[Mechanism of action, clinical indication and results of treatment of botulinum toxin]

Factors Associated With Onabotulinum Toxin-A Discontinuation in a Diverse Urban Population

IMPORTANCE

Although overactive bladder (OAB) is a common condition, affecting 16% of Americans, few patients continue on to advanced therapies. Furthermore, procedural therapies like intravesical onabotulinum toxin-A (BTX-A), which require ongoing repeat treatments, have discontinuation rates ranging from 25% to 51%.

OBJECTIVES

This study sought to investigate factors associated with dis-continuation of BTX-A injections for idiopathic OAB among a diverse urban population.

STUDY DESIGN

This was a retrospective review of adults 18 years and older who underwent BTX-A injection for idiopathic OAB. Patient demographics, past medical history, symptoms, and postprocedural outcomes such as subjective improvement, urinary retention, and incidence of urinary tract infection were compared between groups.

RESULTS

Onabotulinum toxin-A injections were administered to 246 patients who met study criteria, of whom 211 (85.7%) were women. One hundred (40.7%) patients discontinued BTX-A therapy. Patients discontinuing BTX-A therapy were more likely to have developed postprocedural urinary retention (18.4% vs 9.7%, P < 0.05) and had a higher median income by zip code ($59,000 vs $50,000; P < 0.01). Patients were significantly more likely to continue BTX-A therapy if they reported preprocedural nocturia (57.2% vs 36.8%, P < 0.01) or urgency urinary incontinence (UUI) (78.1% vs 64.6%, P < 0.05).

CONCLUSIONS

Adverse outcomes, such as postprocedural urinary retention, are associated with discontinuation of BTX-A therapy. Patients who reported nocturia and UUI before injection were more likely to continue BTX-A suggesting more severe OAB is more responsive to this therapy. Given the large proportion (>40%) of patients who discontinued BTX-A treatment, further research is needed to identify barriers to continuation of care.

Pulmonary Embolism after Botulinum Toxin Treatment for Leg Muscle Hypertrophy

Leg muscle hypertrophy is a unique physical symptom in East Asian women. Compared with traditional surgical treatment for calf muscle hypertrophy, botulinum toxin is widely favored by East Asian women because of its minimal trauma and significant effects. We describe the case of a 22-year-old woman with pulmonary embolism because of deep vein thrombosis, who presented with hypertrophy of bilateral calf muscles, and was administered 300 U of botulinum toxin A injection in July 2022. On the third day after the injection, she experienced swelling and pain in her left leg, which gradually worsened and made walking difficult. She underwent an ultrasound examination of lower limbs, which revealed several deep and shallow vein thrombi in the left lower limb. Computed tomography arterial imaging indicated multiple embolisms in pulmonary arteries. This study aimed to explore and analyze the causes of pulmonary embolism after botulinum toxin treatment for calf muscle hypertrophy by reviewing and analyzing the patient's symptoms, diagnosis, and treatment process to provide management strategies for treatment and prevention of this disease.

Collateral beauty in the damages: an overview of cosmetics and therapeutic applications of microbial proteases

Microbial proteases are enzymes secreted by a variety of microorganisms, including bacteria and fungi, and have attracted significant attention due to their versatile applications in the food and pharmaceutical industries. In addition, certain proteases have been used in the development of skin health products and cosmetics. This article provides a review of microbial proteases in terms of their classification, sources, properties, and applications. Moreover, different pharmacological and molecular investigations have been reviewed. Various biological activities of microbial proteases, such as Arazyme, collagenase, elastin, and Nattokinase, which are involved in the digestion of dietary proteins, as well as their potential anti-inflammatory, anti-cancer, antithrombotic, and immunomodulatory effects have been included. Furthermore, their ability to control infections and treat various disorders has been discussed. Finally, this review highlights the potential applications and future perspectives of microbial proteases in biotechnology and biomedicine, and proposes further studies to develop new perspectives for disease control and health-promoting strategies using microbial resources.

Unusual herpetic reactivation in a young female following botox injection: a case report study

BACKGROUND

Botox injections are commonly used for cosmetic and therapeutic purposes because they temporarily paralyze muscles, reduce wrinkles, and alleviate certain medical conditions. Although generally considered safe and effective, Botox injections may cause potential complications. While herpes reactivation is more commonly associated with immunosuppressive therapies, such as chemotherapy or corticosteroid use, its association with Botox injection is poorly documented.

CASE PRESENTATION

A 33-year-old woman presented with progressive painful rashes and vesicles on her forehead, scalp, and right upper eyelid, accompanied by fever and malaise following a Botox injection to treat wrinkles. A positive Tzanck smear test result confirmed the diagnosis of herpes infection. The patient was treated with antiviral medication, and her symptoms gradually regressed over several days.

CONCLUSIONS

Although herpes reactivation is more commonly associated with immunosuppressive therapies, few cases of herpes zoster and herpes simplex following Botox injection have been reported. The pathogenesis of herpes reactivation following Botox injection is unclear; however, it has been hypothesized that the Botox protein is a potent antigen that may activate the cellular immune system, making it easier for the virus to reactivate. Healthcare providers should be aware of this potential complication and consider it when evaluating patients who present with painful rashes following Botox injections. In addition, individuals who want to receive Botox injections should be informed of this complication. The diagnosis of herpetic infection should be made promptly, and antiviral therapy should be initiated to minimize the risk of complications. Further research is needed to better understand the pathogenesis and risk factors for herpes following Botox injection and to develop strategies for preventing and managing this complication.

Distal Esophageal Spasm: An Updated Review

Distal esophageal spasm is characterized by premature contractions of the distal esophageal smooth muscle leading to non-obstructive dysphagia and non-cardiac chest pain. Diagnosis requires the presence of symptoms along with evidence of at least 20% premature contractions in the setting of a normal lower esophageal sphincter relaxation on high-resolution manometry. New updates to the Chicago Classification have improved the diagnostic accuracy of this method. Functional lumen imaging probe is a growing diagnostic modality that gives a more complete picture of esophageal motility. Pharmacologic treatment remains inadequate. Endoscopic myotomy might be of benefit for non-achalasia esophageal motility disorders. More research is required to better understand the pathophysiology and develop safe and long-lasting management for this disease.

DAXI (DaxibotulinumtoxinA) - An Innovative Approach for Frown Lines

Glabellar frown lines, also known as worry lines, are a common sign of aging. The current treatment option for glabellar lines is subjective and ranges from economical anti-wrinkle creams and skin resurfacing techniques such as microdermabrasion and fillers to highly expensive facelifts. Botox^® has been the mainstream treatment for decades, but the suggested time between treatments for most toxins is 12-16 weeks, and evidence shows that patients being treated for glabellar lines want longer-lasting results. Recently, on September 16th, the US Food and Drug Administration (FDA) approved the development of daxibotulinumtoxinA (DAXI) for injection based on clinical trials (SAKURA 1, 2, and 3). These encouraging findings followed by FDA approval mean that the need for repeated treatments to sustain the desired outcome has decreased. DAXI could be a reliable and secure choice for reducing the appearance of wrinkles on the face caused by muscle activity, and its long duration has the potential to enhance the treatment of both therapeutic and cosmetic disorders.

Comparing Botulinum Toxin Injections with Extraocular Muscle Surgery in Toddlers with Esotropia: A Retrospective Analysis

BACKGROUND

In toddlers with esotropia, early alignment of the visual axes either with extraocular muscle surgery (EOMS) or botulinum toxin injections (BTIs) into both medial rectus muscles may result in improved depth perception. We compared the outcome of BTIs with EOMS in toddlers in order to gain further insight into the advantages and disadvantages of either method.

PATIENTS AND METHODS

In this retrospective study, our encrypted database was searched for toddlers with esotropia aged 35 months or younger at the time of initial treatment with either BTIs or EOMS and who had a follow-up of at least 2 years. We analyzed the angle of deviation, dose effect (DE), and binocularity as well as the number of interventions.

RESULTS

We identified 26 toddlers who received their first treatment for esotropia within the first 35 months of life: 16 with BTIs (9 males, 7 females) and 10 with EOMS (3 males, 7 females). Mean follow-up was considerably longer in the EOMS (87.7 months) than in the BTI group (35.7 months). Age at first intervention was 22.8 months in the BTI and 24.1 months in the EOMS group, and each toddler wore its full cycloplegic refraction. Mean angle at treatment was 41.25 prism diopters (PD) in the BTI compared to 52.9 PD in the EOMS group. The BTI group received an average of 1.68 BTIs, with a mean dosage of 14.5 IU Botox and a mean DE (mDE) of 1.8 PD/IU. In the EOMS group, the average number of surgeries was 1.4, with a mean dosage of 16.85 mm and a mDE of 3.14 PD/mm surgery. Some degree of binocularity could be observed in 9 (56%) of the BTI (5 × Bagolini positive, 2 × 550″, 2 × 220″) and in 4 (40%) of the EOMS group (2 × 3600″, 1 × 550″, 1 × 300″). By the end of the BTI group follow-up, four toddlers electively underwent EOMS rather than a 3rd BTI (followed by a 3rd BTI in 1), which resulted in the appearance of measurable binocularity in all four (1 × Bagolini positive, 1 × 220″, 1 × 200″, 1 × 60″).

CONCLUSIONS

Our results show that BTIs are a viable treatment alternative in early esotropia. Even if EOMS is ultimately required, some binocularity may develop as the visual axes are aligned for some time in the sensitive phase owing to the effects of Botox. Moreover, less surgical dosage is needed than would have otherwise been necessary to treat the original angle of deviation. BTIs are faster, less invasive, and present as an effective alternative when patient compliance is too low to reliably measure the angle of deviation, which is essential for the planning of EOMS.

Knee flexion contracture treated with botulinum toxin type A in patients with haemophilia (PWH)

INTRODUCTION

Knee flexion contracture (KFC) remains a common complication of haemoarthrosis in children and young adults with haemophilia. If the KFC is not treated properly it produces disability, postural and gait abnormalities.

OBJECTIVE

Evaluate the effectiveness of conservative treatment of KFC with Botulinum toxin type A (BTX-A) in PWH.

METHODS

Seventeen patients were treated, with 21 affected knees. Mean age was 26 years. The mean follow up was 12 months. We evaluated flexion and KFC pretreatment BTX-A and up to 12 months posttreatment. BTX-A application was in hamstring and calf muscles. To evaluate the function, a questionnaire about different activities was made, and it was checked 3, 6 and 12 months after BTX-A. According to the degree of KFC, knees were divided into 3 groups: Group 1: -10° to -30° (n = 10), Group 2: -31° to -45° (n = 6) Group 3: -46° or more (n = 5).

RESULTS

The average KFC improved from -38° to -24°. The improvement was 14° (P < 0.001). The average KFC improvement was 9° in group 1, 17° in group 2, and 23° in group 3. There was a high correlation between the improvement in KFC and the total score of the questionnaire R = 0.77.

CONCLUSIONS

Treatment of KFC with BTX-A improves knee-related functional activities, with the advantage of being a low-cost procedure and easy to apply.

Electroconvulsive therapy and ocular dystonia

Electroconvulsive therapy (ECT) has been reported to be beneficial in various movement disorders, especially tardive dystonic reactions. In this article, we report an interesting case of drug-induced blepharospasm with ocular dystonia which improved with ECT. To our knowledge, a case of ocular dystonia improving with ECT has not been previously reported in the literature.

[Botulinum toxin and medical liability: is the patient sufficiently informed?]

INTRODUCTION

The use of botulinum toxin injection therapy is soaring significantly today, with an ever-wider field of applications despite well-known side effects of the treatment. This article aims at analysing the medicolegal practices of practitioners who use this therapy, especially the information given to patients and finding a common practice for providing that information.

METHODS

We sent a questionnaire to 340 practitioners who might use the therapy (physiatrists, neurologists, ophthalmologists, ENT specialists, plastic surgeons) working in hospitals and in physical therapy and rehabilitation centres in France. Besides mentioning the possible side effects of the therapy, the questionnaire focused on how such information was transmitted before the injection.

RESULTS

Data collection and analysis were performed by use of a spreadsheet software programme. A total of 124 questionnaires were analysed. We did not analyse the items dealing with side effects. Sixty-five percent of the responders said they did not seek statutory authorisation for injections. Only 31% provided written, detailed information and 12% required a signed consent form. Complaints were rare, approximately 12%, were written or verbal, and were always dismissed.

DISCUSSION

Side effects after botulinum toxin injection are clearly described in the medical literature. Therefore, it is of utmost importance for this product to be used therapeutically and only by experienced therapists who will carefully respect the product's standard rules of use and inform their patients to the best of their ability. Issuing a detailed letter of information describing all the side effects seems necessary. We suggest a model information letter such as that provided to the patients in our facility.

CONCLUSION

Botulinum toxin is a very worthwhile product for numerous abnormalities but has side effects, often brief, at the site of the injection. Therefore it is our duty to inform patients effectively.

Basic immunological aspects of botulinum toxin therapy

Previous studies in this laboratory had mapped the immune recognition profile of the regions recognized antibodies (Abs) and by T cells on the protective H(C) domain (C-terminal fragment corresponding to residues 855-1296 of the heavy chain) of botulinum neurotoxin serotype A (BoNT/A). The localization of these regions has several potential applications and has provided a basis for the understanding of immunoresistance to treatment. We briefly outline these localized regions and discuss the impact of these findings on the immunotherapeutic applications of BoNT/A. Immunoresistance to toxin therapy can appear in some patients after a few injections with the toxin. Our epitope mapping studies have shown that several factors can influence the immune response to the toxin. These factors include dose, duration of treatment, frequency of immunization, and quality of the toxin. The immune response to the whole toxin is under genetic control, and the response to each epitope is under separate genetic control. Therefore, the appearance of blocking Abs (i.e., immunoresistance) in patients might be controlled by the major histocompatability of the host. Once a patient becomes immunoresistant to one toxin then switching to another toxin will most often be of limited and short-lived benefit, because the patient becomes rapidly immunoresistant to the second toxin. Finally, because of the considerable structural homology between tetanus neurotoxin (TeNT) and BoNTs, it is possible, although not certain, that a prior active immune response to TeNT might play some role in the early appearance on anti-BoNT Abs in some patients.

Dysport

Since the commercial launch of Dysport in 1991, after 10 years of clinical studies on its predecessor formulations, this BTX-A product has shown great therapeutic promise with a good safety profile and low incidence of treatment failures. As with all BTX products, Dysport should not be seen as a generic equivalent but as a specific product with individual unit dosing requirements and side effect profiles. Its role as an important BTX-A molecule looks set to expand as new indications for botulinum toxin arise, and as the cosmetic usage of Dysport is approved in countries outside of South America.

Botulinum toxin: application into acupuncture points for migraine

BACKGROUND

: Botulinum toxin has been employed in orthopedics, physiatrics, gastroenterology, gynecology, neurology, pediatrics, general surgery, plastic surgery, and several other specialties. We have applied this drug to treat hyperhidrosis and wrinkles in dermatology; it offers also a secondary benefit: relief for headaches.

OBJECTIVE

: We have performed studies based on acupuncture principles in order to develop new botulinum toxin application sites for the treatment of migraine. These additional sites are helpful when patients expect results for both their illness and their wrinkles; whereas some patients will show improvement with the classic treatment for wrinkles, additional sites may be required.

METHODS

: Ten patients suffering from migraine, as diagnosed through the criteria proposed by the Headache Classification Committee of the International Headache Society, were selected. We used easily recognizable acupuncture sites for the injection of botulinum toxin.

RESULTS

: There was significant improvement in patients with acupuncture site-guided botulinum toxin injection. It showed to be a safe and effective therapy for migraine.

CONCLUSION

: There are alternative sites besides those used for the treatment of expression lines, which bring forth an improvement of migraine.

Cross reaction of tetanus and botulinum neurotoxins A and B and the boosting effect of botulinum neurotoxins A and B on a primary anti-tetanus antibody response

The present studies were carried out in order to investigate the cross-reaction of botulinum neurotoxins (BoNTs) with human and mouse antibodies against tetanus neurotoxin (TeNT) and determine whether injection of BoNT into a host that has been primed with TeNT would result in boosting of the response to the injected BoNT. Human antisera against TeNT obtained from 9 individuals were found to exhibit substantial cross-reaction with BoNTs A and B. We prepared antibodies (Abs) against inactivated tetanus neurotoxin (TeNT) in outbred mice and determined the binding of these Abs to active TeNT and active botulinum neurotoxins (BoNTs) A and B. Blood samples were collected before immunization (day 0) and on days 42, 82 and 125 after the first injection. The reactions of these sera with the immunizing antigen (inactivated TeNT), active TeNT, active BoNT/A and active BoNT/B were determined. At a fixed dilution (1:62.5 v/v), the sera contained high levels of Abs that reacted with TeNT and also with BoNTs A and B. Throughout the test period (up through day 125) and at different dilutions the cross-reactions of the antisera with BoNT/B were almost twice those with BoNT/A. The reactions of the antisera with the immunizing antigen (inactive TeNT) or with active TeNT were essentially equal throughout the dilution range tested (1:16-1:500 v/v). To determine whether injection of BoNT/A or B into a host that had been primed with TeNT resulted in boosting of the response to the priming antigen (TeNT) as well as BoNT/A or B, mice were primed with TeNT and boosted 21 days later with TeNT, BoNT/A or BoNT/B. Appropriate controls were also employed. Blood samples were collected prior to TeNT priming (day -1) and on days 21, 32, 46 and 67 after priming. In TeNT-primed mice, BoNTs A or B boosted the anti-TeNT Ab responses slightly but had no significant boosting effect on the Ab populations that bind to BoNTs A or B. It is concluded that while Abs against TeNT cross react with BoNTs and the cross reaction with BoNT/B is almost double that of BoNT/A, injection of BoNTs A or B in the presence of a prior active immunity against TeNT is not very likely to make the host mount an Ab response against the injected BoNT.

Effects of the ecdysoneless mutant on synaptic efficacy and structure at the neuromuscular junction in Drosophila larvae during normal and prolonged development

Hormonal regulation in development and maintenance of synaptic transmission involves examination of both the presynaptic and postsynaptic components and a system in which the hormones can be controlled. We used the ecdysoneless heat-sensitive mutation (l(3)ecd(1)/l(3)ecd(1)) of Drosophila to provide the ability to regulate endogenous ecdysone production at various larval stages. In conjunction, we used the neuromuscular junctions of Drosophila since they offer the advantage of assessable preparations for both morphological and physiological measures. The growth in the Ib and Is motor nerve terminals and the corresponding muscle 6 in segment 4 of the larval Drosophila throughout the third instar stage in the presence of normal and a much reduced endogenous ecdysone level was investigated. Muscle 6 and the motor nerve terminals parallel in growth throughout the third instar. The nerve terminals increase in length and varicosity number, thus providing an increase in the number of synaptic release sites. The ecdysoneless larvae also show an increase in muscle size, however the Is and Ib motor nerve terminals do not mature to the extent of the wild-type ecdysone producing flies. The motor nerve terminal length is shorter with fewer numbers of varicosities per terminal. In spite of a shorter nerve terminal and fewer varicosities, with an increasing muscle fiber, the compound excitatory junctional potentials of Ib and Is in the ecdysoneless flies are larger, which is suggestive of synaptic structural modification. This study demonstrates ecdysone's role in modifying nerve terminal development and neuromuscular junction function.

Treatment of facial wounds with botulinum toxin A improves cosmetic outcome in primates

Surgeons have constantly sought to achieve the most aesthetic scar. A major factor determining the final cosmetic appearance of a cutaneous scar is the tension acting on the wound edges during the healing phase. Since Theodor Kocher pioneered the alignment of skin incisions with Langer's lines in 1892, surgical techniques that attempt to overcome closing tension have become standard. Yet, no treatment has been available to minimize underlying muscle contractions, which are the major cause of this tension. Botulinum toxin A is a potent drug that produces temporary muscular paralysis when injected locally. It has proven to be safe and effective in the treatment of a variety of disorders, including hyperkinetic facial lines. The objective of this randomized, double-blind, placebo-controlled primate study was to investigate the efficacy of a single injection of botulinum toxin A to improve the cosmetic appearance of cutaneous scars. Symmetric pairs of standardized excisions were performed on either side of the forehead of six primates. The half foreheads were randomized to the botulinum toxin A treatment side versus the placebo injection side. A panel of three blinded facial surgeons assessed the cosmetic appearance of the mature scars 3 months postoperatively. The wounds that had been immobilized with botulinum toxin A were rated as significantly better in appearance than the control wounds (p < 0.01). Histologic examination confirmed that all scars were mature. Blinded, randomized, placebo-controlled human clinical trials are presently under way at the Mayo Clinic.