Botulinum toxin injection effective for post-peripheral facial nerve palsy synkinesis]

Facial synkinesis is an involuntary activation of muscles innervated by the zygomatic or mandibular branch of the facial nerve in conjunction with voluntary activation of the other branch. It appears frequently after recovery from peripheral facial nerve paralysis. We report 10 patients with facial synkinesis following Bell's palsy with a mean duration of synkinesis of 7 +/- 4 years before treatment with periorbital injections of Botulinum toxin type A. 9 had marked subjective and objective improvement starting a few days after injection and lasting 4-9 months. The results suggest a useful treatment option for post-Bell's palsy facial synkinesis with Botulinum toxin type A.     

Botulinum A toxin for glabellar wrinkles. Dose and response

BACKGROUND: Botulinum A exotoxin injection is a well-established method for treatment of glabellar frown lines, crow's feet, and horizontal furrows of the forehead. However, there is no consensus as to the optimal dosage per injection site or the concentration of injectate to be used. OBJECTIVE: The purpose of this study was to determine the minimal effective dose per injection site to be used as well as the effect of concentration in response to treatment. RESULTS: A total of 46 subjects were divided into ten groups and injected with escalating doses and concentrations of botulinum toxin. The response and longevity of treatment were then followed on a monthly basis. A dose between 2.5-4 U per injection site (12.5-20 U total) was determined to be an effective starting dose, with a duration of 2-5 months (median 14 weeks). CONCLUSIONS: There was no statistically significant difference in safety or efficacy for concentrations ranging from 50 to 200 U/ml of botulinum toxin.     

Botulinum toxin A for hyperkinetic facial lines: results of a double-blind, placebo-controlled study

Although enterotoxins have been implicated in disease states such as food poisoning and toxic shock syndrome, their role in infectious arthritis is not known. To study the arthritogenic properties of toxic shock syndrome toxin 1 (TSST-1), two pairs of S. aureus strains isogenic for TSST-1 production were injected intravenously into healthy Swiss mice. Mice injected with TSST-1-secreting staphylococcal strains developed more frequent and more severe arthritis than did mice inoculated with the isogenic TSST-1-deficient counterparts. Immunohistochemical analysis of arthritic joints revealed an equal number of infiltrating phagocytes in both groups; however, mice inoculated with TSST-1-producing staphylococci had significantly more (P < .01) interleukin-2 receptor-expressing cells in the inflamed synovium than did mice that received the isogenic counterpart. Thus, TSST-1 is a virulence determinant in S. aureus arthritis in mice. The precise mechanism by which this toxin contributes to the development and progression of arthritis needs further investigation.     

Botulinum toxin use in pediatric esophageal achalasia: a case report

Esophageal achalasia (EA) has been historically treated by esophageal dilatation or myotomy with or without fundoplication. Botulinum toxin (Botox-Allergan) use in pediatric EA has not been previously described. The authors' objective was to observe the efficacy of botulinum toxin injection into the lower esophageal sphincter (LES) for EA. An 11-year-old boy presented with a 9-month history of frequent pneumonia, productive cough, and a 1-year history of chest discomfort and odynophagia. Chest radiograph showed changes compatible with aspiration. Upper gastrointestinal (UGI) series showed typical narrowing of the LES, and 24-hour pH study showed no reflux. Esophageal manometry showed classic findings of achalasia. An upper gastrointestinal endoscopy was performed showing a huge volume of retained food. A direct four-quadrant injection was performed with a total of 100 U of botulinum toxin into the LES. UGI series showed improvement in esophageal emptying. Esophageal manometry showed impressive improvement in LES pressure (preinjection, 44.1 mm Hg to postinjection mean of 16.6 mm Hg), percent relaxation (preinjection, 30% to postinjection, 58.8%), and duration of relaxation (preinjection, 1.9 seconds to postinjection, 11 seconds). The patient has not had any further respiratory symptoms, chest pain, or odynophagia in 8 months of follow-up. Botulinum toxin injection is simple and effective for EA and merits its study in a prospective manner in the pediatric population.     

Botulinum toxin for neurological disorders in a movement disorders clinic in Singapore

AIM OF STUDY: This study was done to examine the usefulness of botulinum toxin A injections in treating various neurological disorders such as hemifacial spasm, blepharospasm, focal dystonia and task-specific dystonia. METHODS: This was a prospective, open-labelled trial of patients seen in a Movement Disorders Clinic with dyskinesias potentially treatable with botulinum toxin. All patients were assessed before and after injections using clinical rating scales, and those with focal and task-specific dystonias were also recorded on videotape. RESULTS: There were 102 patients with hemifacial spasm, 3 with blepharospasm, 13 with neck dystonia, 6 with writer's cramp, I with musician's cramp, and I with jaw dystonia. All patients with hemifacial spasm and blepharospasm obtained good results, while 77% of those with cervical dystonia received substantial benefit. Only half of those with writer's cramp improved. Hemifacial spasm seems more prevalent in Singapore compared with Western populations. CONCLUSION: Injections of botulinum toxin are useful in treating the various neurological disorders studied. This is an advancement in the treatment of these dyskinesias which respond poorly to oral medications.     

Botulinum toxin in upper limb spasticity: study of reciprocal inhibition between forearm muscles

To establish whether botulinum A toxin (BTX-A) acts on modifying reciprocal inhibition between forearm muscles in spasticity, 20 patients with post-stroke upper limb spasticity lasting for more than 1 year were studied. Clinical examination, physiotherapeutic evaluation, standardized video-tape assessment and electrophysiological testing (flexor carpi radialis muscle M and H responses with study of reciprocal inhibition) were performed at baseline and 2 weeks, 1, 2, 3, 4 months after BTX-A treatment. BTX-A induced a significant decrease of tone and an improvement of motility and functional status, with a significant decrease of the M wave and the H reflex. The reduction in both inhibitory phases of reciprocal inhibition did not change after BTX-A treatment differently from that reported in upper limb dystonia. These findings indicate that the efficacy of BTX-A in upper limb spasticity is mainly due to peripheral effects.     

Lumbar epidural perineural injection: a new technique

Molecular variants of individual components of the renin-angiotensin system (RAS) are reported to constitute the inherited predisposition to some cardiovascular diseases in man, e.g. essential hypertension or myocardial infarction. The frequency of these variants depends highly on the race and population. Therefore, we examined the M235T molecular variant of the angiotensinogen gene and the I/D polymorphism of the ACE gene in Slovak healthy population, in patients with diagnosed essential hypertension and in patients who had undergone myocardial infarction. DNA from 241 subjects was tested for the presence of M235T and I/D molecular variants. The frequency of both these polymorphisms in the Slovak population is similar to other Caucasian populations. In the group of hypertensive patients, the frequency of the M235T molecular variant was increased compared to controls, predominantly in males (0.45 vs. 0.28), while in the I/D polymorphism the incidence of the D allele was the same for both controls and hypertensives (0.49 vs. 0.50). A significant increase in the D allele frequency compared to the controls occurred in the group of infarcted patients (0.63). The increased frequency of the M235T allele in hypertensive patients compared to the healthy population confirms that the M235T variants associated with increased blood pressure in the Slovak population. In the Slovak population, I/D polymorphism of the ACE gene is associated with myocardial infarction rather than with hypertension.     

Botulinum toxin type A purified neurotoxin complex for the treatment of blepharospasm: a dose-response study measuring eyelid force

The clinical efficacy of botulinum toxin type A was studied in patients with blepharospasm. Clinical symptoms were evaluated using the Jankovic rating scale. To measure dose response, we used a recently developed device to measure eyelid muscle force. The results showed significant improvement (P = 0.0000) in the Jankovic rating scale scores in all dose groups. The number of patients with marked improvement (6-point decrease or more in the total Jankovic rating scale score) increased with higher dose injections. After injections of 0.50, 1.25, or 2.50 U/site, 6 sites/eye, the eyelid muscle force decreased by 33.2 +/- 28.1%, 41.7 +/- 25.1%, or 69.6 +/- 5.0%, respectively. The decrease of eyelid muscle force showed a significant dose response (P = 0.0254). The mean duration of effect was 12.9 weeks in patients after dose injections of 1.25 U/site, which was significantly longer (P = 0.0205) than the 9.6 weeks in patients after dose injections of 0.50 U/site. No severe adverse effects were observed. We concluded that injections of botulinum toxin type A at an initial dose of 1.25 U/site are a safe and effective treatment for blepharospasm.     

Botulinum toxin in spastic infantile cerebral palsy: results in 27 cases during one year

INTRODUCTION AND OBJECTIVES: Positive outcome of patients with spastic cerebral palsy treated with botulinum toxin reported in the last three years has led us to perform this study with the aim to show our experience in the management of spastic cerebral palsy with the toxin, determine its indications, analyze the results and propose new possible indications in the future. MATERIAL AND METHODS: We include 10 hemiplegic and 17 diplegic patients with an average age of 6 years and 7 months, followed up between 5 and 17 months. Clinical improvement was monitored using the PRS and EVFEL scales and articular motion range was measured 6 months before and after the injection while continuing physiotherapy. The injected muscles were adductor, hamstrings, triceps and posterior tibialis, and the doses were 1-2 U/muscle/kg body weight. RESULTS: The values on PRS improved an average of 24%, adductor angle 66% (p < 0.01), knee angle 40% (p = 0.05) and ankle angle 52% (p < 0.01); 96% of patients could get more physiological static or walking patterns because of the decrease of spasticity and those persisted after the effect of the toxin had worn off. It was maximum at 2 months, stabilized 4 to 6 months later and decreased during further 2 months. CONCLUSIONS: This experience leads us to propose higher starting dosage and to take into account the stability of postural pattern of each patient to choice the muscle to be injected. Other therapeutic possibilities are also proposed in children with fixed shortening e.g. combining the toxin with stretching casts.     

Stimulated gracilis neosphincter: a new procedure for anal incontinence

Creutzfeldt-Jakob disease (CJD) is a transmissible neurodegenerative disorder characterized by the accumulation of proteinase-resistant prion protein (PrP) in the brain. Pathological changes in the cerebellum are common and include atrophy of the granular layer, spongiform change in the molecular layer, and astrocytic gliosis of the cerebellar cortex and white matter. In most cases of sporadic CJD immunohistochemistry for PrP shows widespread granular deposits of the scrapie isoform of the prion protein (PrPSc) in the cerebellar cortex. In a minority of cases plaque-like deposits of PrPSc are detectable. The genetic background of this phenomenon was investigated in 47 cases of sporadic CJD. Immunohistochemistry using antibodies against PrP was performed in brain autopsy specimens. A genetic analysis of the prion protein gene (PRNP) showed overrepresentation of homozygosity for either methionine (M/M) or valine (V/V) at the polymorphic codon 129 in CJD patients as compared to 74 controls. No significant difference in allele frequency between the 2 groups was found. Plaques or plaque-like PrPSc deposits were found in 9 cases of CJD and were associated with the presence of valine at codon 129 on at least 1 allele of PRNP. CJD patients homozygous for valine (V/V) were on an average more than 5 years younger than patients with M/M or M/V at codon 129.     

The injured larynx: a new surgical procedure for repair

This case illustrates an instance by which serious stricture of the subglottic lumen was repaired by a composite pedicle graft. A half circular portion of the normal clavicle cortical bone was incorporated in a regional full-thickness pedicle graft. A defect in the cricoid cartilage and adjacent tissues was thus repaired successfully, preserving the patient's physiologic integrity as to breathing, speaking, coughing, eating, and drinking.     

Narrative elaboration: Test of a new procedure for interviewing children.

Because young children provide incomplete accounts of the past and tend to acquiesce to leading questions, procedures are needed to help them describe past events fully, without contaminating memory. This study tests the efficacy of "narrative elaboration," an innovative procedure designed to expand children's spontaneous reports of past events, reducing the need for leading questions. One hundred thirty-two children from 2 age groups (7–8 years and 10–11 years) were assigned randomly to 1 of 3 preparation conditions: (a) narrative elaboration intervention, (b) instruction based intervention, and (c) control group. After participating in a staged activity and subsequent preparation sessions, children were interviewed about the activity. Children in the narrative elaboration condition demonstrated a 53% improvement in spontaneous recall over the control group, without compromising accuracy. Younger children using the narrative elaboration procedure performed at the level of older children in the control group. Discussion centers on implications for interviewing child witnesses and preparing them for courtroom examination. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Posterior proctomucosectomy and ileal pull-through reconstruction: a new restorative procedure after total proctocolectomy

We reported a new method of restorative proctocolectomy using posterior approach and pull-through reconstruction. This method obviated transanal manipulation, a major factor causing damage to the internal sphincter, thus preventing fecal incontinence due to sphincter dysfunction. Also, temporary ileostomy was not necessary because the spout of an S-pouch was pulled down below the anal verge and its distal free end acted as a diverting stoma while the more proximal, healing zone (future anastomotic line) was kept from fecal contamination. This method was applied to a 32-year-old woman with familial polyposis coli and a 50-year-old woman with ulcerative colitis. Their bowel movements steadily decreased to three times and five times a day, respectively. There was no fecal leakage or perianal excoriation. The advantages as well as disadvantages of this method compared with the conventional techniques were discussed.     

Laparoscopic hepatic resection: a new and safe procedure by abdominal wall lifting method

HCC is well known for its high incidence of intrahepatic tumor recurrence and many patients suffering from them, usually undergo further treatments, such as PEI, TAE, MCNT or hepatic resection. However, conventional hepatic resection by large skin incision causes severe intraabdominal adhesions, which disturb US examination and further treatments. The aim of the laparoscopic procedure is to prevent intraabdominal adhesions. This is a study of the feasibility of laparoscopic hepatic resection without CO2 pneumoperitoneum, which is not yet popular, as a safe and effective procedure. The patient in this study had a solitary HCC in the lateral segment. Mobilization of the lateral segment, dissections of the left hepatic artery and portal venous branches, i.e. P2 and P3, were performed under CO2 gas insufflation. However, to avoid CO2 gas embolism, further procedures, including parenchymal compression and hepatic venous dissection, were performed using the abdominal wall lifting method without pneumoperitoneum. The patient could eat on the second postoperative day and had an uneventful postoperative recovery and was discharged from the hospital 13 days after surgery. Hospital stay was shorter than conventional hepatic resections with large skin incisions. The importance of this procedure lies in that it is not only a minimally invasive procedure, but also provides us with the possibilities of further treatments, including PEI and re-hepatic resection.     

Reconstruction of the posterior cruciate ligament: preliminary report of a new procedure

The integrity of the posterior cruciate ligament is necessary for the stability of the knee. The popliteus tendon is a promising, practical, and anatomical donor for reconstructing the posterior cruciate ligament. The procedure can be performed relatively easily using a posterolateral Henderson incision in association with the standard anteromedial parapatellar approach. We have performed the operation in 2 patients, produced good results at 4 and 6 month follow-up examination.     

Assessment of retrograde amnesia: Findings with a new public events procedure.

Existing public events tests for retrograde amnesia quickly become out of date and require frequent restandardization. The initial development of the Oscar Test is reported, which requires Ss to match the titles of Academy Award winning movies with the years in which they were made, a procedure that updates itself automatically every year. Data from 25 normal Ss and 7 patients with severe anterograde amnesia are presented. As a group, the patients demonstrated significant impairment, misdating movies by an average of 14 yrs. Several individual amnesic patients were much more impaired and produced profiles similar to those found on other remote memory tests. Performance on the Oscar Test tended to parallel performance on the Autobiographical Memory Interview in revealing mild, time-limited retrograde amnesia in some patients and severe, temporally extensive retrograde amnesia in others. Neuropathology outside the classical memory system may be required for the latter type. (PsycINFO Database Record (c) 2010 APA, all rights reserved)