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Turin L, Piccione MM, Crosa F, Dall'Ara P, Filipe J, Zarucco L. Therapeutic Applications of Botulinum Neurotoxins in Veterinary Medicine. Vet Sci 2023; 10:460. [PMID: 37505863 PMCID: PMC10386576 DOI: 10.3390/vetsci10070460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/05/2023] [Accepted: 07/10/2023] [Indexed: 07/29/2023] Open
Abstract
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.
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Affiliation(s)
- Lauretta Turin
- Department of Veterinary Medicine and Animal Sciences (DIVAS), University of Milan, Via dell'Università 6, 26900 Lodi, LO, Italy
| | - Marina Michela Piccione
- Department of Veterinary Medicine and Animal Sciences (DIVAS), University of Milan, Via dell'Università 6, 26900 Lodi, LO, Italy
| | - Fabio Crosa
- Department of Veterinary Sciences (DSV), University of Turin, Largo Paolo Braccini 2, 10095 Grugliasco, TO, Italy
| | - Paola Dall'Ara
- Department of Veterinary Medicine and Animal Sciences (DIVAS), University of Milan, Via dell'Università 6, 26900 Lodi, LO, Italy
| | - Joel Filipe
- Department of Veterinary Medicine and Animal Sciences (DIVAS), University of Milan, Via dell'Università 6, 26900 Lodi, LO, Italy
| | - Laura Zarucco
- Department of Veterinary Sciences (DSV), University of Turin, Largo Paolo Braccini 2, 10095 Grugliasco, TO, Italy
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Botulinum toxin A treatment in facial palsy synkinesis: a systematic review and meta-analysis. Eur Arch Otorhinolaryngol 2023; 280:1581-1592. [PMID: 36544062 DOI: 10.1007/s00405-022-07796-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Synkinesis is defined as involuntary movements accompanying by voluntary movements and can occur during the aftermath of peripheral facial palsy, causing functional, aesthetic and psychological problems in the patient. Botulinum toxin A (BTX-A) is frequently used as a safe and effective treatment; however, there is no standardized guideline for the use of BTX-A in synkinesis. The purpose of this article is to review and summarize studies about the BTX-A treatment of synkinesis in patients with a history of peripheral facial palsy; including given dosages, injection sites and time intervals between injections. MATERIALS AND METHODS A multi-database systematic literature search was performed in October 2020 using the following databases: Pubmed, Embase, Medline, and The Cochrane Library. Two authors rated the methodological quality of the included studies independently using the 'Newcastle-Ottawa Quality Assessment Scale' for non-randomised studies' (NOS). RESULTS Four-thousand-five-hundred-and-nineteen articles were found of which 34 studies met the inclusion criteria, in total comprising 1314 patients. Most studies were assessed to be of 'fair' to 'good' methodological quality. The Cohen's kappa (between author FJ and AS) was 0.78. Thirty-one studies investigated the reported dosage injected, 17 studies reported injection location and 17 studies investigated time intervals. A meta-analysis was performed for three studies comprising 106 patients, on the effects of BTX-A treatment on the Synkinesis Assessment Questionnaire (SAQ) scores. The mean difference was 11.599 (range 9.422-13.766), p < 0.01. However, due to inconsistent reporting of data of the included studies, no relationship with the dosage and location could be assessed. CONCLUSIONS Many treatment strategies for synkinesis exist, consisting of varying BTX-A brands, dosages, time intervals and different injection locations. Moreover, the individual complaints are very specific, which complicates creating a standardized chemodenervation treatment protocol. The BTX-A treatment of long-term synkinesis is very individual and further studies should focus on a patient-tailored treatment instead of trying to standardize treatment.
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Dressler D, Bigalke H, Frevert J. The Immunology of Botulinum Toxin Therapy: A Brief Summary. Toxicology 2022; 481:153341. [PMID: 36191878 DOI: 10.1016/j.tox.2022.153341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 09/13/2022] [Accepted: 09/27/2022] [Indexed: 11/28/2022]
Abstract
Like all proteins foreign to the human body, also botulinum toxin (BT) is antigenic and may stimulate an immune response with formulation of antibodies (BT-AB). Affected patients may no longer respond to BT therapy and various degrees of BT-AB related therapy failure (ABF) may result. We want to review the immunological interactions between BT and BT-AB, the prevalence, the time course and the risk factors for BT-AB formation as they are related to the treatment algorithms, the patient's immune system and to exogenic factors. Special emphasis is placed on various features of the BT drugs including the specific biological activity (SBA) as a predictor of their antigenicity. Quantitative detection of BT-AB by the mouse diaphragm assay will be demonstrated. As ABF may have serious consequences for patients affected, careful risk factor analysis is warranted to reduce them wherever possible.
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Affiliation(s)
- Dirk Dressler
- Movement Disorders Section, Department of Neurology, Hannover Medical School, Hannover, Germany.
| | - Hans Bigalke
- Institute of Toxicology, Hannover Medical School, Hannover, Germany.
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Immunogenicity of Botulinum Toxin Formulations: Potential Therapeutic Implications. Adv Ther 2021; 38:5046-5064. [PMID: 34515975 PMCID: PMC8478757 DOI: 10.1007/s12325-021-01882-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 08/02/2021] [Indexed: 12/21/2022]
Abstract
Botulinum neurotoxins (BoNTs) are proteins produced by bacteria of the Clostridium family. Upon oral ingestion, BoNT causes the neuroparalytic syndrome botulism. There are seven serotypes of BoNT (serotypes A-G); BoNT-A and BoNT-B are the botulinum toxin serotypes utilized for therapeutic applications. Treatment with BoNT injections is used to manage chronic medical conditions across multiple indications. As with other biologic drugs, immunogenicity after long-term treatment with BoNT formulations may occur, and repeated use can elicit antibody formation leading to clinical nonresponsiveness. Thus, approaching BoNT treatment of chronic conditions with therapeutic formulations that minimize stimulating the host immune response while balancing patient responsiveness to therapy is ideal. Immunogenicity is a clinical limitation in many settings that use biologic drugs for treatment, and clinically relevant immunogenicity reduction has been achieved through engineering smaller protein constructs and reducing unnecessary formulation components. A similar approach has influenced the evolution of BoNT formulations. Three BoNT-A products and one BoNT-B product have been approved by the Food and Drug Administration (FDA) for therapeutic use: onabotulinumtoxinA, abobotulinumtoxinA, incobotulinumtoxinA, and rimabotulinumtoxinB; a fourth BoNT-A product, daxibotulinumtoxinA, is currently under regulatory review. Additionally, prabotulinumtoxinA is a BoNT-A product that has been approved for aesthetic indications but not therapeutic use. Here, we discuss the preclinical and clinical immunogenicity data that exist within the scientific literature and provide a perspective for considering immunogenicity as a key factor in choice of BoNT formulation.
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Symptomatic Brain Hemorrhages from Cavernous Angioma After Botulinum Toxin Injections, a Role of TLR/MEKK3 Mechanism? Case Report and Review of the Literature. World Neurosurg 2020; 136:7-11. [PMID: 31917316 DOI: 10.1016/j.wneu.2019.12.172] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 12/29/2019] [Accepted: 12/30/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Cavernous angiomas (CAs) are vascular malformations that may result in stroke. CASE DESCRIPTION Herein, we evaluate a CA patient with chronic migraine who experienced 2 documented symptomatic hemorrhages after receiving respective high doses of botulinum toxin (Btx). CONCLUSIONS Recently, bacterial lipopolysaccharide has been reported to contribute to CA development through Toll-like receptor signaling, causing hemorrhagic angiogenic proliferation. Lipopolysaccharide and Btx share a common intracellular signaling pathway driving CA development and hemorrhage. Significance of these observations is demonstrated by previous works on plasma molecules showing prognostic associations with symptomatic hemorrhages in human CA, related to the same canonical pathways. Authors suggest careful tracking of the association of Btx and hemorrhage in CA patients.
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Hu CH, Tseng YW, Lee CW, Chiou CY, Chuang SS, Yang JY, Lee OK. Combination of mesenchymal stem cell-conditioned medium and botulinum toxin type A for treating human hypertrophic scars. J Plast Reconstr Aesthet Surg 2019; 73:516-527. [PMID: 31488377 DOI: 10.1016/j.bjps.2019.07.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 07/06/2019] [Accepted: 07/27/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Both mesenchymal stem cell-conditioned medium (MSC CM) and Botox have demonstrated therapeutic effects for hypertrophic scar (HS). It is unclear whether a synergistic effect occurs when these treatments are used in combination. We aimed to investigate the therapeutic effects of MSC CM and Botox alone when compared with those of a combined regimen on HS. METHODS Fibroblasts from human HS were isolated and treated with Dulbecco's modified Eagle's medium (DMEM), MSCCM, or Botox alone or a combination of MSCCM and Botox. We also used an in vivo HS-buried null mice model to investigate the efficacy of combination treatment. RESULTS The results demonstrated that the combination of MSC CM and Botox downregulated both mRNA and protein levels of type I collagen, type III collagen, and alpha-smooth muscle actin (α-SMA) in HS fibroblasts. The combined regimen also suppressed fibroblast proliferative activity, increased apoptosis, and displayed significant inhibitory effects on the contractile ability of HS fibroblasts compared to MSC CM, Botox, or DMEM alone. Using an in vivo HS-buried null mice model, significant scar weight reduction, cell apoptosis, and less α-SMA expression were observed from the combined regimen of MSC CM and Botox compared to those from the other groups. The combined regimen also significantly improved arrangement and deposition of collagen fibers. CONCLUSIONS This study demonstrates that a combination of MSC CM and Botox exhibited a significant therapeutic effect compared to monotherapy. Clinical translation of this therapy should be further considered.
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Affiliation(s)
- Ching-Hsuan Hu
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan; Institute of Clinical Medicine, and Stem cell Research Center, National Yang-Ming University,Taipei, Taiwan; Stem Cell Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Yi-Wen Tseng
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan; Institute of Clinical Medicine, and Stem cell Research Center, National Yang-Ming University,Taipei, Taiwan; Stem Cell Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Chien-Wei Lee
- Institute for Tissue Engineering and Regenerative Medicine, The Chinese University of Hong Kong; School of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong
| | - Chih-Yung Chiou
- Institute of Clinical Medicine, and Stem cell Research Center, National Yang-Ming University,Taipei, Taiwan
| | - Shiow-Shuh Chuang
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Jui-Yung Yang
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Oscar K Lee
- Institute of Clinical Medicine, and Stem cell Research Center, National Yang-Ming University,Taipei, Taiwan; Stem Cell Research Center, National Yang-Ming University, Taipei, Taiwan.
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Shinn JR, Nwabueze NN, Patel P, Norton C, Ries WR, Stephan SJ. Contemporary Review and Case Report of Botulinum Resistance in Facial Synkinesis. Laryngoscope 2018; 129:2269-2273. [PMID: 30592301 DOI: 10.1002/lary.27709] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 10/09/2018] [Accepted: 10/29/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND Botulinum resistance poses significant treatment challenges for both patients and healthcare practitioners. We first present a case highlighting botulinum resistance in a patient who failed to respond to alternative formulations but who responded remarkably to incobotulinum toxinA, an identical toxin free of complexing proteins. Secondly, we provide a treatment algorithm and a review of the literature detailing clinical and immunochemical botulinum resistance. RESULTS Patients with botulinum resistance show a predisposition to failure on subsequent injections and possess a propensity toward neutralizing and nonneutralizing antibody development. The mechanisms of resistance are not entirely understood but thought to be secondary to an immunologic response. Risk factors for resistance include higher botulinum doses, more frequent injections, and high total lifetime dosage. Patients may still respond to other botulinum formulations or subtypes; however, this effect may be temporary. CONCLUSION This case report describes a patient who responded to incobotulinum toxinA after failing treatment with the identical toxin compounded with buffer proteins, ultimately supporting the possibility of immune-mediated resistance to the surrounding proteins and not the toxin itself. Often, impending treatment resistance is preceded by a poor or limited clinical response. Antibody testing is not indicated because it is neither sensitive nor specific and does not change clinical practice. Initially, higher doses of botulinum may overcome resistance without increasing treatment frequency, and side effects are far less common in those with clinical resistance. If higher dosages fail to produce a response, alternative botulinum formulations or subtypes can be considered. Laryngoscope, 129:2269-2273, 2019.
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Affiliation(s)
- Justin R Shinn
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Nkechi N Nwabueze
- Vanderbilt University School of Medicine, Nashville, Tennessee, U.S.A
| | - Priyesh Patel
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Cathey Norton
- Pi Beta Phi Institute, Bill Wilkerson Center, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - W Russell Ries
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A.,Division of Facial Plastics and Reconstructive Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Scott J Stephan
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A.,Division of Facial Plastics and Reconstructive Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
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Park KS, Lee CH, Lee JW. Use of a botulinum toxin A in dentistry and oral and maxillofacial surgery. J Dent Anesth Pain Med 2017; 16:151-157. [PMID: 28884147 PMCID: PMC5586551 DOI: 10.17245/jdapm.2016.16.3.151] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 09/23/2016] [Accepted: 09/27/2016] [Indexed: 11/15/2022] Open
Abstract
Botulinum toxin (BT) was the first toxin to be used in the history of human medicine. Among the eight known serotypes of this toxin, those currently used in medicine are types A and B. This review article mainly discusses BT type A (BTA) because it is usually used in dentistry including dental anesthesiology and oral and maxillofacial surgery. BTA has been used mainly in the treatment of temporomandibular joint disorder (TMD) and hypertrophy and hyperactivity of the masticatory muscles, along with being a therapeutic option to relieve pain and help in functional recovery from dental and oral and maxillofacial surgery. However, it is currently used broadly for cosmetic purposes such as reducing facial wrinkles and asymmetry. Although the therapeutic effect of BTA is temporary and relatively safe, it is essential to have knowledge about related anatomy, as well as the systemic and local adverse effects of medications that are applied to the face.
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Affiliation(s)
- Kyung-Soo Park
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Kyung Hee University, Seoul, Korea
| | - Chi-Heun Lee
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Kyung Hee University, Seoul, Korea
| | - Jung-Woo Lee
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Kyung Hee University, Seoul, Korea
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Mor N, Tang C, Blitzer A. Botulinum Toxin in Secondarily Nonresponsive Patients with Spasmodic Dysphonia. Otolaryngol Head Neck Surg 2016; 155:458-61. [DOI: 10.1177/0194599816644708] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 03/25/2016] [Indexed: 11/17/2022]
Abstract
Chemodenervation with botulinum toxin (BoNT) has been effective and well tolerated for all types of dystonia for >30 years. We reviewed outcomes of our patients treated with BoNT serotype A (BoNT-A) for spasmodic dysphonia (SD) who became secondarily nonresponsive. We found that 8 of 1400 patients became nonresponsive to BoNT-A (0.57%), which is lower than the secondary nonresponse rate in other dystonias. After a cessation period, 4 of our patients resumed BoNT-A injections, and recurrence of immunoresistance was not seen in any of them. When compared with patients with other dystonias, patients with SD receive extremely low doses of BoNT. Small antigen challenge may explain the lower rate of immunoresistance and long-lasting efficacy after BoNT-A is restarted among secondary nonresponsive patients with SD.
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Affiliation(s)
- Niv Mor
- Voice and Swallowing Disorders, Division of Otolaryngology–Head and Neck Surgery, Maimonides Medical Center, Brooklyn, New York, USA
- Department of Otolaryngology–Head and Neck Surgery, Mount Sinai Roosevelt Hospital, New York, New York, USA
| | - Christopher Tang
- Department of Otolaryngology–Head and Neck Surgery, Mount Sinai Roosevelt Hospital, New York, New York, USA
- Department of Head and Neck Surgery, Kaiser Permanente Medical Center San Francisco, San Francisco, California, USA
| | - Andrew Blitzer
- Department of Otolaryngology–Head and Neck Surgery, Mount Sinai Roosevelt Hospital, New York, New York, USA
- NY Center for Voice and Swallowing Disorders, New York, New York, USA
- Department of Neurology, Ichan School of Medicine at Mount Sinai, New York, New York, USA
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Kane CD, Nuss JE, Bavari S. Novel therapeutic uses and formulations of botulinum neurotoxins: a patent review (2012 - 2014). Expert Opin Ther Pat 2015; 25:675-90. [PMID: 25842964 DOI: 10.1517/13543776.2015.1030337] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Botulinum neurotoxins (BoNTs) are among the most toxic of known biological molecules and function as acetylcholine release inhibitors and neuromuscular blocking agents. Paradoxically, these properties also make them valuable therapeutic agents for the treatment of movement disorders, urological conditions and hypersecretory disorders. Greater understanding of their molecular mechanism of action and advances in protein engineering has led to significant efforts to improve and expand their function with a view towards broadening their therapeutic potential. AREAS COVERED Searches of Espacenet and Google Patent have revealed a number of patents related to BoNTs. This review will focus on novel therapeutic uses and formulations disclosed during 2012 - 2014. The seven patents discussed will include nanoformulations of FDA-approved BoNTs, additional BoNT subtypes and novel BoNT variants and chimeras created through protein engineering. Supporting patents and related publications are also briefly discussed. EXPERT OPINION The clinical and commercial success of BoNTs has prompted investigation into novel BoNTs or BoNT-mediated chimeras with promising in vitro results. Distinct strategies including the use of nanoformulations and targeted delivery have been implemented to identify new indication and improved functionality. Greater understanding of their systemic exposure, efficacy and safety profiles will be required for further development.
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Wang L, Sun Y, Yang W, Lindo P, Singh BR. Type A botulinum neurotoxin complex proteins differentially modulate host response of neuronal cells. Toxicon 2014; 82:52-60. [PMID: 24560879 DOI: 10.1016/j.toxicon.2014.02.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 01/24/2014] [Accepted: 02/06/2014] [Indexed: 12/26/2022]
Abstract
Type A Botulinum neurotoxin (BoNT/A), the most potent poison known to mankind, is produced by Clostridium botulinum type A as a complex with neurotoxin-associated proteins (NAPs). Currently BoNT/A in purified and complex forms are both available in therapeutic and cosmetic applications to treat neuromuscular disorders. Whereas Xeomin(®) (incobotulinumtoxin A, Merz Pharmaceuticals, Germany) is free from complexing proteins, Botox(®) (onabotulinumtoxin A, Allergan, USA) contains NAPs, which by themselves have no known role in the intracellular biochemical process involved in the blockade of neurotransmitter release. Since the fate and possible interactions of NAPs with patient tissues after intramuscular injection are not known, it was the aim of this study to evaluate the binding of BoNT/A and/or the respective NAPs to cells derived from neuronal and non-neuronal human tissues, and to further explore neuronal cell responses to different components of BoNT/A. BoNT/A alone, the complete BoNT/A complex, and the NAPs alone, all bind to neuronal SH-SY5Y cells. The BoNT/A complex and NAPs additionally bind to RMS13 skeletal muscle cells, TIB-152 lymphoblasts, Detroit 551 fibroblasts besides the SH-SY5Y cells. However, no binding to these non-neuronal cells was observed with pure BoNT/A. Although BoNT/A, both in its purified and complex forms, bind to SH-SY5Y, the intracellular responses of the SH-SY5Y cells to these BoNT/A components are not clearly understood. Examination of inflammatory cytokine released from SH-SY5Y cells revealed that BoNT/A did not increase the release of inflammatory cytokines, whereas exposure to NAPs significantly increased release of IL-6, and MCP-1, and exposure to BoNT/A complex significantly increased release of IL-6, MCP-1, IL-8, TNF-α, and RANTES vs. control, suggesting that different components of BoNT/A complex induce significantly differential host response in human neuronal cells. Results suggest that host response to different compositions of BoNT/A based therapeutics may play important role in local and systemic symptoms in patients.
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Affiliation(s)
- Lei Wang
- Prime Bio Inc., Dartmouth, MA 02747, USA.
| | - Yi Sun
- Prime Bio Inc., Dartmouth, MA 02747, USA
| | | | - Paul Lindo
- Prime Bio Inc., Dartmouth, MA 02747, USA
| | - Bal Ram Singh
- Prime Bio Inc., Dartmouth, MA 02747, USA; Department of Chemistry and Biochemistry, University of Massachusetts Dartmouth, Dartmouth, MA 02747, USA
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Ababneh OH, Cetinkaya A, Kulwin DR. Long-term efficacy and safety of botulinum toxin A injections to treat blepharospasm and hemifacial spasm. Clin Exp Ophthalmol 2013; 42:254-61. [PMID: 23844601 DOI: 10.1111/ceo.12165] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 07/03/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND To evaluate efficacy and safety of botulinum toxin A injections after more than 10 consecutive years of treatment for benign essential blepharospasm and hemifacial spasm. DESIGN Retrospective chart review at university-affiliated hospital. PARTICIPANTS Study consisted of 64 patients treated with botulinum toxin A injections between October 2005 and May 2006. METHODS Inclusion criteria included patients treated with at least one annual botulinum toxin-A injection for more than 10 consecutive years. Data collected included diagnoses and patient characteristics, injection dates, doses administered at each visit, response scores, duration of effect, and adverse events. MAIN OUTCOME MEASURES Included changes in doses, response scores, duration of effects, and adverse events between the first and last botulinum toxin A injections. RESULTS Thirty-two of 64 patients (mean age at first injection, 57.2 ± 12.4 years; 25 women) met the inclusion criteria. The mean duration of follow up was 14.1 ± 3.1 years (range 10-20 years; mean total visits 44.4 ± 19). A higher mean injection dose per visit was administered during the last year compared with the first year (26.8 ± 10.3 vs. 22.5 ± 7.5 units, respectively) (P = 0.003). The mean durations of effect during the first and last years were 12.4 ± 7.1 and 14.6 ± 7.0 weeks, respectively (P = 0.076). There were no significant differences between genders or between benign essential blepharospasm and hemifacial spasm subgroups. The most common adverse events were ptosis, lagophthalmos and dry eye. CONCLUSIONS Botulinum toxin A is an effective, safe, long-term treatment for patients with benign essential blepharospasm and hemifacial spasm. Sustained treatment efficacy required higher doses; however, fewer adverse reactions developed.
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Affiliation(s)
- Osama H Ababneh
- Department of Ophthalmology, The University of Jordan, and Jordan University Hospital, Amman, Jordan
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Long-term efficacy and safety of botulinum toxin injections in dystonia. Toxins (Basel) 2013; 5:249-66. [PMID: 23381141 PMCID: PMC3640534 DOI: 10.3390/toxins5020249] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 01/17/2013] [Accepted: 01/23/2013] [Indexed: 11/23/2022] Open
Abstract
Local chemodenervation with botulinum toxin (BoNT) injections to relax abnormally contracting muscles has been shown to be an effective and well-tolerated treatment in a variety of movement disorders and other neurological and non-neurological disorders. Despite almost 30 years of therapeutic use, there are only few studies of patients treated with BoNT injections over long period of time. These published data clearly support the conclusion that BoNT not only provides safe and effective symptomatic relief of dystonia but also long-term benefit and possibly even favorably modifying the natural history of this disease. The adverse events associated with chronic, periodic exposure to BoNT injections are generally minor and self-limiting. With the chronic use of BoNT and an expanding list of therapeutic indications, there is a need to carefully examine the existing data on the long-term efficacy and safety of BoNT. In this review we will highlight some of the aspects of long-term effects of BoNT, including efficacy, safety, and immunogenicity.
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Abstract
Background: Two decades ago, botulinum neurotoxin (BoNT) type A was introduced to the commercial market. Subsequently, the toxin was approved by the FDA to address several neurological syndromes, involving muscle, nerve, and gland hyperactivity. These syndromes have typically been associated with abnormalities in cholinergic transmission. Despite the multiplicity of botulinal serotypes (designated as types A through G), therapeutic preparations are currently only available for BoNT types A and B. However, other BoNT serotypes are under study for possible clinical use and new clinical indications; Objective: To review the current research on botulinum neurotoxin serotypes A-G, and to analyze potential applications within basic science and clinical settings; Conclusions: The increasing understanding of botulinal neurotoxin pathophysiology, including the neurotoxin’s effects on specific neuronal populations, will help us in tailoring treatments for specific diagnoses, symptoms and patients. Scientists and clinicians should be aware of the full range of available data involving neurotoxin subtypes A-G.
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Fiore P, Santamato A, Ranieri M, Bellomo R, Saggini R, Panza F, Megna G, Cristella G, Megna M. Treatment of Upper Limb Spasticity after Stroke: One-Year Safety and Efficacy of Botulinum Toxin Type A NT201. Int J Immunopathol Pharmacol 2012; 25:57S-62S. [DOI: 10.1177/03946320120250s109] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- P. Fiore
- Neuroscience and Sense Organs Department Physical Medicine and Rehabilitation Bari “Aldo Mow” University — Italy
| | - A. Santamato
- Department of Physical Medicine And Rehabilitation University of Foggia Oo Rr
| | - M. Ranieri
- Neuroscience and Sense Organs Department Physical Medicine and Rehabilitation Bari “Aldo Mow” University — Italy
| | - R.G. Bellomo
- Dept. Human Movement, “G. D 'annunzio” University, Chieti, Italy
| | - R. Saggini
- Dept. Neuroscience And Imaging, “G. D 'annunzio” University, Chieti, Italy
| | - F. Panza
- Geriatric Unit And Gerontology — Geriatric Research Laboratory Irccs Casa Sollievo La Sofferenza San Giovanni Rotondo Italy
| | - G. Megna
- Neuroscience and Sense Organs Department Physical Medicine and Rehabilitation Bari “Aldo Mow” University — Italy
| | - G. Cristella
- Osmairm Neuropsychomotor Rehabilitation Center Laterza (Ta) Italy
| | - M. Megna
- Neuroscience and Sense Organs Department Physical Medicine and Rehabilitation Bari “Aldo Mow” University — Italy
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Modulation of botulinum toxin-induced changes in neuromuscular function with antibodies directed against recombinant polypeptides or fragments. Neuroscience 2011; 179:208-22. [PMID: 21277940 DOI: 10.1016/j.neuroscience.2011.01.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Revised: 01/18/2011] [Accepted: 01/20/2011] [Indexed: 11/21/2022]
Abstract
Botulinum toxin is an agent that is typically encountered in two settings: as an agent that can cause disease (e.g. botulism), and as an agent that can be used to treat disease (i.e., a variety of neurologic disorders). In both cases it would be advantageous to develop a sound understanding of the mechanisms by which antibodies neutralize the toxin. In the present study, recombinant antigens were used to generate antibodies against the carboxyterminal half of the toxin heavy chain (HC50), the entire toxin light chain (LC), and the HA17, HA35 and HA70 components of the progenitor toxin complex. These antibodies were then evaluated for their respective abilities to alter botulinum toxin-induced changes in locomotor behavior in mice. The botulinum toxin type A complex was shown to produce dose-dependent depression of locomotor behavior within the dose range of 0.3-0.7 mouse LD50 units. At a dose of 0.5 LD50, the toxin typically reduced running behavior by 90% or more, and full recovery was not observed for approximately 4 weeks. Mice that were actively or passively vaccinated against the HC50 polypeptide were resistant to toxin action, presumably because the antibodies occluded the toxin binding domain. Interestingly, mice that were actively or passively vaccinated against LC were also resistant to toxin action. This effect may have been due to steric hindrance of the binding process. There was no scenario in which anti-HA antibodies altered the effects of toxin on locomotor behavior. This absence of effect was likely due to the fact that HAs and neurotoxin in the progenitor toxin complex spontaneously dissociate in physiologic media.
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Repeated injections of botulinum toxin-A for idiopathic detrusor overactivity. Urology 2009; 75:552-8. [PMID: 20035984 DOI: 10.1016/j.urology.2009.05.097] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2009] [Revised: 04/27/2009] [Accepted: 05/02/2009] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To report the efficacy and safety of repeated injections of botulinum toxin-A (BTX-A) in treating idiopathic detrusor overactivity refractory to anticholinergics. Furthermore, we describe whether dose alteration in patients with poor responses or voiding dysfunction after initial treatment can improve outcomes. METHODS A cohort of 34 patients who participated in a clinical trial was followed up and their progress reported. Twenty from this group had >1 BTX-A injection. Each patient received 200 U BTX-A initially, with subsequent injections between 100 and 300 U, administered by a trigone-sparing flexible cystoscopic technique. Efficacy was measured using voiding diaries and quality of life (QoL) assessed with Incontinence Impact Questionnaire-7 and Urogenital Distress Inventory-6 questionnaires. Urodynamic data were obtained for injections 1-3. All measurements were performed before and 3 months after injections. RESULTS Twenty patients received a repeat injection and of these 9 subsequently received a third and fourth injection. Significant improvements in overactive bladder syndrome symptoms and QoL were observed after each injection as compared with baseline. Maximum cystometric capacity and bladder compliance increased with decrease in the maximum detrusor pressure during filling cystometry. When comparing overactive bladder symptoms, QoL, and urodynamic parameters 3 months after the first and last injections, no significant differences were found. Nine patients had their BTX-A dose altered, with better outcomes in 5. The commonest reported problems were difficulty in emptying the bladder and urinary tract infection. CONCLUSIONS BTX-A appears to be effective and safe after repeated administration in patients with idiopathic detrusor overactivity. Certain patients will benefit from dose optimization to improve efficacy or prevent voiding dysfunction.
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Neutralizing antibodies and secondary therapy failure after treatment with botulinum toxin type A: much ado about nothing? Clin Neuropharmacol 2009; 32:213-8. [PMID: 19620852 DOI: 10.1097/wnf.0b013e3181914d0a] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES As the indications and duration of treatment of botulinum toxin type A (BoNT-A) increase, so do reports of patients who fail therapy after initially responding well. Although a loss of efficacy is commonly thought to be associated with neutralizing antibodies (NAbs), this relationship is not strongly correlated, and other factors may play a significant role. To explore this issue, we evaluated levels of NAbs in a large selected cohort of secondary nonresponders to BoNT-A using the highly sensitive mouse phrenic nerve-hemidiaphragm assay. METHODS Serum samples from 503 patients treated with BoNT-A who had a variety of diagnoses were tested for the presence of NAbs. RESULTS Fewer than half of the patients (n = 224, 44.5%) were found to be NAb-positive, indicating that in more than half of the secondary nonresponders, lack of efficacy is not due to NAb formation. The proportion of secondary nonresponders with NAbs was greater for higher dose indications (focal spasticity and spasmodic torticollis) than for lower dose indications (blepharospasm and hemifacial spasm) and increased with shorter injection intervals. Neutralizing antibody development was independent of the commercial preparation used. CONCLUSIONS Our results indicate that although NAb formation does play a role in secondary treatment failure with BoNT-A, this is not the cause in all patients, and the influence of other factors needs to be investigated. Gaining a better understanding of the underlying mechanisms for secondary treatment failure may help in the prediction, diagnosis, management, and prevention of this problem.
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Abstract
This article reviews the current and most neurologic uses of botulinum neurotoxin type A (BoNT-A), beginning with relevant historical data, neurochemical mechanism at the neuromuscular junction. Current commercial preparations of BoNT-A are reviewed, as are immunologic issues relating to secondary failure of BoNT-A therapy. Clinical uses are summarized with an emphasis on controlled clinical trials (as appropriate), including facial movement disorders, focal neck and limb dystonias, spasticity, hypersecretory syndromes, and pain.
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Affiliation(s)
- John P Ney
- Madigan Army Medical Center, Neurology Service, Tacoma, WA, USA
| | - Kevin R Joseph
- Madigan Army Medical Center, Neurology Service, Tacoma, WA, USA
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22
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Adelson RT. Botulinum neurotoxins: fundamentals for the facial plastic surgeon. Am J Otolaryngol 2007; 28:260-6. [PMID: 17606044 DOI: 10.1016/j.amjoto.2006.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2006] [Accepted: 09/07/2006] [Indexed: 10/23/2022]
Abstract
The most commonly performed nonsurgical cosmetic procedure in the facial plastic surgery armamentarium involves the various commercial preparations of botulinum neurotoxins. These drugs have undergone a transformation from public health scourge to near ubiquitous therapeutic modality across the entire medical spectrum. Herein, the history of botulinum neurotoxins is reviewed, including an exploration of their pharmacology, neuromuscular junction physiology, a description of the commercially available preparations, and the recent research concerning the practicalities of their clinical use.
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Affiliation(s)
- Robert Todd Adelson
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, University of Florida, PO Box 100264, Gainesville, FL 32610, USA.
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Federici T, Liu JK, Teng Q, Yang J, Boulis NM. A Means for Targeting Therapeutics to Peripheral Nervous System Neurons with Axonal Damage. Neurosurgery 2007; 60:911-8; discussion 911-8. [PMID: 17460527 DOI: 10.1227/01.neu.0000255444.44365.b9] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Delivery of biological therapeutics to motor and dorsal root ganglion neurons remains a major hurdle in the development of treatments for a variety of neurological processes, including peripheral nerve injury, pain, and motor neuron diseases. Because nerve cell bodies are important in initiating and controlling axonal regeneration, targeted delivery is an appealing strategy to deliver therapeutic proteins after peripheral nerve injury. METHODS Tet1 is a 12-aa peptide, isolated through phage display that is selected for tetanus toxin C fragment-like binding properties. In this study, we surveyed its uptake and retrograde transport using compartmented cultures and sciatic nerve injections. We then characterized the time course of this delivery. Finally, to confirm the retrograde transport involvement, a colchicine pretreatment was performed. We also performed competitive binding studies between Tet1 and a recombinant tetanus toxin C fragment using recombinant tetanus toxin C fragment enzyme-linked immunosorbent assay. RESULTS We were able to demonstrate efficient uptake and retrograde axonal transport of the Tet1 peptide in vitro and in vivo. Intraneural colchicine pretreatment partially blocked fluorescence detection in the spinal cord, revealing a retrograde axonal transport mechanism. Finally, a competitive enzyme-linked immunosorbent assay experiment revealed Tet1-specific binding to the recombinant tetanus toxin C fragment axon terminal trisialogangliosides receptor. CONCLUSION These properties of Tet1 can be applied to the development of therapeutic viral vectors and fusion proteins for neuronal targeting and enhanced spinal cord delivery in the treatment of nerve regeneration, neuroprotection, analgesia, and spasticity. Small peptides can be easily fused to larger proteins without significantly modifying their function and can be used to alter the binding and uptake properties of these proteins.
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Abstract
Since its introduction into clinical medicine in 1980, botulinum toxin has become a major therapeutic drug with applications valuable to many medical sub-specialties. Its use was spearheaded in ophthalmology where its potential applications have expanded to cover a broad range of visually related disorders. These include dystonic movement disorders, strabismus, nystagmus, headache syndromes such as migraine, lacrimal hypersecretion syndromes, eyelid retraction, spastic entropion, compressive optic neuropathy, and, more recently, periorbital aesthetic uses. Botulinum toxin is a potent neurotoxin that blocks the release of acetylcholine at the neuromuscular junction of cholinergic nerves. When used appropriately it will weaken the force of muscular contraction, or inhibit glandular secretion. Recovery occurs over 3 to 4 months from nerve terminal sprouting and regeneration of inactivated proteins necessary for degranualtion of acetylcholine vesicles. Complications are related to chemodenervation of adjacent muscle groups, injection technique, and immunological mechanisms.
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Affiliation(s)
- Jonathan J Dutton
- Department of Ophthalmology, University of North Carolina, Chapel Hill, NC 27599-7040, USA
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Lim ECH, Ong BKC, Seet RCS. Botulinum toxin-A injections for spastic toe clawing. Parkinsonism Relat Disord 2006; 12:43-7. [PMID: 16198612 DOI: 10.1016/j.parkreldis.2005.06.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2005] [Revised: 06/22/2005] [Accepted: 06/24/2005] [Indexed: 11/23/2022]
Abstract
Spastic toe clawing describes extension at the metatarsophalangeal joints of the feet, flexion at the proximal interphalangeal joints and flexion at the distal interphalangeal joints that results from upper motor neuron lesions, such as stroke, intracranial hemorrhage, cervical myelopathy and brain tumors. Even though toe clawing is often asymptomatic, it can be painful. Previous studies have described the efficacy of injections of botulinum toxin type-A (BTX-A) to the long flexors of the toes, but this is often unsatisfactory as high dosages (up to 175 units) have been required, and patients often report significant residual toe clawing. We performed an open label, prospective study to assess the efficacy of BTX-A injections, targeting the long and short flexors of the toes, performed with electrical (motor point) stimulation under electromyographic guidance. Outcome measures, which included timed walking over 20m, objective assessment of toe clawing (modified Ashworth scale and a visual analog scale rating) and patient assessment of functional disability, were assessed before injections and at six-weeks' follow-up. Seven patients (five male and two female) of mean age 51 (range 38-70) were recruited. Four had spasticity from underlying intracranial hemorrhage, the remaining three from cerebral infarct, astrocytoma and post-traumatic cervical myelopathy. The total dose of BTX-A injected for toe clawing ranged from 40 to 90 units. Improvements were observed in all outcome measures except timed walking. Injecting BTX-A to the long and short flexors of the toes, with electrical stimulation under electromyographic guidance, is well tolerated and efficacious in the treatment of toe clawing from spasticity, allowing for lower dosages to be used.
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Affiliation(s)
- Erle C H Lim
- Division of Neurology, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074, Singapore.
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Abstract
The number of migraine treatments and our understanding of migraine pathophysiology are both increasing. Newer treatments focus on migraine prevention. Botulinum toxin (BTX) is a potent neurotoxin used primarily to treat diseases associated with increased muscle activity. Recently, BTX was found to have antinociceptive effects that are probably independent of its muscle-relaxant action. Clinical trials support the efficacy of BTX type A (and possibly also type B) in the treatment of migraine. The anticonvulsant topiramate was recently shown to be effective for migraine prevention. At the low doses used for this indication, cognitive side effects are not a major concern. Another new approach to migraine prevention is angiotensin type 1 (AT1) receptor blockade. The high tolerability of the AT1 receptor blocker candesartan warrants further studies to assess its role in migraine prevention.
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Affiliation(s)
- Avi Ashkenazi
- Jefferson Headache Center, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania 19107, USA
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Affiliation(s)
- Bahman Jabbari
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA.
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Affiliation(s)
- P Prithvi Raj
- World Institute of Pain, Section of Pain Practice, Antioch, California, USA.
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