Botulinum and tetanus neurotoxins: structure, function and therapeutic utility

Peripheral and central neurobiological effects of botulinum toxin A (BoNT/A) in neuropathic pain: a systematic review

ABSTRACT

Botulinum toxin (BoNT), a presynaptic inhibitor of acetylcholine (Ach) release at the neuromuscular junction (NMJ), is a successful and safe drug for the treatment of several neurological disorders. However, a wide and recent literature review has demonstrated that BoNT exerts its effects not only at the "periphery" but also within the central nervous system (CNS). Studies from animal models, in fact, have shown a retrograde transport to the CNS, thus modulating synaptic function. The increasing number of articles reporting efficacy of BoNT on chronic neuropathic pain (CNP), a complex disease of the CNS, demonstrates that the central mechanisms of BoNT are far from being completely elucidated. In this new light, BoNT might interfere with the activity of spinal, brain stem, and cortical circuitry, modulating excitability and the functional organization of CNS in healthy conditions. Botulinum toxins efficacy on CNP is the result of a wide and complex action on many and diverse mechanisms at the basis of the maladaptive plasticity, the core of the pathogenesis of CNP. This systematic review aims to discuss in detail the BoNT's mechanisms and effects on peripheral and central neuroplasticity, at the basis for the clinical efficacy in CNP syndromes.

Effect of refractive errors on the results of botulinum neurotoxin administration in patients with infantile esotropia

PURPOSE

To investigate the effect of refractive errors on the results of patients followed up with infantile esotropia (IE) and treated with botulinum neurotoxin (BNT) injection.

METHODS

The files of patients with IE who presented to the ophthalmology pediatric ophthalmology unit and underwent BNT injection into both medial rectus muscles between 2019 and 2021 were reviewed retrospectively. Sixty eyes of 30 patients were included in the study. Patients with additional systemic or ocular diseases and those with a history of ocular surgery were excluded. Distance and near deviations were measured (with the prism cover test or Krimsky method) before and at the first, third, and sixth months after BNT injection.

RESULTS

In Group 1 (n = 20) with a spherical equivalent of + 2.0 diopters (D) or less, the mean near and distance deviation value was both 36.8 ± 12.7 prism diopter (PD) before injection. In Group 2 (n = 10) with a spherical equivalent of above + 2.0 D, the near deviation was measured as 35.0 ± 7.1 PD and distance deviation as 31.8 ± 7.9. At six months after BNT injection, the near and distance deviation values were 20.6 ± 12.3 and 20.6 ± 11.6 PD, respectively in Group 1 and 10.1 ± 10.3 and 8.8 ± 10.8 PD, respectively in Group 2. The change in deviation did not statistically significantly differ between the groups (p > 0.05), but the distance and near deviation values were lower in Group 2 at sixth months after BNT injection.

CONCLUSIONS

BNT injection is a preferred method in IE. Higher hypermetropic values seem to increase the success of BNT injection.

Experimental study on the effect and mechanism of adipose stem cell-derived exosomes combined with botulinum toxin A on skin trauma in rats

BACKGROUND

Adipose stem cell-derived exosomes (ADSC-EXO) and botulinum toxin type A (BTX-A) individually showed a therapeutic effect on skin wound repair.

AIMS

This study investigated their synergistic effect on promoting skin wound healing in vitro and in vivo and the underlying molecular events.

METHODS

ADSCs were isolated from Sprague-Dawley (SD) rats to obtain ADSC-EXO by ultrafiltration and ultracentrifugation and were confirmed using nanoparticle tracking analysis and transmission electron microscopy. Human skin fibroblasts (HSF) were cultured and treated with or without ADSC-EXO, BTX-A, or their combination. Changes in cell phenotypes and protein expression were analyzed using different in vitro assays, and a rat skin wound model was used to assess their in vivo effects.

RESULTS

The isolated ADSC-EXO from primarily cultured ADSCs had a circular vesicle shape with a 30-180 nm diameter. Treatment of HSF with ADSC-EXO and/or BTX-A significantly accelerated HSF migration in vitro and skin wound healing in a rat model. Moreover, ADSC-EXO plus BTX-A treatment dramatically induced VEGFA expression but reduced COL III and COL I levels in vivo. ADSC-EXO and/or BTX-A treatment significantly upregulated TGF-β3 expression on Day 16 after surgery but downregulated TGF-β1 expression, suggesting that ADSC-EXO plus BTX-A promoted skin wound healing and reduced inflammatory cell infiltration.

CONCLUSIONS

The ADSC-EXO plus BTX-A treatment demonstrated a synergistic effect on skin wound healing through upregulation of VEGF expression and the TGF-β3/TGF-β1 and COL III/COL I ratio.

The efficacy of botulinum toxin type A treatment and surgery for acute acquired comitant esotropia

Aim

To compare the long-term efficiency of botulinum toxin type A (BTXA) injection and surgery on acute acquired comitant esotropia (AACE).

Methods

This retrospective study enrolled patients with AACE from January 2020 to August 2022. The horizontal angle of deviation pre- and post-treatment was measured. Deviations in BTXA and surgical treatment were compared. The BTXA group was divided into adequate treatment (AT) and inadequate treatment (inAT) subgroup based on the deviation of no more than 4 prism diopters (at near and distance) or temporary exotropia at the 2 week follow-up. The two subgroups were compared to determine the long-term efficacy of BTXA treatment.

Results

Ninety-two patients with AACE were included. Follow-up was 6 months. The deviations of the surgery and BTXA group were significantly smaller at the 6 month follow-up than at pre-treatment (p < 0.001). The deviation before treatment in the surgery group was larger than in the BTXA groups (p < 0.001) but smaller at the 6 month follow-up (p < 0.001). The deviation was similar in the AT-BTXA and inAT-BTXA subgroups before treatment (p = 0.322 for distance and p = 0.051 for near) but smaller in the AT-BTXA subgroup at 6 month follow-up (p < 0.001 for near and distance).

Conclusion

Surgery and BTXA successfully treat AACE. Surgery has a more precise and lasting therapeutic effect than BTXA. AACE patients adequately treated with BTXA and with deviations of no more than 4 prism diopters at 2 weeks follow-up had better outcomes.

Soil microbiome influences human health in the context of climate change

Soil microbiomes continue to evolve and shape the human microbiota according to external anthropogenic and climate change effects. Ancient microbes are being exposed as a result of glacier melting, soil erosion and poor agricultural practices. Soil microbes subtly regulate greenhouse gas emissions and undergo profound alterations due to poor soil maintenance. This review highlights how the soil microbiome influences human digestion processes, mineral and vitamin production, mental health and mood stimulation. Although much about microbial functions remains unknown, increasing evidence suggests that beneficial soil microbes are vital for enhancing human tolerance to diseases and pathogens. Further research is essential to delineate the specific role of the soil microbiome in promoting human health, especially in light of the increasing anthropogenic pressures and changing climatic conditions.

Therapeutic Applications of Botulinum Neurotoxins in Veterinary Medicine

Botulinum neurotoxins (BoNTs) are emerging as multipurpose therapeutic compounds for the treatment of several different syndromes involving peripheral and central nervous systems, and muscular and musculoskeletal disorders both in human and veterinary medicine. Therefore, the study of BoNTs is rapidly developing and identifying newly produced BoNT variants. Efforts should be made to clarify the biological and pharmacological characteristics of these novel BoNTs as well as the natural ones. The high potential of BoNTs as a therapeutic compound for medical syndromes lies in its ability to reach a specific cell type while bypassing other cells, thus having mild or no side effects. In this paper the recent developments in BoNTs are reviewed with the aim of analyzing the current knowledge on BoNTs' biological mechanisms of action, immunogenicity, formulations, and therapeutic applications in the veterinary field, highlighting advantages and drawbacks and identifying the gaps to be filled in order to address research priorities.

Dual therapy with Erenumab and onabotulinumtoxinA: No synergistic effect in chronic migraine: A retrospective cohort study

OBJECTIVE

To assess whether dual therapy with erenumab and onabotulinumtoxinA (BoNTA) was more effective than erenumab alone in chronic migraine.

BACKGROUND

Calcitonin gene-related peptide (CGRP) is crucial in migraine. Erenumab binds to the canonical CGRP receptor in Aδ-fibers, and BoNTA prevents the release of CGRP from meningeal and extracranial C-fibers. It is still unknown whether dual therapy is more effective.

METHODS

This was a retrospective study in a Headache Unit. There was a thorough revision of charts of patients receiving erenumab from December 2019 to March 2021. The cohort was divided into three groups according to BoNTA at the start of erenumab: (1) WBT: were on BoNTA and maintained it as dual therapy; (2) WoBT: were on BoNTA and discontinued; (3) NoBT: were not on BoNTA. Primary endpoint was reduction in monthly headache days (MHD) at 12 weeks. Secondary endpoints were percent improvement and ≥50% reduction in MHD.

RESULTS

Of 237 charts reviewed, 187 met the inclusion criteria. Seventy-three (39%) were included in WBT, 44 (23.5%) in WoBT, and 70 (37.4%) in NoBT. The reduction in MHD was less with dual therapy [WBT 4.7 ± 7.68, WoBT 5.12 ± 7.98 (p = 0.80), NoBT 8.21 ± 7.84 p = 0.009]. The percentage of improvement was higher in the erenumab-alone group [NoBT 35%, WoBT 22.3% (p = 0.92), WBT 21.7% (p = 0.001)]. The probability of achieving a ≥ 50% reduction in MHD was lower in WBT than in WoBT (OR 0.66, p = 0.35) and in the NoBT group (OR 0.57, p = 0.14).

CONCLUSIONS

Our findings suggest that dual therapy is less effective than erenumab alone. However, since the design has multiple limitations, further prospective studies are required to validate these data.

Botulinum Neurotoxin Type A Directly Affects Sebocytes and Modulates Oleic Acid-Induced Lipogenesis

Excess sebum (seborrhea) results in oily skin and is associated with large pore size and acne. Studies in healthy, seborrheic volunteers have reported that intradermal injection of commercial preparations of botulinum neurotoxin type A (BoNT/A) (onabotulinumtoxinA, abobotulinumtoxinA, and incobotulinumtoxinA) reduced sebum production, and thus, skin oiliness and pore size. The mechanism for these effects has not been fully elucidated; however, several theories involving direct or indirect effects of BoNT/A on neuronal and/or dermal cells (e.g., sebocytes) have been proposed. In the present study, we evaluated the direct effect of native research grade BoNT/A complex, a commercial preparation of BoNT/A (onabotA), and BoNT/A variants on sebocyte lipogenesis using an in vitro sebocyte cell model. We show that picomolar concentrations of BoNT/A (BoNT/A complex: half maximal effective concentration [EC₅₀] = 24 pM; BoNT/A 150 kDa: EC₅₀ = 34 pM) modulate sebocyte lipogenesis and reduce oleic acid-induced sebocyte differentiation, lipogenesis, and holocrine-like secretion. Comparative studies with the binding domain of BoNT/A, which lacks enzymatic activity, show that this effect is independent of the enzymatic activity of BoNT/A and likely occurs via sebocyte cell surface receptors (e.g., fibroblast growth factor receptors). Overall, these results shed light on the potential mechanism of action and rationale for use of BoNT/A for treatment of sebum-related conditions.

Characterization of Neutralizing Human Anti-Tetanus Monoclonal Antibodies Produced by Stable Cell Lines

Tetanus toxin (TeNT) is produced by C. tetani, a spore-forming bacillus broadly spread in the environment. Although an inexpensive and safe vaccine is available, tetanus persists because of a lack of booster shots and variable responses to vaccines due to immunocompromised status or age-decreased immune surveillance. Tetanus is most prevalent in low- and medium-income countries, where it remains a health problem. Neutralizing monoclonal antibodies (mAbs) can prevent the severity of illness and death caused by C. tetani infection. We identified a panel of mAbs that bind to TeNT, some of which were investigated in a preclinical assay, showing that a trio of mAbs that bind to different sites of TeNT can neutralize the toxin and prevent symptoms and death in mice. We also identified two mAbs that can impair the binding of TeNT to the GT1b ganglioside receptor in neurons. In this work, to generate a series of cell lines, we constructed vectors containing sequences encoding heavy and light constant regions that can receive the paired variable regions resulting from PCRs of human B cells. In this way, we generated stable cell lines for five mAbs and compared and characterized the antibody produced in large quantities, enabling the characterization experiments. We present the results regarding the cell growth and viability in a fed-batch culture, titer measurement, and specific productivity estimation. The affinity of purified mAbs was analyzed by kinetics and under steady-state conditions, as three mAbs could not dissociate from TeNT within 36,000 s. The binding of mAbs to TeNT was confirmed by ELISA and inhibition of toxin binding to GT1b. The use of the mAbs mixture confirmed the individual mAb contribution to inhibition. We also analyzed the binding of mAbs to FcγR by surface plasmon resonance (SPR) and the glycan composition. Molecular docking analyses showed the binding site of an anti-tetanus mAb.

Clostridial Diseases (Botulism and Tetanus)

Botulism and tetanus are the 2 primary manifestations of neurologic disease caused by clostridial toxins. Only a small dose of clostridial toxin is required to induce severe, and often fatal, disease. Consequently, definitive diagnosis of either disease is nearly impossible to achieve antemortem or postmortem; presumptive diagnosis is usually made based on physical and neurologic examination findings. Because the severity of clinical signs can worsen rapidly, prognosis worsens when therapeutic intervention is delayed. Highly effective vaccines are available against both botulism and tetanus and are critical in preventative approaches to control.

Multi-dimensional nanoscale liquid chromatography and nano-electrospray ion-trap mass spectrometry for detection of Clostridium botulinum type C and the produced botulinum neurotoxin type C complex

Botulinum neurotoxin types C, D and their mosaic forms C/D and D/C produced mainly by Clostridium botulinum types C and D cause botulism in animals and belong to the most toxic substances for poultry and fish. In addition to intoxications, also toxoinfections with C. botulinum types C and D play a role that should not be underestimated, especially in veterinary medicine. Contrary to other botulinum neurotoxin complexes (BT x), the biosynthesis of these types is phage-encoded. Currently, the gold standard for neurotoxin detection in cases of clinical botulism is the mouse bioassay. In the last few years, alternatives for replacing this mouse bioassay have become increasingly interesting for the detection and characterisation of botulinum neurotoxins. Therefore, immunological techniques based mainly on antibodies, PCR or mass spectral methods have been developed. In this context, the most promising development is that of different endopeptidase assays. In our study, we were able to show that the 2D-nano-LC-MS/MS method presented by Klaubert et al. 2009 especially for detecting BT x A, B, E and F in complex culture media can also be used for detecting BT x C. The focus was therefore on transferring this method to detecting BT x C and pointing out necessary modifications of this current method. For method development, we used different culture preparations and sample conditions. To find out whether BT x C is just as stable against acetic peptic pretreatment as other BT x, we used sample preparations with and without peptic pretreatment. The decisive difference to previous publications is the detection of produced BT x C directly from culture supernatant of different strains of C. botulinum type C. In addition, we present a new approach of detecting protein fragments from C3 and C2 toxin and some specific host cell proteins of the bacterium Clostridium spp. in order to specify the carrier bacterium, therefore verifying the presence of an intact neurotoxin-encoding phage also without directly detecting BT x C and thus the possibility to produce neurotoxin. Herein, we describe a new method to examine environmental samples or suspected feed samples in cases of toxoinfections as well as finding out the causes of clinical botulism. This new approach is particularly interesting for veterinary medicine, especially for diseases like chronic botulism in cows or equine grass sickness.

The changing face of trigeminal neuralgia-A narrative review

OBJECTIVE

This narrative review aims to update the reader on the new classification of trigeminal neuralgia (TN), clinical signs, pathophysiologic evidence, and their implications on management. This review is based on the authors' collective experience and knowledge of the literature in addition to a literature search.

BACKGROUND

In recent years, the phenotype of TN has been intensively studied leading to discrete groups of patients. These include patients with TN with additional continuous pain, and patients with and without neurovascular compression of the trigeminal dorsal root entry zone. A number of associated clinical signs such as tearing and sensory changes need further research.

METHODS

The literature on TN was searched in PubMed with the aims of providing evidence for the recently published third edition of the International Classification of Headache Disorders (ICHD) and update the clinical phenotype and management of the TN subcategories.

RESULTS

The ICHD's new classification for TN is based on reliable clinical data, imaging, and neurophysiologic studies. The TN classification reflects current knowledge and has improved the possibility for clinicians to choose adequate management options. However, there is a lack of effective, safe drugs for the management of TN and sparse, robust data on neurosurgical options.

CONCLUSION

Research into all aspects of TN-diagnosis, pharmacotherapy, surgery, long-term management prognosis, and natural history-is needed. Research should adhere to the ICHD's schema for TN. Improved drugs are needed along with rigorous research into surgical options and their efficacy for different subtypes of TN.

Botulinum toxin in the management of primary and secondary Raynaud's phenomenon

Raynaud's phenomenon (RP) is common in rheumatic diseases. In the setting of systemic sclerosis (SSc), it can be complicated by digital ischemia that includes ulceration and gangrene. Systemic adverse effects may preclude the use of oral or topical vasodilators for the treatment of RP and its complications. In this article, we review effectiveness/efficacy of botulinum toxin injection in primary and secondary RP. We discuss botulinum toxin formulations, dosage, sites of administration, and adverse effects. The evidence for botulinum toxin in the treatment of primary and SSc-associated RP is promising. Consistency across patient populations, treatment options (botulinum serotype, dose, and injection site), and outcome measures will be essential for further research.

The Effect of Botulinum Toxin on Flap Viability of the Posterior Thigh Perforator Flap in Rats

BACKGROUND

The use of perforator propeller flaps in lower limb reconstruction has increased recently. Many pharmacological agents are used to increase flap viability. Botulinum toxin has been used in various types of flaps in the literature. However, there is no study regarding the use of botulinum toxin in the lower limb propeller flaps. This study investigates the effect of botulinum toxin administration on flap survival for lower limb propeller flap in rats.

MATERIALS AND METHODS

The study included 20 male Wistar albino rats, divided into two groups with a flap rotation of 90° in group 1 and 180° in group 2. In both groups, botulinum toxin was administered to the right thigh and a physiological saline solution was applied to the left thigh. Five days later, flaps were elevated over the posterior aspect of the right and left thighs and inset after 90° and 180° rotation was performed. Histopathological, immunohistochemical, and necrosis area analyses were performed.

RESULTS

Necrosis area, edema, polymorphonuclear leukocyte infiltration, and necrosis were found to be higher on the left side of the groups, whereas epidermal thickness, collagen density, vascularization, and hair root density were found to be higher on the right side of the groups. No significant difference was found between the right posterior thighs in either group on any parameter other than vascularization. Histopathologically and immunochemically statistically significant differences were found between the two groups.

CONCLUSIONS

The present study found that botulinum toxin increases flap viability in lower limb perforator-based propeller flaps.

Characterization of clostridium botulinum neurotoxin serotype A (BoNT/A) and fibroblast growth factor receptor interactions using novel receptor dimerization assay

Clostridium botulinum neurotoxin serotype A (BoNT/A) is a potent neurotoxin that serves as an effective therapeutic for several neuromuscular disorders via induction of temporary muscular paralysis. Specific binding and internalization of BoNT/A into neuronal cells is mediated by its binding domain (H_C/A), which binds to gangliosides, including GT1b, and protein cell surface receptors, including SV2. Previously, recombinant H_C/A was also shown to bind to FGFR3. As FGFR dimerization is an indirect measure of ligand-receptor binding, an FCS & TIRF receptor dimerization assay was developed to measure rH_C/A-induced dimerization of fluorescently tagged FGFR subtypes (FGFR1-3) in cells. rH_C/A dimerized FGFR subtypes in the rank order FGFR3c (EC₅₀ ≈ 27 nM) > FGFR2b (EC₅₀ ≈ 70 nM) > FGFR1c (EC₅₀ ≈ 163 nM); rH_C/A dimerized FGFR3c with similar potency as the native FGFR3c ligand, FGF9 (EC₅₀ ≈ 18 nM). Mutating the ganglioside binding site in H_C/A, or removal of GT1b from the media, resulted in decreased dimerization. Interestingly, reduced dimerization was also observed with an SV2 mutant variant of H_C/A. Overall, the results suggest that the FCS & TIRF receptor dimerization assay can assess FGFR dimerization with known and novel ligands and support a model wherein H_C/A, either directly or indirectly, interacts with FGFRs and induces receptor dimerization.

New technology to improve the thermal stability of botulinum toxin type D by biomimetic mineralization

The advanced biomimetic mineralization technology was applied to protect the Botulinum neurotoxin type D, and the processing of the mineralization granule of botulinum toxin type D was successfully screened. The loss of activity of the toxin protein at different temperatures and the destructive strength of the gastrointestinal tract against the toxin were determined biologically. The lethal toxicity of the mineralized toxin to wild rodents was determined by median lethal dose. Protective tests at different temperatures showed that the preservation period of botulinum toxin type D mineralized sample 2 was significantly higher than that of the control group at three different temperatures, and its toxicity loss was significantly reduced. The damage intensity of the mineralized toxin to the gastrointestinal contents of plateau zokor and plateau pika was significantly reduced. The minimum lethal doses of the mineralized toxin particles to plateau zokor, plateau pika, and mice were 5200, 8,600,000, and 25,000 MLD/kg. These results showed that biomimetic mineralization could greatly improve the thermal stability of botulinum toxin type D and reduce the damaging effect of the gastrointestinal contents of target animals to botulinum toxin type D. The mineralized toxin could be used to control the population density of urban rodents. This research provides new insights into the protection of toxin protein substances.

New approach for the rational selection of markers to identify botulinum toxins

The application of mass spectrometry (MS) to detect unique peptide markers has been widely employed as a means of identifying bacterial proteins. Botulinum neurotoxins (BoNTs) are bacterial proteins that cause the life-threatening disease botulism. BoNTs are divided into several antigenically distinct serotypes and several dozen subtypes. The toxins' molecular heterogeneity makes their detection highly challenging. In this study, we describe a new LC-MS/MS-based platform for the direct identification of proteins derived from various species and subspecies in a single assay, as exemplified by BoNTs. The platform employs a rational down-selection process through several steps based on a combination of bioinformatics, tryptic digestion, and LC-MS, each leads to the final panel of markers. This approach has been demonstrated for all 8 subtypes of botulinum serotype A (BoNT/A). Ab-independent and Ab-dependent assays were developed based on the identification of 4 rationally selected markers or a combination of some of them, which enables full selectivity coverage. The Ab-independent assay, which is highly simple and rapid, has a sample-to-result turnaround time of approximately 40 min and enables the identification of 500 MsLD₅₀/mL (5 ng/mL) BoNT/A in complex environmental matrices. The Ab-dependent assay, which is based on toxin's specific enrichment, has a turnaround time of 100 min, but enables improved sensitivity (50 MsLD₅₀/mL, 0.5 ng/mL). Both assays were verified and validated using various environmental samples. This approach can easily be expanded to other botulinum serotypes and exhibits the potential for even further extension as a highly multiplexed assay for protein-based toxins, viruses, and organisms.

Botulinum Toxin Injection with Conjunctival Microincision for the Treatment of Acute Acquired Comitant Esotropia and Its Effectiveness

Purpose

To report on an improved botulinum toxin injection with conjunctival microincision for beginners, and to determine the effectiveness of botulinum toxin A (BTXA) in the treatment of patients with acute acquired comitant esotropia (AACE).

Methods

Medical records of 29 AACE patients were retrospectively analyzed. BTXA was injected into the unilateral or bilateral medial rectus muscle with conjunctival microincision without electromyographic guidance. Success was defined as total horizontal deviation ≤10 prism diopters (PD) and evidence of binocular vision.

Results

Twenty-nine patients were included, of whom 22 were male and 7 were female. The mean age at onset was 14.2 ± 7.4 (range, 4-34) years. The mean time from onset of AACE to injection was 18.4 ± 20.3 (range, 1-96) weeks. All patients completed at least 6 months of follow-up, and the mean follow-up after BTXA injection was 12.3 ± 4.8 months (range, 7-24 months). Neurological evaluation and brain magnetic resonance imaging (MRI) were unremarkable in all patients. The mean spherical equivalent refraction was -1.22 ± 2.85D and -0.97 ± 2.80D in the right and left eyes, respectively. Mean preinjective esotropia was 38.4 ± 18.9 PD (range, +10-+80 PD) at near and 40.2 ± 17.7 PD (range, +20-+80 PD) at far distance. The mean angle of deviation at 6 months after injection was 0.6 ± 4.1 PD (range, -3-+15 PD) at near and 3.0 ± 5.9 PD (range, 0-+20 PD) at far distance. There was significant difference in the angle of deviation at near and far fixation between pre-BTXA and post-BTXA 6 months (p < 0.001, p < 0.001, resp.). There was no significant difference in the angle of deviation at near and far fixation between post-BTXA 6 months and post-BTXA at final follow-up (p = 0.259 and 0.326, resp.). Mean stereoacuity improved from 338 to 88 arc seconds. During the follow-up period, 5 of 29 patients had recurrent esotropia. Two patients refused all further treatment, and the other 3 patients required incisional strabismus surgery. The success rates were 86.2% (25/29) at 6 months and 82.8% (24/29) at final follow-up.

Conclusion

Conjunctival microincision injection of botulinum toxin is a practical and safe method for beginners to locate an extraocular muscle, which is as effective as the traditional methods. Botulinum toxin injection can be preferred as the first-line treatment for AACE patients with potential binocular vision.

Functional acute acquired comitant esotropia: clinical characteristics and efficacy of single Botulinum toxin type A injection

Background

To examine the clinical features of acute acquired comitant esotropia (AACE) and to evaluate the clinical effectiveness of a single injection of botulinum toxin type A (BTXA) on binocular visual function (BVF).

Methods

This retrospective, observational case series study enrolled patients with AACE examined from October 2018–May 2019. BTXA was injected into the both medial rectus muscles. The refractive error, best-corrected visual acuity (BCVA), stereoacuity, vergence, accommodation, the horizontal angle of deviation, and the gradient accommodative convergence/accommodation (AC/A) ratio were measured pre- and post-BTXA injection. Data pre- and postinjection were compared by the Wilcoxon signed-rank test. A Spearman correlation coefficient was calculated to explore the relationships between demographic characteristics and BVF.

Results

Twenty-two AACE cases were included. Compared with preinjection deviation, the postinjection deviation in the primary position was smaller for near (p < 0.001) and distance (p < 0.001) fixation at 3 months after injection (BTXA). Furthermore, convergence was better for near (p = 0.003) and distance (p < 0.001) fixation, divergence was better for near (p = 0.021) and distance (p < 0.001) fixation, accommodation was better in the right (p = 0.011) and left (p = 0.004) eyes, and the gradient AC/A ratio was better at the third month after injection (p = 0.001). Stereoacuity was improved in 11 (50%), unchanged in 5 (22.73%) and decreased in 6 (27.27%) patients. The preinjection stereoacuity (p = 0.013, r = 0.522) and preinjection deviation for near (p = 0.015 r, = − 0.512) and distance (p = 0.009, r = − 0.541) were significantly associated with patient age.

Conclusions

AACE is characterized by a high AC/A ratio and low accommodation. A single injection of BTXA is effective for AACE. Deviation, stereoacuity, and the therapeutic effect of BTXA may be correlated with patient age.

Inactivated tetanus as an immunological smokescreen: A major step towards harnessing tetanus-based therapeutics

BACKGROUND AND PURPOSE

Tetanus neurotoxin has many potential therapeutic applications, due to its ability to increase localised muscle tone when injected directly into a muscle. It is a closely related molecule to botulinum neurotoxin (most commonly known as Botox), which has been widely used to release muscle tension for therapeutic and cosmetic applications. However, tetanus toxin has been relegated to the "maybe pile" for protein therapeutics - as most of the population is vaccinated, leading to highly effective antibody-mediated protection against the toxin. The potential for tetanus-based therapeutics remains substantial if the problem of pre-existing immunity can be resolved.

EXPERIMENTAL APPROACH

A well-established murine model of localised muscular contraction was utilised. We administered functional tetanus toxin combined with an immunogenic, but functionally inactive, decoy molecule.

KEY RESULTS

Incorporation of the decoy molecule greatly reduces the dose of active toxin required to induce a localised increase in muscle tone in mice vaccinated with the human toxoid vaccine.

CONCLUSION AND IMPLICATIONS

Our results clearly demonstrate that the barriers to developing a tetanus toxin therapeutic are not insurmountable and the technology presented here is the first major step towards realising the therapeutic potential of this powerful neurotoxin. Opening the therapeutic potential of tetanus toxin will have huge implications for the wide range of diseases caused by low-tone muscle.

Characterization of immune response induced against catalytic domain of botulinum neurotoxin type E

Botulinum neurotoxins (BoNTs) represent a family of bacterial toxins responsible for neuroparalytic disease 'botulism' in human and animals. Their potential use as biological weapon led to their classification in category 'A' biowarfare agent by Centers for Disease Control and Prevention (CDC), USA. In present study, gene encoding full length catalytic domain of BoNT/E-LC was cloned, expressed and protein was purified using Ni-NTA chromatography. Humoral immune response was confirmed by Ig isotyping and cell-mediated immunity by cytokine profiling and intracellular staining for enumeration of IFN-γ secreting CD4⁺ and CD8⁺ T cells. Increased antibody titer with the predominance of IgG subtype was observed. An interaction between antibodies produced against rBoNT/E-LC was established that showed the specificity against BoNT/E in SPR assay. Animal protection with rBoNT/E-LC was conferred through both humoral and cellular immune responses. These findings were supported by cytokine profiling and flow cytometric analysis. Splenocytes stimulated with rBoNT/E-LC showed a 3.27 and 2.8 times increase in the IFN-γ secreting CD4⁺ and CD8⁺ T cells, respectively; in immunized group (P < 0.05). Protection against BoNT/E challenge tended to relate with increase in the percentage of rBoNT/E-LC specific IL-2 in the splenocytes supernatant (P = 0.034) and with IFN-γ-producing CD4⁺ T cell responses (P = 0.045). We have immunologically evaluated catalytically active rBoNT/E-LC. Our results provide valuable investigational report for immunoprophylactic role of catalytic domain of BoNT/E.

Effect of perivascular low dose ethanol on rat femoral vessels: Preliminary study

Vasospasm is one of the important causes of morbidity in free flap and replantation surgery. In secondary Raynaud's phenomenon, nearly half of the patients experience digital ulceration, pain and loss of function at least once in their lifetime. The aim of this study is to investigate the vasodilation effect of ethanol-mediated chemical denervation on peripheral vessels by topical administration. In this study, 27 Wistar albino male rats weighing 250-300 grams were used. The rats were randomly divided into three groups: saline (group S, n = 8), lidocaine (group L, n = 9) and 96% ethanol (group E, n = 9). According to group, 0.1 mL saline, 0.1 mL lidocaine and 0.1 mL ethanol were applied around the rat femoral neurovascular bundle. After the application, on the 0th day and 3th weeks, femoral artery and vein diameters were measured. After 3. weeks, histopathological samples from femoral artery, vein and nerve were evaluated. On the 0th day, the mean diameter of the femoral artery and vein was similar in group E and L and higher than group S. After three weeks, the vasodilatation effect of ethanol was increased in group E. In Group L and S, the vasodilatation effect was lost. Histopathological examination showed that ethanol significantly caused perivascular inflammation and nerve degeneration compared to other agents and did not cause endothelial damage. Vasodilatation obtained by ethanol is a rapid onset and long-lasting effect. It is also inexpensive and effective for peripheral vasodilatation.

Protective efficacy of recombinant bacterin vaccine against botulism in cattle

Botulism is a paralytic disease caused by the intoxication of neurotoxins produced by Clostridium botulinum. Among the seven immunologically distinct serotypes of neurotoxins (BoNTs A - G), serotypes C and D, or a chimeric fusion termed C/D or D/C, are responsible for animal botulism. The most effective way to prevent botulism in cattle is through vaccination; however, the commercially available vaccines produced by detoxification of native neurotoxins are time-consuming and hazardous. To overcome these drawbacks, a non-toxic recombinant vaccine was developed as an alternative. In this study, the recombinant protein vaccine was produced using an Escherichia coli cell-based system. The formaldehyde-inactivated E. coli is able to induce 7.45 ± 1.77 and 6.6 ± 1.28 IU/mL neutralizing mean titers against BoNTs C and D in cattle, respectively, determined by mouse neutralization bioassay, and was deemed protective by the Brazilian legislation. Moreover, when the levels of anti-BoNT/C and D were compared with those achieved by the recombinant purified vaccines, no significant statistical difference was observed. Cattle vaccinated with the commercial vaccine developed 1.33 and 3.33 IU/mL neutralizing mean titers against BoNT serotypes C and D, respectively. To the best of our knowledge, this study is the first report on recombinant E. coli bacterin vaccine against botulism. The vaccine was safe and effective in generating protective antibodies and, thus, represents an industry-friendly alternative for the prevention of cattle botulism.

Can Botulinum Toxin A Still Have a Role in Treatment of Lower Urinary Tract Symptoms/Benign Prostatic Hyperplasia Through Inhibition of Chronic Prostatic Inflammation?

Patients with benign prostatic hyperplasia (BPH) can exhibit various lower urinary tract symptoms (LUTS) owing to bladder outlet obstruction (BOO), prostatic inflammation, and bladder response to BOO. The pathogenesis of BPH involves an imbalance of internal hormones and chronic prostatic inflammation, possibly triggered by prostatic infection, autoimmune responses, neurogenic inflammation, oxidative stress, and autonomic dysfunction. Botulinum toxin A (BoNT-A) is well recognized for its ability to block acetylcholine release at the neuromuscular junction by cleaving synaptosomal-associated proteins. Although current large clinical trials have shown no clinical benefits of BoNT-A for the management of LUTS due to BPH, BoNT-A has demonstrated beneficial effects in certain subsets of BPH patients with LUTS, especially in males with concomitant chronic prostatitis/chronic pelvic pain syndrome and smaller prostate. We conducted a review of published literature in Pubmed, using Botulinum toxin, BPH, BOO, inflammation, LUTS, and prostatitis as the key words. This article reviewed the mechanisms of BPH pathogenesis and anti-inflammatory effects of BoNT-A. The results suggested that to achieve effectiveness, the treatment of BPH with BoNT-A should be tailored according to more detailed clinical information and reliable biomarkers.

Identification of Inhibitors against Botulinum Neurotoxins: 8-Hydroxyquinolines Hold Promise

Botulinum neurotoxins (BoNTs) are the most toxic category A biological warfare agents. There is no therapeutics available for BoNT intoxication yet, necessitating the development of a medical countermeasure against these neurotoxins. The discovery of small molecule-based drugs has revolutionized in the last two decades resulting in the identification of several small molecule inhibitors of BoNTs. However, none progressed to clinical trials. 8-Hydroxyquinolines scaffold-based molecules are important 'privileged structures' that can be exploited as inhibitors of a diverse range of targets. In this review, our study of recent reports suggests the development of 8-hydroxyquinoline derived molecules as a potential drug may be on the horizon.

Botulinum Toxin a Valuable Prophylactic Agent for Migraines and a Possible Future Option for the Prevention of Hormonal Variations-Triggered Migraines

BACKGROUND

In 1989, Botulinum toxin (BoNT) was accepted by the FDA for the management of some ophthalmic disorders. Although it was initially considered a lethal toxin, in recent times, Botulinum toxin A (BoNT-A), which is the more used serotype, has expanded to cover different clinical conditions, primarily characterized by neuropathic pain, including migraines and headaches. Evidence suggests that migraines are influenced by hormonal factors, particularly by estrogen levels, but very few studies have investigated the prevalence and management strategies for migraines according to the hormonal status. The effects of several therapeutic regimens on migraines have been investigated, but the medications used varied widely in proven efficacies and mechanisms of action. BoNT-A is increasingly used in the management of migraine and several placebo-controlled trials of episodic and chronic migraine are currently underway. This paper is a review of the recently published data concerning the administration of BoNT-A in the prevention of chronic migraines. Considering the lack of population-based studies about the effectiveness of BoNT-A in the alleviation of premenstrual and perimenopausal migraines, this study proposes a new perspective of the therapeutic approach of migraine syndrome associated with menopausal transition and the premenstrual period.

METHODS

We selected the reviewed papers from CrossRef, PubMed, Medline, and GoogleScholar, and a total of 21 studies met our inclusion criteria.

RESULTS

To date, no specific preventive measures have been recommended for menopausal women with migraines. BoNT-A often reduces the frequency and intensity of migraine attacks per month; the treatment is well tolerated and does not exhibit a significantly higher rate of treatment-related side effects. No population-based studies were conducted in order to highlight the role of BoNT-A in menopause-related migraines, neither in menstrual migraines.

CONCLUSION

There is a need for further research in order to quantify the real burden of menstrual and perimenopausal migraines and to clarify if BoNT-A could be used in the treatment of refractory postmenopausal and premenstrual migraines.

Botulinum toxin type A applications for masticatory myofascial pain and trigeminal neuralgia: what is the evidence regarding adverse effects?

OBJECTIVES

The objective of the study was to conduct a systematic review of literature assessing botulinum toxin type A (BoNT-A) safety and adverse effects in the treatment of myofascial pain (MFP) and trigeminal neuralgia (TN).

MATERIALS AND METHODS

The search for articles by two specific researchers involved the PubMed, EMBASE, Web of Science, and Scopus databases. Specific terms were used, and no publication time and language restrictions were applied. Clinical trials that investigated the effects of BoNT-A among participants with myofascial pain in masticatory muscles or trigeminal neuralgia were considered eligible for this systematic review. Data for each study were extracted and analyzed according to a PICO-like structured reading.

RESULTS

The search strategy provided 436 citations. After analysis, 16 citations were included, seven for MFP and nine for TN. In all studies, BoNT-A was well tolerated and improved pain. The most common adverse effects were temporary regional weakness, tenderness over the injection sites, and minor discomfort during chewing. Most studies reported a spontaneous resolution of adverse effect.

CONCLUSIONS

It can be concluded that BoNT-A treatment is well tolerated, since minor adverse effects were the most frequently reported; however, it is recommended that future studies aim to assess the safety and possible adverse effects of multiples applications or high doses of this treatment.

CLINICAL RELEVANCE

BoNT-A has been increasingly diffused in dentistry, being used for the management of masticatory myofascial pain and trigeminal neuralgia. Nonetheless, there is no consensus about its efficacy and adverse effects that could occur when this treatment is applied.

Development and evaluation of candidate subunit vaccine and novel antitoxin against botulinum neurotoxin serotype E

Botulinum neurotoxins (BoNTs) are among the most toxic proteins. Vaccination is an effective strategy to prevent botulism. To generate a vaccine suitable for human use, a recombinant non-His-tagged isoform of the Hc domain of botulinum neurotoxin serotype E (rEHc) was expressed in Escherichia coli and purified by sequential chromatography. The immunogenicity of rEHc was evaluated in mice and dose- and time-dependent immune responses were observed in both antibody titers and protective potency. Then, the pilot-scale expression and purification of rEHc were performed, and its immunological activity was characterized. Our results showed rEHc has good immunogenicity and can elicit strong protective potency against botulinum neurotoxin serotype E (BoNT/E) in mice, indicating that rEHc is an effective botulism vaccine candidate. Further, we developed a novel antitoxin against BoNT/E by purifying F(ab')₂ from pepsin-digested serum IgG of rEHc-inoculated horses. The protective effect of the F(ab')₂ antitoxin was determined in vitro and in vivo. The results showed that our F(ab')₂ antitoxin can prevent botulism in BoNT/E-challenged mice and effectively alleviate the progression of paralysis caused by BoNT/E to achieve therapeutic effects. Therefore, our results provide valuable experimental data for the production of a novel antitoxin, which is a promising candidate for the treatment of BoNT/E-induced botulism.

Effect of Perivascular Injection of Botulinum Toxin Type A versus Lidocaine in Survival of Random Pattern Flaps in a Rat Model

BACKGROUND

Botulinum toxin type A has gained popularity in many clinical fields, for a variety of aesthetic and therapeutic purposes. In addition, there have been reports regarding the positive effect of botulinum toxin type A on flap survival by various mechanisms. This study examines the role of botulinum toxin type A and lidocaine in augmentation of flap survival and decreasing the rate of necrosis in random pattern cutaneous flaps.

METHODS

In 45 male Sprague-Dawley rats, random pattern skin flaps with different width-to-length ratios were elevated. Botulinum toxin type A, lidocaine, or saline was administered to the base and whole length of the flap. Flap survival was evaluated on day 10 after surgery. The area of flap survival was determined grossly on the basis of its appearance, color, and texture.

RESULTS

The botulinum toxin type A group had a greater survival area (p < 0.05) compared with the lidocaine or saline group in flaps with width-to-length ratios of 1:2 and 1:3; however, compared with a width-to-length ratio of 1:1, the flap survival rate shows no statistically significant variations.

CONCLUSION

Injection of botulinum toxin type A in random pattern skin flaps improves tissue perfusion and increases the rate of flap survival more than lidocaine in flaps with width-to-length ratios of 1:2 and 1:3.

Development and evaluation of candidate subunit vaccine against botulinum neurotoxin serotype B

Botulinum neurotoxins (BoNTs) are potential biological weapons because of their high toxicity and mortality. Vaccination is an effective strategy to prevent botulism. The carboxyl-terminus of the heavy chain (Hc domain) is nontoxic and sufficient to generate protective immune responses against natural BoNTs in animals. To produce a vaccine suitable for human use, a recombinant non His-tagged isoform of the Hc domain of botulinum neurotoxin serotype B (BHc) was expressed in Escherichia coli and purified by sequential chromatography. The immunogenicity of recombinant E.coli-expressed BHc and the yeast-expressed mBHc antigens was explored and compared in Balb/c mice. BHc provided comparable protective potency but elicited significantly higher antibody titer and neutralization potency against BoNT/B after twice immunization, indicating that the recombinant BHc protein expressed in E.coli have better immunogenicity than the yeast-expressed mBHc. Moreover, a frequency and dose-dependent effect was observed in mice immunized with BHc subunit vaccine and the anti-BHc ELISA antibody titers correlated well with neutralizing antibody titers and protection potency. In summary, the Alhydrogel-formulated BHc subunit vaccine afforded effective protection against BoNT/B challenge. Therefore, the non-His-tagged and homogeneous BHc expressed in E.coli represents a good potential candidate subunit vaccine for human use.

Masticatory hypofunction effects induced by BTXA injection of hippocampal neurons in developing rats

BACKGROUND AND OBJECTIVE

In clinical practice, malocclusion is often encountered during the period of growth and development of individuals. In addition to nutritional imbalance, some studies have found that mastication affects learning and memory ability. Tooth loss and masticatory hypofunction have been suggested as risk factors of Alzheimer disease. However, relatively little research has been done in developing animals. The present study evaluated the relationship between masticatory hypofunction and neuropathological changes of the hippocampus in developing rats.

DESIGN

Four-week-old Wistar rats were randomly divided into saline-injected and botulinum toxin type A (BTXA)-injected groups. After an experiment period of 4 weeks, the rats were sacrificed for evaluation of neuropathological changes in the hippocampus through Nissl staining and phosphorylated cyclic AMP (cAMP) response element binding protein (CREB) immunohistochemistry.

RESULTS

Nissl staining revealed a significant reduction in the density of neurons in the BTXA-injected rats. The BTXA-injected rats exhibited a decreased level of CREB phosphorylation. The degree of p-CREB immunoreactivity differed significantly between the two groups.

CONCLUSION

The BTXA-injected rats exhibited a reduction in neuron density and phosphorylated CREB, indicating that mastication might influence the learning and memory ability during the growth period. Therefore, it is strongly suggested that malocclusion be corrected as soon as possible during growth and development.

Tetanus toxin C-fragment protects against excitotoxic spinal motoneuron degeneration in vivo

The tetanus toxin C-fragment is a non-toxic peptide that can be transported from peripheral axons into spinal motoneurons. In in vitro experiments it has been shown that this peptide activates signaling pathways associated with Trk receptors, leading to cellular survival. Because motoneuron degeneration is the main pathological hallmark in motoneuron diseases, and excitotoxicity is an important mechanism of neuronal death in this type of disorders, in this work we tested whether the tetanus toxin C-fragment is able to protect MN in the spinal cord in vivo. For this purpose, we administered the peptide to rats subjected to excitotoxic motoneuron degeneration induced by the chronic infusion of AMPA in the rat lumbar spinal cord, a well-established model developed in our laboratory. Because the intraspinal infusion of the fragment was only weakly effective, whereas the i.m. administration was remarkably neuroprotective, and because the i.m. injection of an inhibitor of Trk receptors diminished the protection, we conclude that such effects require a retrograde signaling from the neuromuscular junction to the spinal motoneurons. The protection after a simple peripheral route of administration of the fragment suggests a potential therapeutic use of this peptide to target spinal MNs exposed to excitotoxic conditions in vivo.

Structural and biochemical characterization of the protease domain of the mosaic botulinum neurotoxin type HA

The extreme toxicity of botulinum neurotoxins (BoNTs) relies on their specific cleavage of SNARE proteins, which eventually leads to muscle paralysis. One newly identified mosaic toxin, BoNT/HA (aka H or FA), cleaves VAMP-2 at a unique position between residues L54 and E55, but the molecular basis underlying VAMP-2 recognition of BoNT/HA remains poorly characterized. Here, we report a ∼2.09 Å resolution crystal structure of the light chain protease domain of BoNT/HA (LC/HA). Structural comparison between LC/HA and LC of BoNT/F1 (LC/F1) reveals distinctive hydrophobic and electrostatic features near the active sites, which may explain their different VAMP-2 cleavage sites. When compared to BoNT/F5 that cleaves VAMP-2 at the same site as BoNT/HA, LC/HA displays higher affinity for VAMP-2, which could be caused by their different surface charge properties surrounding a VAMP-2 exosite-binding cleft. Furthermore, systematic mutagenesis studies on VAMP-2 and structural modeling demonstrate that residues R47 to K59 spanning the cleavage site in VAMP-2 may adopt a novel extended conformation when interacting with LC/HA and LC/F5. Taken together, our structure provides new insights into substrate recognition of BoNT/HA and paves the way for rational design of small molecule or peptide inhibitors against LC/HA.

Variability of Botulinum Toxins: Challenges and Opportunities for the Future

Botulinum neurotoxins (BoNTs) are the most potent known toxins, and are therefore classified as extremely harmful biological weapons. However, BoNTs are therapeutic drugs that are widely used and have an increasing number of applications. BoNTs show a high diversity and are divided into multiple types and subtypes. Better understanding of the activity at the molecular and clinical levels of the natural BoNT variants as well as the development of BoNT-based chimeric molecules opens the door to novel medical applications such as silencing the sensory neurons at targeted areas and dermal restoration. This short review is focused on BoNTs’ variability and the opportunities or challenges posed for future clinical applications.

Protein Biotoxins of Military Significance

There is a spectrum of several threat agents, ranging from nerve agents and mustard agents to natural substances, such as biotoxins and new, synthetic, bioactive molecules produced by the chemical industry, to the classical biological warfare agents. The new, emerging threat agents are biotoxins produced by animals, plants, fungi, and bacteria. Many types of organisms produce substances that are toxic to humans. Examples of such biotoxins are botulinum toxin, tetanus toxin, and ricin. Several bioactive molecules produced by the pharmaceutical industry can be even more toxic than are the classical chemical warfare agents. Such new agents, like the biotoxins and bioregulators, often are called mid-spectrum agents. The threat to humans from agents developed by modern chemical synthesis and by genetic engineering also must be considered, since such agents may be more toxic or more effective in causing death or incapacitation than classical warfare agents. By developing effective medical protection and treatment against the most likely chemical and mid-spectrum threat agents, the effects of such agents in a war scenario or following a terrorist attack can be reduced. Toxin-mediated diseases have made humans ill for millennia. Unfortunately, the use of biological agents as weapons of terror has now been realized, and separating naturally occurring disease from bioterroristic events has become an important public health goal. The key to timely identification of such attacks relies on education of primary care physicians, first responders, and public health officials.

Onabotulinumtoxin A (BOTOX®) for ProphylaCTIC Treatment of Pediatric Migraine: A Retrospective Longitudinal Analysis

BACKGROUND

The use of onabotulinumtoxin A in the pediatric population has not been evaluated for chronic migraine in a longitudinal study. This retrospective study sought to determine the efficacy and safety of onabotulinumtoxin A in prophylactic treatment of chronic migraine in the pediatric population.

METHODS

The authors retrospectively evaluated pediatric patients who had been treated with onabotulinumtoxin A in the outpatient pain clinic for chronic migraine. Demographic data and pre- and posttreatment migraine days (frequency), pain scores (intensity), and duration of migraine episodes were collected from patient records.

RESULTS

Ten patients were included. Median pretreatment to posttreatment headache frequency was 15.5 [8, 29.5] to 4 [2, 10] days/month ( P < .0001), durations were 8 [0, 24] to 1 [0, 7] hours ( P = .025), and intensity was 6 [4, 8] to 4 [2, 5] ( P = .0063). No serious adverse events were reported.

CONCLUSIONS

This review over a 5-year longitudinal period demonstrates statistically significant improvement from baseline.

Frequency of Acute Kidney Injury in tetanus patients of Paedriatic Intensive Care Unit: A Public Hospital Experience

Background and Objective:

Tetanus is a potentially fatal but preventable disease. Mortality is related to severity of the disease, cardiovascular, pulmonary and renal complications. Acute kidney injury (AKI) is a frequent and lethal complication of tetanus. The objective was to determine the frequency of AKI in tetanus patients managed in a public hospital.

Methods:

Children aged 1-12 years admitted in Paediatric Intensive Care Unit (PICU) with the clinical diagnosis of tetanus over three and half years were recruited for the retrospective study. pRIFLE (Pediatric Risk, Injury, Failure, Loss, End) criteria was applied to all cases of tetanus to categorize them as having AKI or not, on the basis of estimated creatinine clearance (ECCL). Comparison was done between AKI and non-AKI cases, as well as between AKI survivors and AKI non-survivors. The study was conducted at PICU of Dr. Ruth K.M. PFau Civil Hospital Karachi for tetanus cases admitted during July 2013 to December 2016

Results:

During the study period, 44 patients of tetanus were enrolled. Nearly 32 % of tetanus patients developed acute renal dysfunction according to PRIFLE criteria. There were overall 15 (34.09%) expiries among tetanus patients among which nine (60%) had AKI. Oliguria was observed in five (35.71%) cases. All the AKI non-survivors had ECCL below 50% and all had autonomic instability. AKI developed towards the end of first week in three cases, mid of second week in four cases and third week in seven cases. Renal replacement therapy (RRT) i.e. peritoneal dialysis (PD) was done in four AKI cases but it did not improve the outcome. CRP was more than 50 in 24 (54.54%) cases. Ventilatory support was given to 85.71% with AKI as compared to 66.66% of non AKI patients.

Conclusion:

Development of AKI in tetanus is multifactorial. Major contributors are severity of the tetanus itself, presence of autonomic instability, ventilator dependency, and sepsis. Presence of AKI worsens the outcome of tetanus in terms of survival, length of stay, hospital cost and ventilator days.

Botulinum Toxin Type A: Assessing The Effects on The Brain Stem

BACKGROUND

In this study, our aim is to investigate the possible effects of Botulinum toxin type A administrations in the early and late periods on the brain stem.

METHODS

Eighteen white New Zealand rabbits were used in this study with the subjects being divided into three groups. Group I received 0.05 mL sterile saline to the left anterior auricular muscles. Group II and III were injected with Botulinum toxin type A (Botox, Allergan) to the left anterior auricular muscles. Group II was sacrificed 5 days after application and Group III was sacrificed 12 weeks after application; brain stem tissues were then taken. The samples were examined with Caspase 3, 8, and 9 immunohistochemical stainings.

RESULTS

In the control group with Caspase-3 immune staining, moderate-to-strong immune reactivity was seen in a small number of neurons. In the Caspase-8 and 9 immune stainings, the immune reactive neurons were seen in greater numbers when compared with the Caspase-3 immune reactive neurons. In the early and late period, groups with Caspase-8 and 9 immune stainings, the immune reactive neurons were seen in greater numbers and in the wider area when compared with the Caspase-3 immune reactive neurons. No significant differences were recognized in the Caspase immune stainings between the early and late period groups. The results were statistically supported.

CONCLUSION

It was concluded that Botulinum toxin type A application did not trigger apoptosis in stem cell tissues.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Highly fluorescent, monolithic semiconductor nanorod clusters for ultrasensitive biodetection

Signal amplified, ultrasensitive fluorescence detection of the tetanus toxoidviahighly fluorescent, monolithic semiconductor nanorod clusters.

Dual-route targeted vaccine protects efficiently against botulinum neurotoxin A complex

Clostridium botulinum readily persists in the soil and secretes life-threatening botulinum neurotoxins (BoNTs) that are categorized into serotypes A to H, of which, serotype A (BoNT/A) is the most commonly occurring in nature. An efficacious vaccine with high longevity against BoNT intoxication is urgent. Herein, we developed a dual-route vaccine administered over four consecutive weeks by mucosal and parenteral routes, consisting of the heavy chain (Hc) of BoNT/A targeting dendritic cell peptide (DCpep) expressed by Lactobacillus acidophilus as a secretory immunogenic protein. The administered dual-route vaccine elicited robust and long-lasting memory B cell responses comprising germinal center (GC) B cells and follicular T cells (Tfh) that fully protected mice from lethal oral BoNT/A fatal intoxication. Additionally, passively transferring neutralizing antibodies against BoNT/A into naïve mice induced robust protection against BoNT/A lethal intoxication. Together, a targeted vaccine employing local and systemic administrative routes may represent a novel formulation eliciting protective B cell responses with remarkable longevity against threatening biologic agents such as BoNTs.

Canonical germinant receptor is dispensable for spore germination in Clostridium botulinum group II strain NCTC 11219

Clostridium botulinum is an anaerobic sporeforming bacterium that is notorious for producing a potent neurotoxin. Spores of C. botulinum can survive mild food processing treatments and subsequently germinate, multiply, produce toxin and cause botulism. Control of spore germination and outgrowth is therefore essential for the safety of mildly processed foods. However, little is known about the process of spore germination in group II C. botulinum (gIICb), which are a major concern in chilled foods because they are psychrotrophic. The classical model of spore germination states that germination is triggered by the binding of a germinant molecule to a cognate germinant receptor. Remarkably, unlike many other sporeformers, gIICb has only one predicted canonical germinant receptor although it responds to multiple germinants. Therefore, we deleted the gerBAC locus that encodes this germinant receptor to determine its role in germination. Surprisingly, the deletion did not affect germination by any of the nutrient germinants, nor by the non-nutrient dodecylamine. We conclude that one or more other, so far unidentified, germinant receptors must be responsible for nutrient induced germination in gIICb. Furthermore, the gerBAC locus was strongly conserved with intact open reading frames in 159 gIICb genomes, suggesting that it has nevertheless an important function.

Factors that affect the onset of action of non-depolarizing neuromuscular blocking agents

Neuromuscular blockade plays an important role in the safe management of patient airways, surgical field improvement, and respiratory care. Rapid-sequence induction of anesthesia is indispensable to emergency surgery and obstetric anesthesia, and its purpose is to obtain a stable airway, adequate depth of anesthesia, and appropriate respiration within a short period of time without causing irritation or damage to the patient. There has been a continued search for new neuromuscular blocking drugs (NMBDs) with a rapid onset of action. Factors that affect the onset time include the potency of the NMBDs, the rate of NMBDs reaching the effect site, the onset time by dose control, metabolism and elimination of NMBDs, buffered diffusion to the effect site, nicotinic acetylcholine receptor subunit affinity, drugs that affect acetylcholine (ACh) production and release at the neuromuscular junction, drugs that inhibit plasma cholinesterase, presynaptic receptors responsible for ACh release at the neuromuscular junction, anesthetics or drugs that affect muscle contractility, site and methods for monitoring neuromuscular function, individual variability, and coexisting disease. NMBDs with rapid onset without major adverse events are expected in the next few years, and the development of lower potency NMBDs will continue. Anesthesiologists should be aware of the use of NMBDs in the management of anesthesia. The choice of NMBD and determination of the appropriate dosage to modulate neuromuscular blockade characteristics such as onset time and duration of neuromuscular blockade should be considered along with factors that affect the effects of the NMBDs. In this review, we discuss the factors that affect the onset time of NMBDs.

TFOS DEWS II iatrogenic report

Dry eye can be caused by a variety of iatrogenic interventions. The increasing number of patients looking for eye care or cosmetic procedures involving the eyes, together with a better understanding of the pathophysiological mechanisms of dry eye disease (DED), have led to the need for a specific report about iatrogenic dry eye within the TFOS DEWS II. Topical medications can cause DED due to their allergic, toxic and immuno-inflammatory effects on the ocular surface. Preservatives, such as benzalkonium chloride, may further aggravate DED. A variety of systemic drugs can also induce DED secondary to multiple mechanisms. Moreover, the use of contact lens induces or is associated with DED. However, one of the most emblematic situations is DED caused by surgical procedures such as corneal refractive surgery as in laser-assisted in situ keratomileusis (LASIK) and keratoplasty due to mechanisms intrinsic to the procedure (i.e. corneal nerve cutting) or even by the use of postoperative topical drugs. Cataract surgery, lid surgeries, botulinum toxin application and cosmetic procedures are also considered risk factors to iatrogenic DED, which can cause patient dissatisfaction, visual disturbance and poor surgical outcomes. This report also presents future directions to address iatrogenic DED, including the need for more in-depth epidemiological studies about the risk factors, development of less toxic medications and preservatives, as well as new techniques for less invasive eye surgeries. Novel research into detection of early dry eye prior to surgeries, efforts to establish appropriate therapeutics and a greater attempt to regulate and oversee medications, preservatives and procedures should be considered.