 indicated statistical significance between or among compared groups&#46; SPSS version 20 software package &#40;SPSS&#44; Chicago&#44; IL&#44; USA&#41; was used for analysis&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Comparison of various factors of CMI self-assessment questionnaire between HFS group and control group</span><p id="par0045" class="elsevierStylePara elsevierViewall">The scores of somatization&#44; depression&#44; anxiety&#44; inadaptation&#44; sensitivity&#44; anger&#44; tension&#44; and M-R and total scores in the HFS group were significantly higher than those in the control group &#40;all <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#59; There was no significant difference in scores of fatigue&#44; habit&#44; previous health status and medical history &#40;all <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#59; see <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Effect of BTX-A on HFS</span><p id="par0050" class="elsevierStylePara elsevierViewall">Cohen grades before treatment in the HFS group were as follows&#58; 8 cases of grade II&#44; 43 cases of grade III&#44; and 14 cases of grade IV&#46; The average effect onset time of BTX-A injection was five days&#44; and the effect was significant in about three weeks&#46; After two months&#44; 42 &#40;64&#46;6&#37;&#41; of the 65 patients had complete relief&#44; 16 &#40;24&#46;6&#37;&#41; had significant relief&#44; 7 &#40;10&#46;8&#37;&#41; had partial relief&#44; and 0 &#40;0&#37;&#41; were invalid&#46; The total effective rate was 89&#46;2&#37;&#46; See <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">The correlation between Cohen&#39;s grades and various factors of CMI self-assessment questionnaire in the HFS group before BTX-A treatment</span><p id="par0055" class="elsevierStylePara elsevierViewall">Before BTX-A treatment&#44; the somatization&#44; previous health status and medical history&#44; depression&#44; anxiety&#44; inadaptation&#44; sensitivity&#44; anger&#44; tension&#44; M-R&#44; and total scores of patients in the HFS group were significantly correlated with Cohen&#39;s grades &#40;all <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; See <a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Comparison of various factors of CMI self-assessment questionnaire in HFS patients before and after BTX-A treatment</span><p id="par0060" class="elsevierStylePara elsevierViewall">The scores of somatization&#44; tension&#44; anxiety&#44; depression&#44; and sensitivity in patients with HFS at two months post-treatment with BTX-A were significantly lower than those before treatment &#40;all <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; There was no significant difference in scores of fatigue and habits&#44; previous health status and medical history&#44; inadaptation&#44; and anger after BTX-A treatment compared with those before treatment &#40;all <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; See <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> and <a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">Although HFS is not fatal&#44; it can have a relatively significant effect on patients&#8217; quality of life&#46; Patients cannot control their HFS&#46; If it is not effectively managed for a long time&#44; HFS can change the patient&#39;s appearance and cause emotional problems such as anxiety and depression&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">14</span></a> The etiology of HFS is not completely clear&#44; and compression of the facial nerve byabnormal venous or arterial loops is considered to be the most common cause&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">15&#44;16</span></a> Treatments of HFS mainly include oral drugs&#44; local injection of BTX-A&#44;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">11&#44;17</span></a> and microvascular decompression&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">18&#44;19</span></a> Studies have shown that oral medications have poor therapeutic effects and large side effects&#46; Microvascular decompression surgery can result in cerebrospinal fluid leakage and cranial nerve damage and postoperative symptoms of some patients cannot be fully improved&#46; Local injection of BTX-A has been the preferred treatment for many patients with positive efficacy and low side effects&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">20</span></a> This study showed that the average scores of depression&#44; anxiety&#44; inadaptation&#44; sensitivity&#44; anger&#44; tension&#44; and somatization of HFS patients are significantly higher than those of healthy people&#46; And the somatization&#44; previous health status and medical history&#44; depression&#44; anxiety&#44; inadaptation&#44; anger&#44; tension&#44; M-R&#44; and total scores were significantly correlated with Cohen grades in the HFS group&#46; In addition&#44; we found that BTX-A has significant benefits for HFS patients&#46; It leads to a decrease in the scores of somatization&#44; tension&#44; anxiety&#44; depression&#44; and sensitivity after treatment&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Patients with HFS tend to focus only on physical discomfort and rarely mention psychological and spiritual issues&#46; The CMI self-assessment questionnaire is currently a widely used checklist for mental illness and mental disorders&#46; In this study&#44; we used the CMI self-assessment questionnaire to conduct self-evaluation among all research subjects and compared various factors&#46; Our results showed that average scores of somatization&#44; interpersonal sensitivity&#44; depression&#44; anxiety&#44; and phobia in patients with HFS were higher than those of normal volunteers&#44; indicating that patients had the obvious tendency of somatization&#44; interpersonal sensitivity&#44; depression&#44; anxiety&#44; and inadaptation at patient&#39;s first clinical visit&#46; One of the possible reasons we assumed is that HFS affects the patient&#39;s self-image&#44; influences the patient&#39;s satisfaction of life&#44; and promotes the development of related mental and psychological problems&#46; Second&#44; previous studies have found that the brains of patients with HFS were involved in activating the hemifacial motor cortex and increasing the excitability of the gray matter nuclei&#44; while the function of inhibiting the hemifacial motor cortex facial motor cortex was weakened&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">21</span></a> It was suggested that the central nervous system was involved in the pathogenesis of HFS and it may also be involved in the mental and psychological changes of HFS patients&#46; Evaluation results of Chengyun Wang et al&#46; found that average scores of interpersonal sensitivity&#44; phobia&#44; anxiety&#44; depression&#44; and somatization of HFS patients were significantly higher than those of healthy people&#44;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">20</span></a> in line with our reports&#46; In addition&#44; because female patients&#44; especially young female patients&#44; pay more attention to their appearance&#44; their HFS&#8217;mental and psychological impact on them may be more prominent&#46; It is known that most HFS patients are middle-aged and elderly&#44; and many female patients are in menopause&#44; which may aggravate their mental and psychological problems&#46; This study is only an overall analysis of patients with HFS and failed to discuss the mental and psychological problems between males and females&#46; It is expected that a more detailed analysis can be conducted in subsequent studies&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">BTX-A&#44; produced by gram-positive anaerobic Clostridium bacteria&#44; prevents the release of acetylcholine from nerve endings&#44; causing muscle relaxation and paralysis&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">22</span></a> In line with the study by Batisti et al&#46; and Xing et al&#44; our research reveals that BTX-A has a considerable treatment effect and low side effects in the therapy of HFS&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">11&#44;23</span></a> The ability of BTX-A to relieve anxiety and depression in patients with HFS was further supported in this study&#46; BTX-A alleviates somatization&#44; tension&#44; anxiety&#44; depression&#44; sensitivity&#44; and other psychiatric problems&#44; which may be due to the relief of HFS symptoms&#44; reducing it&#39;s negative impact on patients&#46; In the future&#44; more studies on the mechanisms of BTX-A involvement in HFS should be conducted&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In summary&#44; patients with HFS are frequently coupled with somatization&#44; interpersonal sensitivity&#44; depression&#44; anxiety&#44; anger&#44; tension&#44; and inadaptation&#46; BTX-A exhibits potent efficacy and safety with low side effects in the treatment of HFS&#44; alleviating somatization&#44; tension&#44; anxiety&#44; depression&#44; and sensitivity&#46; BTX-A plays an important role in improving HFS patients&#8217; quality of life and promoting their physical and mental health&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Availability of data and materials</span><p id="par0085" class="elsevierStylePara elsevierViewall">The analyzed data sets generated during the study are available from the corresponding author on reasonable request&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Ethics approval</span><p id="par0090" class="elsevierStylePara elsevierViewall">This study was approved by the Ethics Committee of Huai&#8217;an First People&#39;s Hospital&#46; All procedures performed in studies involving human participants were in accordance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Consent to participate</span><p id="par0095" class="elsevierStylePara elsevierViewall">The written informed consent to participate was provided by all participants&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Funding</span><p id="par0100" class="elsevierStylePara elsevierViewall">This work was supported by Science and Technology Development Fund of Nanjing Medical University&#44; China &#40;No&#46;NMUB2020146&#41;&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflict of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hemifacial spasm &#40;HFS&#41; is a debilitating disease characterized by involuntary tonic and clonic contractions of muscles innervated by the facial nerve&#46; Botulinum toxin A &#40;BTX-A&#41; is the first-line option and the most effective medical treatment for HFS&#46; The objective of this study was to evaluate the effect of BTX-A therapy on the physical and mental health of HFS patients&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Participants included 65 HFS patients and 65 matched healthy controls in the study&#46; Cornell Medical Index &#40;CMI&#41; self-assessment questionnaire was used to detect the psychological health of all participants&#46; Local injection of BTX-A was applied&#44; and the Cohen hierarchical criteria were employed to stratify the degree of spasticity&#44; further evaluating the efficacy of BTX-A before and two months after treatment in HFS patients&#46; The HFS patients at two months post-treatment were re-evaluated by CMI self-assessment questionnaire&#44; and the evaluated factors of these patients were compared with those of patients before treatment&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The scores of somatization&#44; depression&#44; anxiety&#44; inadaptation&#44; sensitivity&#44; anger&#44; tension&#44; M-R&#44; and total scores in the HFS group were significantly higher than those in the control group &#40;all <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; Two months post-treatment&#44; among 65 HFS patients who received with BTX-A treatment&#44; 42 &#40;64&#46;6&#37;&#41; were completely relieved&#44; 16 &#40;24&#46;6&#37;&#41; were significantly relieved&#44; 7 &#40;10&#46;8&#37;&#41; were partially relieved&#44; and 0 &#40;0&#37;&#41; cases were invalid&#44; and the total effective rate was 89&#46;2&#37;&#46; Two months after BTX-A treatment&#44; the scores of somatization&#44; tension&#44; anxiety&#44; depression&#44; sensitivity&#44; M-R and total scores of patients with HFS were lower than those before treatment &#40;all <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Patients with HFS are often accompanied by somatization&#44; anger&#44; inadaptation&#44; sensitivity&#44; anxiety&#44; depression&#44; and tension&#46; BTX-A can not only alleviate the symptoms of HFS&#44; but also improve the somatization&#44; tension&#44; anxiety&#44; depression&#44; and sensitivity&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El espasmo hemifacial &#40;EH&#41; es una enfermedad debilitante que se caracteriza por contracciones t&#243;nico-cl&#243;nicas involuntarias de los m&#250;sculos inervados por el nervio facial&#46; La toxina botul&#237;nica A &#40;TBA&#41; es el tratamiento de primera l&#237;nea y el m&#225;s efectivo para el EH&#46; El objetivo de nuestro estudio es analizar el efecto del tratamiento con TBA en la salud f&#237;sica y mental de los pacientes con EH&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Incluimos 65 pacientes con EH y 65 controles sanos en el estudio&#46; Utilizamos un cuestionario de autoevaluaci&#243;n&#44; el &#237;ndice m&#233;dico de Cornell &#40;IMC&#41;&#44; para determinar la salud psicol&#243;gica de todos los participantes y realizar una comparaci&#243;n de los factores m&#225;s relevantes&#46; Inyectamos TBA localmente y aplicamos los criterios jer&#225;rquicos de Cohen para determinar el grado de espasticidad&#44; evaluando la eficacia de la TBA a los dos meses de haber administrado el tratamiento&#46; Igualmente&#44; volvimos a usar el IMC en los pacientes con EH y comparamos los resultados con los obtenidos antes de administrar el tratamiento en este mismo grupo&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Las puntuaciones en s&#237;ntomas corporales&#44; depresi&#243;n&#44; ansiedad&#44; inadaptaci&#243;n&#44; sensibilidad&#44; irritabilidad&#44; tensi&#243;n&#44; s&#237;ntomas psicol&#243;gicos &#40;&#237;tems M-R&#41; y puntuaci&#243;n total en el grupo de pacientes eran significativamente superiores que las del grupo control &#40;p &#60; 0&#44;05&#41;&#46; A los dos meses del tratamiento&#44; 42 pacientes presentaron una resoluci&#243;n total de los s&#237;ntomas &#40;64&#44;6&#37;&#41;&#44; 16 una mejor&#237;a importante &#40;24&#44;6&#37;&#41; y siete una mejor&#237;a parcial &#40;10&#44;8&#37;&#41;&#59; en ning&#250;n caso se report&#243; un efecto nulo del tratamiento&#44; por lo que la tasa de efectividad fue del 89&#44;2&#37;&#46; Dos meses despu&#233;s del tratamiento con TBA&#44; las puntuaciones en s&#237;ntomas som&#225;ticos&#44; tensi&#243;n&#44; ansiedad&#44; depresi&#243;n&#44; sensibilidad&#44; s&#237;ntomas psicol&#243;gicos &#40;&#237;tems M-R&#41; y puntuaci&#243;n total de los pacientes con EH fueron significativamente menores a las obtenidas antes del tratamiento &#40;p &#60; 0&#44;05&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La EH a menudo tambi&#233;n se manifiesta acompa&#241;ada de s&#237;ntomas corporales&#44; irritabilidad&#44; inadaptabilidad&#44; sensibilidad&#44; ansiedad&#44; depresi&#243;n y tensi&#243;n&#46; El tratamiento con TBA no solo puede aliviar los s&#237;ntomas de la EH&#44; sino tambi&#233;n mejorar los s&#237;ntomas corporales&#44; tensi&#243;n&#44; ansiedad&#44; depresi&#243;n y sensibilidad&#46;</p></span>"
        "secciones" => array:4 [
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            "titulo" => "Introducci&#243;n"
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            "titulo" => "M&#233;todos"
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            "identificador" => "abst0035"
            "titulo" => "Resultados"
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            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Contributed equally to this work&#46;</p>"
        "identificador" => "fn0005"
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    ]
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">The workflow of this study&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Schematic diagram of injection site and dosage of botulinum toxin A&#46; Take the spasm of the left hemifacial muscle&#44; including orbicularis oculi muscle&#44; zygomatic muscle&#44; orbicularis oris muscle&#44; and mental muscle&#44; as an example&#46; Round&#58; Required injection site&#59; Square&#58;Alternative injection site&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Comparison of various factors of Cornell Medical Index self-assessment between the hemifacial spasm &#40;HFS&#41; and control groups&#46;</p>"
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        "identificador" => "fig0020"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">The correlation of Cohen&#39;s grades and various factors of Cornell Medical Index self-assessment questionnaire in the hemifacial spasm group before botulinum toxin A treatment&#46;</p>"
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      4 => array:7 [
        "identificador" => "fig0025"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Comparison of various factors of Cornell Medical Index self-assessment questionnaire in hemifacial spasm patients before and after botulinum toxin A treatment&#46;</p>"
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">CMI&#58; Cornell Medical Index&#59; HFS&#58; hemifacial spasm&#46;</p>"
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                  \t\t\t\t">Somatization&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">67 &#40;31&#8211;107&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">47 &#40;3&#8211;105&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6&#46;02E&#8722;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Depression&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;2&#8211;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;0&#8211;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;21E&#8722;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">IL &#40;fatigue and habit&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9 &#40;5&#8211;13&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9 &#40;4&#8211;13&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;9963&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">JK &#40;previous health status and medical history&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">15 &#40;5&#8211;23&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">13 &#40;4&#8211;24&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0&#46;2659&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anxiety&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">7 &#40;4&#8211;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">6 &#40;1&#8211;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;01506&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Inadaptation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">8 &#40;4&#8211;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">6 &#40;2&#8211;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;92E&#8722;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Sensitivity&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">4 &#40;3&#8211;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">3 &#40;1&#8211;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;001431&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anger&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;4&#8211;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;1&#8211;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;03601&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;4&#8211;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;1&#8211;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;75E&#8722;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M-R&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&#46;34<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#46;14<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;20E&#8722;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SUM &#40;the total scores&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">126 &#40;89&#8211;172&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">112 &#40;40&#8211;159&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;22E&#8722;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">BTX-A&#58; botulinum toxin A&#59; HFS&#58; hemifacial spasm&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Grades&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Numbers &#40;<span class="elsevierStyleItalic">n</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Complete relief &#40;<span class="elsevierStyleItalic">n</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Significant relief &#40;<span class="elsevierStyleItalic">n</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Partial relief &#40;<span class="elsevierStyleItalic">n</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Invalid <span class="elsevierStyleItalic">&#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Valid <span class="elsevierStyleItalic">&#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Summation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42 &#40;64&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;24&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;10&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">58 &#40;89&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">The therapeutic effect of BTX-A on HFS&#46;</p>"
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          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">CMI&#58; Cornell Medical Index&#59; HFS&#58; hemifacial spasm&#59; BTX-A&#58; botulinum toxin A&#46;</p>"
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            0 => array:2 [
              "tabla" => array:1 [
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Before treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">After treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>-value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Somatization&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">67 &#40;31&#8211;107&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">55 &#40;20&#8211;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;69E&#8722;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Depression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;2&#8211;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;1&#8211;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;84E&#8722;04&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">IL &#40;fatigue and habit&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8&#46;31E&#8722;04&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Inadaptation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">7 &#40;4&#8211;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46;49E&#8722;06&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">M-R&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">36&#46;34<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;91&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">31&#46;54<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;98&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46;03E&#8722;08&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">SUM &#40;the total scores&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">126 &#40;89&#8211;172&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">113 &#40;67&#8211;158&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;27E&#8722;03&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Comparison of various factors of CMI self-assessment questionnaire in HFS patients before and after BTX-A treatment &#40;X&#175;&#177;s&#41;&#46;</p>"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos