Botulism

Neurochirurgie, 1998 Sep, 44(3), 192 - 6
{Treatment of spasticity with injections of botulinum toxin . Review of the literature}; Feve A et al.; Botulinum toxin injections are a new treatment for limb spasticity . Intramuscular injections can be performed in spastic muscles; efficacy occurs one or two weeks later, with a mean duration of three months . Clinical action is related to chemical denervation of presynaptic motor end nerves by the botulinum toxin . Double blind studies versus placebo have demonstrated the improvement of limb spasticity after injections of botulinum toxin . Ashworth scales, articular angulations, pain and spasms improve both in upper and lower limb spasticity . Functional scores are not changed in the upper limb, but quality of life improves . Kinematic parameters of gait are improved in lower limb spasticity, especially in children with cerebral palsy disorders . There were no reports of serious side effects . Botulinum toxin is a safe and effective treatment of localized spasticity in adults and children.

Muscle Nerve Suppl, 1997, 6, S221 - 31
Physical and occupational therapy considerations in adult patients receiving botulinum toxin injections for spasticity; Albany K; Physical and occupational therapists play important roles in the evaluation and management of patients receiving botulinum toxin injections for spasticity . Baseline evaluation includes areas beyond the muscles being injected, since local spasticity reduction may lead to more widespread functional changes . Because the evaluation itself influences tone, a consistent order of muscle evaluation is recommended . The range of preinjection assessments includes evaluation of tone, mobility, strength, balance, endurance, assistive devices, and others . After injection, therapeutic interventions have multiple aims, including strengthening and facilitation, increasing range of motion, retraining of ambulation and gait, improving the fit and tolerance of orthoses, and improved functioning in ADLs.

Muscle Nerve Suppl, 1997, 6, S208 - 20
Dosing, administration, and a treatment algorithm for use of botulinum toxin A for adult-onset spasticity . Spasticity Study Group; Brin MF; Botulinum toxin type A (BTX-A) has been shown to be a safe and effective treatment for focal or segmental muscle overactivity, including spasticity . Local injections of BTX-A are particularly valuable in relieving focal spasticity around a joint or a series of joints . When integrated into an overall spasticity treatment plan with clearly outlined functional goals, BTX-A may offer significant benefits to the appropriately selected adult or pediatric patient . A range of clinical outcome measures are used to evaluate the patient prior to injection . Initial dosing guidelines are offered, though each patient may have a unique drug response profile and set of modifying factors that will be used as a basis for dose adjustments . Clinical benefit usually lasts for approximately 12 weeks, though in some patients the duration of effect may be longer . Assessment of the patient's clinical and functional status is performed at each follow-up appointment, and the contribution of BTX therapy to the goals of the patient and caregiver are evaluated . Other therapeutic options should be considered where appropriate, and the treatment plan revised when necessary . Guidelines for dilution, handling, and office procedure are offered.

Muscle Nerve Suppl, 1997, 6, S194 - 207
Children undergoing treatment with botulinum toxin: the role of the physical therapist; Leach J; For the cerebral palsy patient undergoing botulinum toxin (BTX) therapy, the physical therapist is involved in each step of treatment, from patient selection to outcome assessment . Prior to treatment, the therapist collects detailed baseline information, including assessment of motor ability, functional activities, current therapies and assistive devices, and the concerns of the caregiver and family . After BTX injection, the therapy program may include exercise, neurodevelopmental training, functional training, modalities, splinting, casting, orthoses, and positioning . The weakness brought on by BTX treatment provides important opportunities for functional retraining . It may also necessitate new assistive devices or modifications in the old ones.

Muscle Nerve Suppl, 1997, 6, S176 - 80
Injection techniques for botulinum toxin using electromyography and electrical stimulation; O'Brien CF; Increasing data supports the use of botulinum toxin injection as a therapeutic intervention in the management of spasticity . The avid binding of botulinum toxin (BTX) to presynaptic neuron terminals and the diffusion characteristics of the medication allow relative ease of administration . For many clinical applications, efficacy may be improved, and adverse effects reduced, by more precise targeting of the muscles to be injected . Electromyographic guidance (EMG) is commonly used to confirm appropriate localization of the injection needle in specific muscles immediately before injection . Electrical stimulation (ES) may be more useful in patients who are unresponsive or sedated . Equipment options and technical aspects of EMG and ES are discussed, including some adjunctive imaging methods for injecting difficult-to-localize muscles.

Muscle Nerve Suppl, 1997, 6, S169 - 75
Clinical trials of botulinum toxin in the treatment of spasticity; Simpson DM; Botulinum toxin has been tested as a treatment for spasticity resulting from cerebral palsy, multiple sclerosis, traumatic brain injury, spinal cord injury, and stroke . The results of 18 studies are reviewed in this article . In both open label and double-blind, placebo-controlled trials, botulinum toxin has proven to be an effective measure for reduction of focal spasticity . Improvements have been documented in tone reduction, range of motion, hygiene, autonomic dysreflexia, gait pattern, positioning, and other criteria, though not all criteria tested showed improvement in all studies . In none of the studies were there significant adverse effects . Future trials may be improved by refinement of several design parameters, including patient selection, treatment timing, and selection of dose and injection site.

Muscle Nerve Suppl, 1997, 6, S61 - 91
Traditional pharmacological treatments for spasticity . Part I: Local treatments; Gracies JM et al.; Spasticity is a velocity-dependent increase in stretch reflex activity . It is one of the forms of muscle overactivity that may affect patients with damage to the central nervous system . Spasticity monitoring is relevant to function because the degree of spasticity may reflect the intensity of other disabling types of muscle overactivity, such as unwanted antagonistic co-contractions, permanent muscle activity in the absence of any stretch or volitional command (spastic dystonia), or inappropriate responses to cutaneous or vegetative inputs . In addition, spasticity, like other muscle overactivity, can cause muscle shortening, which is another significant source of disability . Finally, spasticity is the only form of muscle overactivity easily quantifiable at the bedside . Under the name pharmacological treatments of spasticity, we understand the use of agents designed to reduce all types of muscle overactivity, by reducing excitability of motor pathways, at the level of the central nervous system, the neuromuscular junctions, or the muscle . Pharmacologic treatment should be an adjunct to muscle lengthening and training of antagonists . Localized muscle overactivity of specific muscle groups is often seen in a number of common pathologies, including stroke and traumatic brain injury . In these cases, we favor the use of local treatments in those muscles where overactivity is most disabling, by injection into muscle (neuromuscular block) or close to the nerve supplying the muscle (perineural block) . Two types of local agents have been used in addition to the newly emerged botulinum toxin: local anesthetics (lidocaine and congeners), with a fully reversible action of short duration, and alcohols (ethanol and phenol), with a longer duration of action . Local anesthetics block both afferent and efferent messages . The onset of action is within minutes and duration of action varies between one and several hours according to the agent used . Their use requires resuscitation equipment available close by . When a long-lasting blocking agent is being considered, we favor the use of transient blocks with local anesthetics for therapeutic tests or diagnostic procedures to answer the following questions: Can function be improved by the block? What are the roles played by overactivity and contracture in the impairment of function? Which muscle is contributing to pathologic posturing? What is the true level of performance of antagonistic muscles? A short-acting anesthetic can also serve as preparation to casting or as an analgesic for intramuscular injections of other antispastic treatment . Alcohol and phenol provide long-term chemical neurolysis through destruction of peripheral nerve . Experience with ethanol is more developed in children using intramuscular injection, while experience with phenol is greater in adults with perineural injection . In both cases, there are anecdotal reports of efficacy but studies have rarely been controlled . Side effects are numerous and include pain during injection, chronic dysesthesia and chronic pain, and episodes of local or regional vascular complications by vessel toxicity . In the absence of controlled studies, a theoretical comparison of neurolytic agents with botulinum toxin is proposed . Neurolytic agents may be preferred to botulinum toxin on a number of grounds, including earlier onset, potentially longer duration of effect, lower cost, and easier storage . Conversely, pain during injection, tissue destruction with chronic sensory side effects, and lack of selectivity on motor function with neurolytic agents may favor the use of botulinum toxin . Neurolytic agents and botulinum toxin may be used in combination, the former for larger proximal muscles and the latter for selective injection into distal muscles . In the future, neurolytic agents may prove more appropriate in very severely affected patients for whom the purposes of the block are comfort and hygiene . (ABSTRACT TRUNCATED)

Muscle Nerve Suppl, 1997, 6, S36 - 60
Outcome measures in spasticity management; Pierson SH; Development of validated and reliable outcome measures for spasticity rehabilitation has been hampered by the difficulty of quantifying functionally important parameters such as pain, ease of care, and mobility . Nonetheless, a combination of measures designed to assess technical and functional outcomes, patient satisfaction, and the cost effectiveness of treatment can be used together to evaluate status and track change in spasticity management, including treatment programs involving botulinum toxin . While double-blind, placebo-controlled studies remain the gold standard for clinical testing, the single-subject design is a useful alternative in many treatment protocols . Because no single tool can measure the many types of changes possible with treatment, the choice of assessment tools must be based on the functional changes expected from the treatment . A wide range of assessment tools are critically reviewed for their sensitivity, reliability, validity, and ease of administration.

Eur J Morphol, 1998 Aug, 36 Suppl, 46 - 9
Snare proteins essential for cyclic AMP-regulated exocytosis in salivary glands; Fujita-Yoshigaki J et al.; Rat parotid acinar cells secrete amylase through the stimulation of beta-adrenoceptors followed by accumulation of intracellular cAMP . However, it remains unclear at the molecular level how secretory granules fuse with the apical membranes . We have examined whether SNARE proteins are involved in exocytosis in the salivary glands, and have found that one of the SNARE proteins, VAMP-2, is localized at the secretory granule membrane of rat parotid acinar cells . Moreover, botulinum neurotoxin B, which has endoprotease activity that cleaves VAMP-2, inhibited cAMP-dependent amylase release but did not inhibit basal secretion in the absence of cAMP . These results suggest that VAMP-2 is essential for cAMP-regulated exocytosis in rat parotid acinar cells . In contrast, both neurotoxins A and C1 (endoproteases that cleave SNAP-25 and syntaxin 1 respectively) failed to inhibit cAMP-dependent amylase release . Therefore, neither SNAP-25 nor syntaxin 1 are involved in amylase secretion in the parotid glands . Clarification of the mechanism of secretion will require the identification of proteins that interact and function cooperatively with VAMP-2 . This approach may also reveal details of the molecular mechanism by which the cAMP facilitates secretion in other systems, including neurotransmission.

Med Hypotheses, 1998 Oct, 51(4), 305 - 7
A re-evaluation of the mechanism of action of botulinum toxin on facial movement disorders in man; Leon-S FE et al.; Despite a lot of research aimed at clarifying the mechanism of action of botulinum toxin, mostly at supraspinal levels, a complete understanding of it is still elusive . However, recent investigations, including our own, allow us to suggest that, in facial muscles, the effects of botulinum toxin are not only in the neuromuscular junctions affecting the acetylcholine release but also modify the sensory inflow with subsequent changes on the muscle spindle-gammamotoneuron system.

Eur J Neurosci, 1998 Nov, 10(11), 3369 - 78
Dual effects of botulinum neurotoxin A on the secretory stages of chromaffin cells; Gil A et al.; Truncation of the C-terminal domain of the synaptosomal associated protein of 25 kDa (SNAP-25) by botulinum neurotoxin A (BoNT A) has been shown to block neuroendocrine cell secretion . It is unclear, however, if toxin mechanism involved the affection of a single or more events of the exocytotic cascade . BoNT A induced changes in both the degree of inhibition and the kinetics of catecholamine secretion from populations of cultured bovine chromaffin cells . Ca2+-dependent secretion from digitonin-permeabilized cells showed partial inhibition associated with the alteration of a slow secretory phase at different toxin concentrations . In contrast, in intact cells stimulated by depolarization, cell treatment with low concentrations (1 nM) of the toxin affected the late phase of secretion, whereas 100 nM BoNT A-poisoned cells showed an alteration even of fast components . The high degree of inhibition associated with fast secretory component alteration was dependent on Ca2+ entry through the Ca2+ channels, as it was absent from cells permeated with the A23187 Ca2+ ionophore . Vesicle pools implicated in the effect of BoNT A on the secretory response from single cells were identified using amperometry . These studies supported the macroscopic view by showing that secretion from BoNT A-treated permeabilized cells presented specific inhibition of late vesicle fusions . Intact cells showed alterations in the late vesicle pool (t1/2 = 39 s) recruited during prolonged or repetitive KCI depolarizations using 1 nM BoNT A-treated cells as well as in an intermediate kinetic pool (t1/2 = 18 s) at higher toxin concentrations (100 nM) . The faster resolved component (t1/2 = 8 s) or the membrane fusion event itself were not affected . Our results demonstrate that removal of the last nine C-terminal amino acids of SNAP-25 by BoNT A has a specific effect on two different and distal secretory stages in chromaffin cells.

Neurology, 1998 Nov, 51(5), 1494 - 6
Botulinum toxin type F for treatment of dystonia: long-term experience; Chen R et al.; The authors analyzed retrospectively the results of open-labeled botulinum toxin type F (BTXF) treatment for 1 year or longer in 18 BTXA-resistant patients . All patients except one primary nonresponder to BTXA improved initially with BTXF . Most patients continued to respond to BTXF for 1 year or longer, but four patients became resistant to BTXF . BTXF-resistant patients received a higher dose per treatment and a higher cumulative dose than BTXF-responsive patients . BTXF can be used for long-term treatment of dystonia . It seems prudent to limit BTX doses of all serotypes to the lowest necessary for clinical efficacy.

Semin Neurol, 1998, 18(3), 389 - 95
Multiple sclerosis: symptomatic therapies; Metz L; Although new disease-altering treatments offer hope for those with multiple sclerosis, they are not appropriate for most . Management of symptoms, however, can help everyone with the disease . Several new therapies, including tizanidine, intrathecal baclofen, botulinum toxin injections, gabapentin, ondansitron, thalamic stimulation, and lamotrigine, increase our treatment options . Better understanding of the sleep disorders that commonly occur in those with multiple sclerosis will help us treat another disabling symptom . This chapter reviews the medical and surgical management of multiple sclerosis symptoms, including these new options.

HNO, 1998 Sep, 46(9), 786 - 98
{Idiopathic facial paralysis}; Wolf SR; Although acute idiopathic facial paresis is often labelled "Bell's palsy", historical studies show that Nicolaus Anton Friedreich (1761-1836) from Wurzburg was the first physician to describe the typical symptoms of the disorder in 1797, approximately 24 years prior to the paper published by Sir Charles Bell . Diagnostics has now improved to the extent that acute idiopathic facial palsy can more frequently be assigned to etiologies caused by inflammatory disorders . Herpes simplex virus type I and Borrelia burgdorferi are particularly relevant . Underestimation of the degree of paresis is, particularly in children, a drawback of the clinical examination . "Incomplete eyelid closure" is not a reliable indicator of remaining nerve function . For this reason complete electromyography (EMG) is recommended in all cases of severe facial paresis . Since electroneurography does not reliably reflect the degree of denervation present, needle EMG is preferred . The therapy of the facial palsy of unclear etiology is still not well defined . Nevertheless, we recommend that a combined treatment should be used early, at least in patients with disfiguring pareses . Combinations may consist of cortisone, virostatic agents and hemorrheologic substances and possibly antibiotics . Surgical decompression of the facial nerve remains controversial, since positive surgical results lack statistical support . Individual instructions for facial exercises, massage and muscle relaxation can support rehabilitation and possibly reduce the production of pathological synkinesia . Electrical stimulation should not be used . There are a number of possibilities available to reduce the effects of misdirected reinnervation, especially the use of botulinum-A-toxin . However, intensive diagnosis and therapy in the early phase of paresis are decisive in obtaining a favorable outcome . Further refinements in rehabilitation and comparative multicenter controlled studies are still required for future improvements in affected patients.

J Neurol Neurosurg Psychiatry, 1998 Nov, 65(5), 722 - 8
Peripherally induced oromandibular dystonia; Sankhla C et al.; OBJECTIVES: Oromandibular dystonia (OMD) is a focal dystonia manifested by involuntary muscle contractions producing repetitive, patterned mouth, jaw, and tongue movements . Dystonia is usually idiopathic (primary), but in some cases it follows peripheral injury . Peripherally induced cervical and limb dystonia is well recognised, and the aim of this study was to characterise peripherally induced OMD . METHODS: The following inclusion criteria were used for peripherally induced OMD: (1) the onset of the dystonia was within a few days or months (up to 1 year) after the injury; (2) the trauma was well documented by the patient's history or a review of their medical and dental records; and (3) the onset of dystonia was anatomically related to the site of injury (facial and oral) . RESULTS: Twenty seven patients were identified in the database with OMD, temporally and anatomically related to prior injury or surgery . No additional precipitant other than trauma could be detected . None of the patients had any litigation pending . The mean age at onset was 50.11 (SD 14.15) (range 23-74) years and there was a 2:1 female preponderance . Mean latency between the initial trauma and the onset of OMD was 65 days (range 1 day-1 year) . Ten (37%) patients had some evidence of predisposing factors such as family history of movement disorders, prior exposure to neuroleptic drugs, and associated dystonia affecting other regions or essential tremor . When compared with 21 patients with primary OMD, there was no difference for age at onset, female preponderance, and phenomenology . The frequency of dystonic writer's cramp, spasmodic dysphonia, bruxism, essential tremor, and family history of movement disorder, however, was lower in the post-traumatic group (p<0.05) . In both groups the response to botulinum toxin treatment was superior to medical therapy (p<0.005) . Surgical intervention for temporomandibular disorders was more frequent in the post-traumatic group and was associated with worsening of dystonia . CONCLUSION: The study indicates that oromandibular-facial trauma, including dental procedures, may precipitate the onset of OMD, especially in predisposed people . Prompt recognition and treatment may prevent further complications.

J Fr Ophtalmol, 1998 Aug-Sep, 21(7), 508 - 14
{Value of delayed botulinum toxin injection in esotropia in the child as first line treatment}; Robert PY et al.; PURPOSE: Evaluation of botulinum toxin to treat esotropia in children over 3 years old . MATERIAL AND METHODS: Eight children (6 boys and 2 girls), aged from 3 to 6 years (mean 4), underwent bilateral injection of 1.25 UI botulinum toxin Botox in medial rectus muscles, under general anesthesia . Preoperative diagnosis was infantile esotropia in 7 cases, and decompensated esophoria in 1 case . Six children had alternating isoacuity before injection, and two had amblyopia . Mean follow-up was 1.8 months (6 to 24 months) . RESULTS: One transient exotropia, and one transient ptosis were reported . Lasting orthotropia was achieved in four children (including one who presented again spasms in near vision), and lasting angle reduction in another child . Another child had late recurrence at 18 months . The injection was a failure for the two amblyopic children . DISCUSSION: Botulinum therapy allowed to avoid surgery in three cases, and to perform a more limited operation in one case . CONCLUSION: Botulinum toxin injection in extraocular muscles is of interest in infantile esotropia as a first treatment, even in children over 3 years . The success relies principally on the absence of deep amblyopia, and muscular elongation troubles . However, the use of botulinum is limited, because it requires general anesthesia, and because of its price.

Clin Rehabil, 1998 Oct, 12(5), 381 - 8
Botulinum toxin type A and short-term electrical stimulation in the treatment of upper limb flexor spasticity after stroke: a randomized, double-blind, placebo-controlled trial; Hesse S et al.; OBJECTIVE: To investigate whether the combined approach of botulinum toxin type A (BtxA) and electrical stimulation was more effective than the toxin alone in the treatment of chronic upper limb spasticity after stroke . DESIGN: Randomized, placebo-controlled study with four treatment groups: 1000 units BtxA (Dysport) + electrical stimulation (A), 1000 units BtxA (B), placebo + electrical stimulation (C) and placebo (D) . SETTING: A neurological rehabilitation clinic . SUBJECTS: Twenty-four stroke patients with chronic upper limb spasticity after stroke, six patients in each treatment group . INTERVENTIONS: Intramuscular injection of either toxin or placebo into six upper imb flexor muscles . In group A and C additional electrical stimulation of the injected muscles with surface electrodes, three times half an hour each day for three days . MAIN OUTCOME MEASURES: Muscle tone rated with the modified Ashworth score, limb position at rest and difficulties encountered during three upper limb motor tasks assessed before and 2, 6 and 12 weeks after injection . RESULTS: Most improvements were observed in patients of group A . Cleaning the palm (p = 0.004) differed across groups . Pairwise comparison for this target variable showed that group A differed from group B and D (p <0.01), but not from C . Indicative across-group differences were obtained for elbow spasticity reduction (p = 0.011), and improvement of putting the arm through a sleeve (p = 0.020) . CONCLUSIONS: The placebo-controlled trial favours the concept that electrical stimulation enhances the effectiveness of BtxA in the treatment of chronic upper limb flexor spasticity after stroke.

Histochem Cell Biol, 1998 Oct, 110(4), 395 - 406
Intracellular dynamics of alkaline phosphatase-containing granules in electropermeabilized human neutrophils; Kobayashi T et al.; Human neutrophils possess alkaline phosphatase-containing intracellular granules which are upregulated to the cell surface upon stimulation . The mechanism that governs the intracellular dynamics of these granules is, however, poorly understood . The aim of the present study was to investigate the possible participation of GTP-binding proteins in the reorganization and exocytosis of the alkaline phosphatase-containing granules using electropermeabilized cells . Biochemical assays using intact neutrophils showed that the alkaline phosphatase activity was upregulated and exocytosed into the extracellular space upon stimulation with AIF4 and N-formyl peptide . This upregulation was inhibited by treatment of cells with pertussis toxin and botulinum toxin . Alkaline phosphatase activity was also upregulated in electropermeabilized cells stimulated with guanosine 5'-O-(3-thiotriphosphate) (GTPgammaS), but not with guanosine 5'-O-(2-thiodiphosphate) (GDPbetaS) . Cytochemically, alkaline phosphatase-containing granules were dispersed throughout the cytoplasm in unstimulated electropermeabilized neutrophils . Upon stimulation with GTPgammaS, but not with GDPbetaS, these granules fused to form elongated tubular structures which eventually became associated with the plasma membrane . Nocodazole disturbed the reorganization of the alkaline phosphatase-containing granules in cells stimulated with GTPgammaS . The results from this study indicate that GTP-binding proteins participate in the reorganization and exocytosis of alkaline phosphatase-containing granules associated with the microtubules in electropermeabilized human neutrophils.

Toxicon, 1998 Nov, 36(11), 1539 - 48
Development of recombinant vaccines for botulinum neurotoxin; Smith LA; Synthetic genes encoding non-toxic, carboxyl-terminal regions (approximately 50 kDa) of botulinum neurotoxin (BoNT) serotypes A and B (referred to as fragment C or HC) were constructed and cloned into the methylotropic yeast, Pichia pastoris . Genes specifying BoNTA(HC) and BoNTB(HC) were expressed as both intracellular and secreted products . Recombinants, expressed intracellularly, yielded products with the expected molecular weight as judged by SDS PAGE and Western blot (immunoblot) analysis, while secreted products were larger due to glycosylation . Gene products were used to vaccinate mice and evaluated for their ability to elicit protective antibody titers in vivo . Mice given three intramuscular vaccinations with yeast supernatant containing glycosylated BoNTA(HC) were protected against an intraperitoneal challenge of 10(6) 50% mouse lethal doses (MLD50) of serotype A neurotoxin, a result not duplicated by its BoNTB(HC) counterpart . Vaccinating mice with cytoplasmically produced BoNTA(HC) and BoNTB(HC) protected animals from a challenge of 10(6) MLD50 of serotype A and B toxins, respectively . Because of the glycosylation encountered with secreted BoNT(HC), our efforts focused on the production and purification of products from intracellular expression.

Clin Neuropharmacol, 1998 Sep-Oct, 21(5), 307 - 11
Blink reflex recovery cycle in patients with blepharospasm unilaterally treated with botulinum toxin; Grandas F et al.; To determine whether Botulinum Toxin Type A (BTXA) has an effect on the Central Nervous System, the authors studied the excitability of the blink reflex recovery cycle in 12 patients with blepharospasm before and 3 weeks after unilateral BTXA injections . To avoid recording from severely denervated muscles, the R2 response of the blink reflex was obtained from the untreated orbicularis oculi with both ipsilateral and contralateral supraorbital nerve stimulation . Baseline recovery curves were compared with a control group (n = 11) and showed an enhanced recovery of the R2 component . There were no significant differences between the recovery curves of the R2 component of the blink reflex taken before BTXA treatment and those taken after treatment . This finding confirms that BTXA does not modify the excitability of brainstem interneurons that mediate the bilateral R2 response of the blink reflex in patients with blepharospasm.

Schweiz Rundsch Med Prax, 1998 Sep 16, 87(38), 1213 - 21
{Achalasia: botulinus toxin, interventional balloon dilatation, myotomy?}; Schneider JH et al.; 67 patients with achalasia were treated either medically, endoscopically or surgically from 1987 to 1997 in the Department of Surgery of the University of Tubingen . 27/67 (40%) of the patients, who were pneumatically dilatated, had a very successful therapy within the first year after dilatations . 12/67 (17%) of the patients had good results with a dysphagia score less than 1 after dilatations within the first year . The perforation rate of interventionally treated patients was 1.4% without any surgical procedure . Open myotomy according to Heller was performed in 28 of 67 patients (41%); after 1993 a laparoscopic procedure was performed in all patients . The average hospitalization for MIC was 5.4 days . The manometric control investigations showed a decrease of the basal LES pressure from preoperative values . When evaluated manometrically 87% showed good results in the follow up time of at least 24 months . 14% of those who underwent surgery had to be endoscopically dilatated after surgery.

Semin Ophthalmol, 1998 Sep, 13(3), 142 - 8
Cosmetic indications for botulinum A toxin; Foster JA et al.; This article describes the use of botulinum toxin type A in the cosmetic treatment of facial wrinkles . Injection techniques, volumes, and concentration of the botulinum A toxin are described for various types of facial wrinkles.

Int J Biochem Cell Biol, 1998 Oct, 30(10), 1069 - 73
SNAP-25; Hodel A; SNAP-25 belongs to a family of evolutionarily conserved proteins whose members are essential for exocytosis . Neurons and neuroendocrine cells differentially express two SNAP-25 isoforms in a developmentally regulated manner, and related homologues have been detected in most eukaryotic cells . SNAP-25 is localised on the cytoplasmic face of the plasma membrane and on secretory vesicles . It forms a stable ternary complex with two other exocytotic proteins: syntaxin and the synaptic vesicle protein synaptobrevin . A cytosolic ATPase dissociates this complex during priming of the exocytotic apparatus . Subsequent reassembly is promoted by SNAP-25 and may drive Ca(2+)-triggered vesicle-plasma membrane fusion . A mutant mouse that lacks the SNAP-25 gene is defective in neuronal dopamine signalling and exhibits similar behaviour as sufferers from hyperactivity disorders . Use of this animal model thus provides a promising avenue for the development of therapeutic treatments . Additionally, SNAP-25-based peptides that mimic the effect of botulinum neurotoxin A may be used for the treatment of involuntary muscle spasms.

Ophthal Plast Reconstr Surg, 1998 Sep, 14(5), 305 - 17
Blepharospasm: past, present, and future; Anderson RL et al.; To investigate causes, associations, and results of treatment with blepharospasm, 1,653 patients were evaluated by extensive questionnaires to study blepharospasm and long-term results of treatment with the full myectomy operation, botulinum-A toxin, drug therapy, and help from the Benign Essential Blepharospasm Research Foundation (BEBRF) . The percent of patients improved by the BEBRF was 90%, full myectomy 88%, botulinum-A toxin 86%, and drug therapy 43% . The patient acceptance rate for the BEBRF was 96%, full myectomy 82%, botulinum-A toxin 95%, and drug therapy 57% . Blepharospasm is multifactorial in origin and manifestation . A vicious cycle and defective circuit theory to explain in origin and direct treatment rather than a defective specific locus is presented . All four forms of therapy evaluated are useful and must be tailored to the patient's needs . Mattie Lou Koster and the BEBRF have helped blepharospasm sufferers more than any other modality, and all patients should be informed of this support group . The full myectomy is reserved for botulinum-A toxin failures, and the limited myectomy is an excellent adjunct to botulinum-A toxin.

J Nat Toxins, 1998 Oct, 7(3), 227 - 38
Predictions of secondary structure and solvent accessibility of the light chain of the clostridial neurotoxins; Lebeda FJ et al.; Predictions were made of the secondary, two-dimensional (2-D) structures and side-chain solvent accessibilities of the light (L) chains of the clostridial neurotoxins (botulinum neurotoxin serotypes A-G and tetanus neurotoxin) . An artificial neural network was used to make these predictions from a multiple alignment of their primary structures and was the approach used in making successful predictions for the C-fragments of these neurotoxins (Lebeda et al., J . Prot . Chem., 17:311, 1998) . We also exploited the fact that the L-chains are Zn-dependent proteases . Although no other metalloproteases were found to be sequentially homologous to these neurotoxin L-chains, a sequence clustering algorithm showed that several bacterially derived Zn-dependent proteases, including thermolysin, were the most similar . A 2-D structure topology map for the type A L-chain was constructed by using thermolysin as a design template . As in thermolysin, the region containing the Zn-binding sequence motif, which is part of the active site in these neurotoxins, was predicted to be minimally solvent accessible . On the other hand, the locations of residues with highly exposed side chains were predicted to occur in non-periodic structure elements . Together, these 2-D structure and solvent accessibility predictions can be used to identify important solvent-exposed regions of the L-chain . These regions may include sites that interact with residues of the neurotoxin heavy chain, sites that bind to vesicle-docking substrates or sites that form antibody epitopes.

J Physiol Paris, 1998 Apr, 92(2), 135 - 9
On the action of botulinum neurotoxins A and E at cholinergic terminals; Washbourne P et al.; Botulinum neurotoxins type A and E (BoNT/A and /E) are metalloproteases with a unique specificity for SNAP-25 (synaptosomal-associated protein of 25 kDa), an essential protein component of the neuroexocytotic machinery . It was proposed that this specificity is based on the recognition of a nine-residue sequence, termed SNARE motif, which is common to the other two SNARE proteins: VAMP (vesicle-associated membrane protein) and syntaxin, the only known substrates of the other six clostridial neurotoxins . Here we report on recent studies which provide evidence for the involvement of the SNARE motif present in SNAP-25 in its interaction with BoNT/A and /E by following the kinetics of proteolysis of SNAP-25 mutants deleted of SNARE motifs . We show that a single copy of the motif is sufficient for BoNT/A and /E to recognise SNAP-25 . While the copy of the motif proximal to the cleavage site is clearly involved in recognition, in its absence, other more distant copies of the motif are able to support proteolysis . We also report on studies of poisoning human neuromuscular junctions with either BoNT/A or BoNT/E and describe the unexpected finding that the time of recovery of function after poisoning is much shorter in the case of type E with respect to type A intoxication . These data are discussed in terms of the different sites of action of the two toxins within SNAP-25.

Arch Phys Med Rehabil, 1998 Oct, 79(10), 1303 - 5
Management of focal dystonia of the extensor hallucis longus muscle with botulinum toxin injection: a case report; Sherman AL et al.; Recently botulinum toxin has been used with increasing frequency as a safe and effective treatment for many previously refractory conditions associated with excessive muscle activity . The indications for use of botulinum toxin injection continue to expand . This report describes the case of an 83-year-old woman with a history of diabetes mellitus and lumbar spinal stenosis who developed a severe focal dystonia of the left great toe, such that the toe maintained the extended position . Functionally, the resultant deformity prevented the patient from wearing shoes . In addition, the patient had significant pain in the left great toe . Under needle electromyographic localization, 50 units of botulinum toxin were injected into the left extensor hallucis longus muscle . Two weeks after the injection the patient was symptom free and could place her left foot into a shoe . Seven months later, she remained symptom free . This case illustrates that localized injection of botulinum toxin to a specific lower limb muscle can effectively result in decreased muscle activity and functional improvement.

Laryngoscope, 1998 Oct, 108(10), 1435 - 41
Botulinum toxin management of spasmodic dysphonia (laryngeal dystonia): a 12-year experience in more than 900 patients; Blitzer A et al.; OBJECTIVES: This paper reviews a 12-year experience in more than 900 patients with spasmodic dysphonia who have been treated with botulinum toxin . STUDY DESIGN: This is a retrospective analysis of patients with adductor spasmodic dysphonia (strain-strangled voice), abductor spasmodic dysphonia (whispering voice), and adductor breathing dystonia (paradoxical vocal fold motion), all of whom have been treated with botulinum toxin injections for relief of symptom . METHODS: All of the patients were studied with a complete head and neck and neurologic examination; fiberoptic laryngostroboscopy; acoustic and aerodynamic measures; and a speech evaluation including the Universal spasmodic dysphonia rating scale . Some were given electromyography . All patients received botulinum toxin injections into the affected muscles under electromyographic guidance . RESULTS: The adductor patients had an average benefit of 90% of normal function lasting an average of 15.1 weeks . The abductor patients had an average benefit of 66.7% of normal function lasting an average of 10.5 weeks . Adverse effects included mild breathiness and coughing on fluids in the adductor patients, and mild stridor in a few of the abductor patients . CONCLUSION: Botulinum toxin A injection of the laryngeal hyperfunctional muscles has been found over the past 12 years to be the treatment of choice to control the dystonic symptoms in most patients with spasmodic dysphonia.

J Biol Chem, 1998 Oct 23, 273(43), 28322 - 31
Actin filaments facilitate insulin activation of the src and collagen homologous/mitogen-activated protein kinase pathway leading to DNA synthesis and c-fos expression; Tsakiridis T et al.; The exact mechanism of the spatial organization of the insulin signaling pathway leading to nuclear events remains unknown . Here, we investigated the involvement of the actin cytoskeleton in propagation of insulin signaling events leading to DNA synthesis and expression of the immediate early genes c-fos and c-jun in L6 muscle cells . Insulin reorganized the cellular actin network and increased the rate of DNA synthesis and the levels of c-fos mRNA, but not those of c-jun mRNA, in undifferentiated L6 myoblasts . Similarly, insulin markedly elevated the levels of c-fos mRNA but not of c-jun mRNA in differentiated L6 myotubes . Disassembly of the actin filaments by cytochalasin D, latrunculin B, or botulinum C2 toxin significantly inhibited insulin-mediated DNA synthesis in myoblasts and abolished stimulation of c-fos expression by the hormone in myoblasts and myotubes . Actin disassembly abolished insulin-induced phosphorylation and activation of extracellulor signal-regulated kinases, activation of a 65-kda member of the p21-activated kinases, and phosphorylation of p38 mitogen-activated protein kinases but did not prevent activation of phosphatidylinositol 3-kinase and p70(S6k) . Under these conditions, insulin-induced Ras activation was also abolished, and Grb2 association with the Src and collogen homologous (Shc) molecule was inhibited without inhibition of the tyrosine phosphorylation of Shc . We conclude that the actin filament network plays an essential role in insulin regulation of Shc-dependent signaling events governing gene expression by facilitating the interaction of Shc with Grb2.

Muscle Nerve, 1998 Nov, 21(11), 1540 - 2
Intrasphincteric injection of botulinum toxin is effective in long-term treatment of esophageal achalasia; Annese V et al.; We investigated the long-term efficacy and safety of intrasphincteric injections of botulinum toxin (100 U) in 57 patients with esophageal achalasia . One month after treatment, 50 patients had improved (88%); both symptom score and LES pressure were significantly reduced (P < 0.001) . After a mean follow-up of 24+/-15 months (range 6-48), 43 patients (75%) are still in remission, although repeat injections of toxin were needed to achieve a stable effect on symptoms.

J Neurol Neurosurg Psychiatry, 1998 Oct, 65(4), 472 - 8
Outcome of selective ramisectomy for botulinum toxin resistant torticollis; Ford B et al.; OBJECTIVE: To investigate the long term outcome of selective ramisectomy denervation in patients with botulinum toxin resistant spasmodic torticollis . BACKGROUND: The published surgical series of ramisectomy treatment for torticollis do not provide systematic information on patients who develop resistance to the current standard of treatment-botulium toxin injections . Moreover, there is little information on surgical outcome using rating scale measurements of torticollis, or assessments of functional and occupational capacity . METHODS: Using a structured interview format and videotape assessments of severity of dystonia in a retrospective fashion, detailed follow up information was obtained on 16 patients who underwent open label selective denervation for severe, disabling torticollis, refractory to injections of botulinum toxin . RESULTS: Of 16 patients with disabling torticollis followed up postoperatively for a mean of 5 years, six (37.5%) had a moderate or complete return of normal neck function, as determined using functional capacity scales, whereas 10 had only minimal relief of dystonia or gain in function . Six of the 16 patients (37.5%) underwent a second peripheral denervation operation, and one required a third . Of 11 patients working outside the home before surgery, nine were disabled by dystonia, and only one continued to work after surgery . Dystonia rating scale scores of videotaped examinations using a modification of the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) improved in 12 of 14 patients (85.7%) who underwent selective ramisectomy . When patients with primary botulinum toxin resistance were excluded, the magnitude of benefit for this subgroup was 31.9% of the baseline dystonia score (p<0.0002), comparable with the degree of improvement in a group of control patients receiving botulinum toxin treatment for torticollis . CONCLUSION: About one third of patients with torticollis resistant to injections of botulinum toxin may derive modest long term functional improvement from selective denervation, with a reduction in dystonia by about 30%, but remain unable to work.

Aesthetic Plast Surg, 1998 Sep-Oct, 22(5), 366 - 71
Eyebrow asymmetry: ways of correction; Muhlbauer W et al.; Ocassionally a patient asks for correction of his asymmetric eyelids . In many instances, however, a careful analysis reveals that the actual cause is an asymmetry of the eyebrows . Generally, asymmetric eyebrows are due to excessive muscle dynamics (i.e., a hyperkinesia of the frontalis or the depressor supercilii muscles) . Therefore, the asymmetry will not be corrected by an asymmetric blepharoplasty, which will instead disclose the preexisting asymmetry, much to the concern of the patient . Management of the asymmetric brow is demanding and requires a preoperative problem-oriented and detailed analysis of the individual patient to achieve satisfactory results . We present 10-years' experience using a problem-specific approach . This included intramuscular botulinum toxin A injection, superselective neurotomy, endoscopic browlift and traditional procedures such as the coronal and direct browlift . Indication, patient selection, results, and complications are discussed.

J Paediatr Child Health, 1998 Oct, 34(5), 480 - 2
A Chinese girl with Leigh syndrome: effect of botulinum toxin on dystonia; Leung TF et al.; Leigh syndrome is a form of neurodegenerative disease which is associated with intracranial infarcts . The diagnosis is made by finding hyperlactacidaemia together with cerebral infarcts on neuroimaging . We report a 4-year-old Chinese girl with Leigh syndrome who had several atypical features . She presented with generalized dystonia and developmental regression . In addition, she suffered from an unusual feature of bladder dystonia . This patient appeared to be suffering from respiratory chain complex I deficiency from studies on cultured skin fibroblasts . Assays for respiratory chain enzymes as well as mitochondrial DNA point mutations and major deletions in muscle were normal . Dystonia persisted despite treatments with muscle relaxants and a ketogenic diet . Intramuscular botulinum toxin resulted in significant relief of dystonia.

Eur J Neurosci, 1998 Aug, 10(8), 2617 - 28
Presynaptic protein interactions in vivo: evidence from botulinum A, C, D and E action at frog neuromuscular junction; Raciborska DA et al.; The present study examines the paralytic action of botulinum neurotoxins at their natural target, the neuromuscular junction . We asked whether syntaxin, synaptosome-associated protein of 25 kDa (SNAP-25) and vesicle-associated membrane protein (VAMP/synaptobrevin), the proteins proteolysed by botulinum, are susceptible to cleavage in frog nerve terminals, and whether they form complexes in vivo . In control terminals, the three SNAREs were distributed in broad bands at 1 micrometer intervals, at sites consistent with presynaptic Ca2+ channels . Within 3 h, botulinum A, C, D and E (BoNT/A/C/D/E) blocked nerve-evoked muscle contractions but their effects on substrate immunoreactivity varied . The effect of BoNT/A on either C-terminus or N-terminus immunoreactivity of SNAP-25 was undetectable after 3-h incubation, although C-terminus immunoreactivity was reduced after 24 h; N-terminus immunoreactivity was not affected even after 36 h . BoNT/E reduced C-terminus immunoreactivity of SNAP-25 1.5 h after toxin application when transmitter release was blocked, but required 24 h to reduce N-terminus immunoreactivity . BoNT/C reduced syntaxin immunoreactivity after 24-h incubation but did not affect SNAP-25 . BoNT/D reduced VAMP immunoreactivity at 3 h while it increased SNAP-25 C-terminal staining fourfold . BoNT/A and BoNT/C applied together for 24 h reduced syntaxin immunoreactivity and that of both C- and N-terminus of SNAP-25, indicating that retention of SNAP-25 N-terminus after cleavage by BoNT/A depended on intact syntaxin . Therefore, we infer that SNAP-25 interacts with VAMP and with syntaxin in vivo . Neurotoxin action abolished only 40-60% of SNAP-25, VAMP or syntaxin immunoreactivity suggesting that distinct pools of these proteins, not immediately involved in triggered exocytosis, are resistant to proteolysis.

Dev Med Child Neurol, 1998 Sep, 40(9), 622 - 5
Musculoskeletal modelling in determining the effect of botulinum toxin on the hamstrings of patients with crouch gait; Thompson NS et al.; This study aimed to determine the effect of hamstring botulinum toxin A (Btx-A) injection in 10 children with crouch gait in terms of changes in muscle length and lower-limb kinematics . Before Btx-A injection limb kinematics were recorded . Maximum hamstring lengths and excursions were calculated by computer modelling of the lower limb . Data were compared with the averaged hamstring lengths of 10 control children . Hamstrings were defined as short if their length was shorter than the average maximum length minus one standard deviation . Gait analysis was repeated 2 weeks after isolated hamstring Btx-A injection . Pre- and postinjection kinematic data and muscle lengths were then compared . Four of 18 injected limbs in three subjects had short medial hamstring before injection, none of the subjects had short lateral hamstrings . Muscle excursion was significantly reduced in the short and adequate maximum muscle length groups . A significant increase in the semimembranosus and semitendinosus length in all of the injected limbs was noted . Only in the short muscle group was a significant increase in muscle excursion observed . Knee extension improved by 13 degrees in the adequate muscle length group and by 15.6 degrees in the short muscle length group . Pelvic tilt and hip flexion increased in both groups non-significantly . Average walking speed postinjection increased from 0.60 ms(-1) to 0.71 ms(-1) . Short hamstrings are over-diagnosed in crouch gait . Hamstring Btx-A injection in patients with crouch gait produces significant, repeatable muscle lengthening and improved ambulatory function.

J Biol Chem, 1998 Oct 16, 273(42), 27620 - 4
Brain-derived neurotrophic factor induces rapid and transient release of glutamate through the non-exocytotic pathway from cortical neurons; Takei N et al.; There is increasing interest in the involvement of neurotrophins in neural transmission and plasticity . Thus, we investigated the effects of brain-derived neurotrophic factor (BDNF) on glutamate release from cortical neurons . Treatment of cultured cortical neurons with BDNF induced rapid and transient release of glutamate . This effect was suggested to be mediated by TrkB activation because K252a inhibited the release of glutamate and BDNF phosphorylated TrkB within 30 s . BDNF-induced glutamate release was observed even when using Ca2+-free assay buffer but was inhibited by BAPTA-AM, a cell-permeable Ca2+ chelator . Therefore, BDNF-induced glutamate release was independent of extracelluar Ca2+ but dependent on intracellular Ca2+ . Because normal neurotransmitter release is exocytotic, the involvement of the exocytotic pathway in BDNF-induced glutamate release was examined . As botulinum toxin is known to cleave exocytosis-associated proteins, thereby inhibiting exocytosis, it was applied to neurons prior to the release assay . Although botulinum toxin B cleaved VAMP2 and inhibited Ca2+-triggered glutamate release, it did not inhibit the BDNF-induced release of glutamate . These results strongly suggested that BDNF induces rapid and transient release of glutamate from cortical neurons through a non-exocytotic pathway.

Rev Invest Clin, 1998 May-Jun, 50(3), 263 - 76
{New concepts on the physiopathology, diagnosis, and treatment of achalasia}; Carmona-Sanchez R et al.; OBJECTIVES: To review the most relevant publications on the pathophysiology, clinical manifestations, diagnosis and treatment of esophageal achalasia, and the clinical experience achieved at our institution in order to propose a practical strategy to facilitate the management of these patients . DATA SOURCES: Manual and MEDLINE search of key articles published between January 1986 and July 1997 in addition to publications of our institute of thirty years . STUDY SELECTION: All kinds of publications with substantial clinical experience, new information or research protocols . DATA SYNTHESIS: Achalasia is an uncommon disorder of the myenteric plexus of the esophagus . Main symptoms are dysphagia, regurgitations and chest pain . The diagnosis is established by manometric criteria . Esophagogram, endoscopy and radionuclide esophageal emptying test help to differentiate other conditions and evaluate the response to treatment . Pharmacotherapy may provide relief to patients with mild symptoms and is useful for patients with high risk of complications . Dilations and myotomy are safe, effective and long lasting procedures . Botulinum toxin may be effective in selected cases . Predictive factors of response have been described for each therapy . CONCLUSION: A systematic approach to the management of patients with achalasia is necessary . Introduction of new therapies as botulinum toxin and minimal invasion surgery are changing the therapeutic decisions in this field . Drugs and BoTox are considered the first line of treatment for high risk patients and dilation and surgery for patients with no risk.

J Comp Neurol, 1998 Oct 12, 400(1), 1 - 17
Effects of botulinum neurotoxin type A on the expression of gephyrin in cat abducens motoneurons; Moreno-Lopez B et al.; In this study, we investigated the effects of long-term synaptic blockade on postsynaptic receptor clustering at central inhibitory glycinergic synapses . High doses of botulinum neurotoxin type A injected in the lateral rectus muscle completely abolishes inhibitory postsynaptic potentials onto abducens motoneurons within 2 days postinjection, and transmission remains blocked for at least 2 months . Using this model, we analyzed the expression of gephyrin, a glycine receptor clustering protein, on the membrane of motoneuron somata after botulinum neurotoxin type A injection in their target muscle . Immunofluorescence or electron microscopy immunohistochemistry revealed gephyrin-immunoreactive clusters (most < 0.5 microm in diameter) densely covering the surface of control abducens motoneurons . Ultrastructurally, presynaptic terminals containing flattened synaptic vesicles (F terminals) were found associated with multiple gephyrin-immunoreactive postsynaptic densities (average 1.24 gephyrin clusters/F+ profile) . No significant changes in gephyrin-immunoreactive clusters were observed at 5 days postinjection, but we found significant reductions (25-40%) in the density of gephyrin clusters 19 and 35 days postinjection . Hence, the physiological alterations reported in this model precede structural changes on postsynaptic receptor cluster density . The decrease in gephyrin-immunoreactive clusters was paralleled by reductions in synaptic covering (F+ terminals per 100 microm of membrane) . Presumed inactive F+ terminals that remained attached to the motoneuron surface displayed normal gephyrin-immunoreactive clusters; however, the pre- and postsynaptic membranes in between synaptic active zones frequently appeared separated by enlarged extracellular spaces . We concluded that postsynaptic receptor cluster dissolution seemed more directly related to terminal retraction than to inactivity alone.

J Voice, 1998 Sep, 12(3), 389 - 98
Does botulinum toxin alter laryngeal secretions and mucociliary transport?
Fisher KV, Giddens CL, Gray SD.
Localized botulinum toxin injection disrupts cholinergic transmission and has potential to cause focal dysautonomia . Mucociliary transport and laryngeal secretions are thought to be mediated in part by autonomic, cholinergic transmission . We questioned whether patients who receive Botox injection for adductor spasmodic dysphonia (ADSD) report postinjection symptoms possibly related to altered mucociliary clearance or laryngeal secretions . Medical histories, audiotaped interviews, and symptom ratings were retrospectively examined for 29 patients with ADSD who were followed after one or more Botox injections . Patients had received bilateral, percutaneous Botox injections of 2.5 units using an EMG-guided approach . One or more weeks after injection, four patients reported either burning, tickling, or irritation of the larynx/throat, excessive thick secretions, or dryness . Symptoms recurred with subsequent injections in two patients and were not associated with swallowing difficulty . These symptoms are consistent with, but not diagnostic of, the known effects of botulinum toxin on cholinergic, autonomic transmission.

J Voice, 1998 Sep, 12(3), 383 - 8
Laryngeal rebalancing for the treatment of arytenoid dislocation; Rontal E et al.; In almost every type of functional laryngeal operation a successful result hinges on the surgeon's ability to control the muscular and ligamentous forces that act upon the vocal folds . Most of the time these forces are small in relation to the manipulations and resections performed . Occasionally, the forces are significant relative to the problem encountered, resulting in a failed surgery . Of all the many conditions that fit in to this latter description, perhaps the best example in arytenoid dislocation . Dislocation of the arytenoid is usually secondary to trauma with the majority of reported cases resulting from some type of anesthetic misadventure . Two types of dislocation have been described, anteromedial and posterolateral, each with a different mechanism of causation . This paper concerns itself with the more common anteromedial variety and its treatment using botulinum toxin.

Neurol Neurochir Pol, 1998 Mar-Apr, 32(2), 277 - 84
{Facial hemispasm: modern views on the etiology, pathogenesis and treatment . Personal experience with botulinum A toxin treatment}; Slawek J et al.; The authors present current opinions on the etiology and strategies of treatment of hemifacial spasm . In the vast majority of patients it is caused by compression of facial nerve by redundant loops of vertebral and basilar arteries and their branches . It was confirmed by neuroradiology imaging techniques and during surgical interventions . In recent years a new, non-invasive method of treatment has gained a wide approval--the local injections of botulinum toxin A into contracting muscles is a highly effective (90%) and safe method of treatment . Our own material (10 patients, 22 sessions) confirms it as well.

J Biol Chem, 1998 Oct 9, 273(41), 26772 - 8
Activation of cyclin-dependent kinase 2 (Cdk2) in growth-stimulated rat astrocytes . Geranylgeranylated Rho small GTPase(s) are essential for the induction of cyclin E gene expression; Tanaka T et al.; The role of the mevalonate cascade in the control of cell cycle progression in astrocytes has been investigated . Serum stimulation of rat astrocytes in primary culture induces the expression of cyclin E followed by the activation of cyclin-dependent kinase 2 (Cdk2) during G1/S transition . The expression of p27, cyclin D1, and the activities of Cdk4 and Cdk-activating kinase (CAK), composed of Cdk7 and cyclin H, were not affected . Serum did, however, stimulate the expression of 3-hydroxy-3-methylglutaryl-CoA (HMG-CoA) reductase mRNA at mid-G1 phase . Moreover, an inhibitor of HMG-CoA reductase, pravastatin, reduced cyclin E expression and Cdk2 activation and caused G1 arrest in the astrocytes . In contrast, mevalonate and its metabolite, geranylgeranylpyrophosphate (GGPP) but not farnesylpyrophosphate (FPP), reversed the inhibitory effects of pravastatin on cyclin E expression and Cdk2 activation and allowed G1/S transition . Rho small GTPase(s) were geranylgeranylated and translocated to membranes in the presence of GGPP during G1/S transition . The effect of GGPP on cyclin E expression was abolished by botulinum C3 exoenzyme, which specifically inactivates Rho . These data indicate that geranylgeranylated Rho small GTPase(s) are essential for the induction of cyclin E expression, Cdk2 activation, and G1/S transition in rat astrocytes.

J Laparoendosc Adv Surg Tech A, 1998 Aug, 8(4), 201 - 7
Laparoscopic resection of esophageal epiphrenic diverticulum; Myers BS et al.; Symptomatic esophageal epiphrenic diverticula are usually repaired with a diverticulectomy and esophagomyotomy via a left thoracotomy with substantial postoperative pain and morbidity . If a laparoscopic approach could be shown to be safe and effective, the decrease in postoperative pain and potentially shorter hospital stay would make this technique beneficial . We report three cases repaired via a transabdominal approach . The first two cases were done laparoscopically . The third case was attempted laparoscopically and completed via a midline laparotomy, demonstrating that thoracotomy is not necessary even if laparoscopy is not possible . All three patients had long-standing debilitating symptoms refractory to standard nonsurgical therapies (botulinum toxin injection, pneumatic dilation, antispasmodic medication) with abnormal esophageal motility . There was one intraoperative complication of a left pneumothorax that required neither laparotomy nor thoracostomy . An esophagram on the first postoperative day demonstrated no extravasation and good flow into the stomach . The postoperative course was uneventful for all three patients, with the laparoscopic patients discharged on the second postoperative day and the laparotomy patient discharged on the seventh postoperative day . In conclusion, laparoscopic repair of symptomatic esophageal epiphrenic diverticula is a safe and effective technique with minimal postoperative pain and morbidity . It should be considered as an alternative to the traditional transthoracic approach, and may become the standard technique.

FEBS Lett, 1998 Sep 11, 435(1), 84 - 8
The 26-mer peptide released from SNAP-25 cleavage by botulinum neurotoxin E inhibits vesicle docking; Ferrer-Montiel AV et al.; Botulinum neurotoxin E (BoNT E) cleaves SNAP-25 at the C-terminal domain releasing a 26-mer peptide . This peptide product may act as an excitation-secretion uncoupling peptide (ESUP) to inhibit vesicle fusion and thus contribute to the efficacy of BoNT E in disabling neurosecretion . We have addressed this question using a synthetic 26-mer peptide which mimics the amino acid sequence of the naturally released peptide, and is hereafter denoted as ESUP E . This synthetic peptide is a potent inhibitor of Ca2+-evoked exocytosis in permeabilized chromaffin cells and reduces neurotransmitter release from identified cholinergic synapses in in vitro buccal ganglia of Aplysia californica . In chromaffin cells, both ESUP E and BoNT E abrogate the slow component of secretion without affecting the fast, Ca2+-mediated fusion event . Analysis of immunoprecipitates of the synaptic ternary complex involving SNAP-25, VAMP and syntaxin demonstrates that ESUP E interferes with the assembly of the docking complex . Thus, the efficacy of BoNTs as inhibitors of neurosecretion may arise from the synergistic action of cleaving the substrate and releasing peptide products that disable the fusion process by blocking specific steps of the exocytotic cascade.

FEBS Lett, 1998 Sep 11, 435(1), 61 - 4
Type A botulinum neurotoxin proteolytic activity: development of competitive inhibitors and implications for substrate specificity at the S1' binding subsite; Schmidt JJ et al.; Type A botulinum neurotoxin (botox A) is a zinc metalloprotease that cleaves only one peptide bond in the synaptosomal protein, SNAP-25 . Single-residue changes in a 17-residue substrate peptide were used to develop the first specific, competitive inhibitors of its proteolytic activity . Substrate analog peptides with P4, P3, P2' or P3' cysteine were readily hydrolyzed by the toxin, but those with P1 or P2 cysteine were not cleaved and were inhibitors . Peptides with either D- or L-cysteine as the N-terminus, followed by the last six residues of the substrate, were the most effective inhibitors, each with a Ki value of 2 microM . Elimination of the cysteine sulfhydryl group yielded much less effective inhibitors, suggesting that inhibition was primarily due to binding of the active-site zinc by the sulfhydryl group . Botox A displayed an unusual requirement for arginine as the P1' inhibitor residue, demonstrating that the S1' binding subsite of botox A is dissimilar to those of most other zinc metalloproteases . This characteristic is an important element in shaping the substrate specificity of botox A.

J Clin Gastroenterol, 1998 Sep, 27(2), 166 - 8
Symptomatic gastroparesis in a patient with achalasia; Gutierrez-Galiana E et al.; We present a case of a patient with achalasia who developed symptomatic gastroparesis after botulinum toxin injection therapy . Symptoms responded to prokinetics . Pathophysiology of gastric motility disturbances in patients with achalasia is discussed.

Neurology, 1998 Sep, 51(3), 815 - 9
Electromyography in cervical dystonia: changes after botulinum and trihexyphenidyl; Brans JW et al.; BACKGROUND: The value of physical examination in detecting involved neck muscles in cervical dystonia (CD) is uncertain and little is known about changes in electromyographic (EMG) features after botulinum toxin type A (BTA) treatment . METHODS: In a double-blind, randomized study we recorded the EMG activities of 420 neck muscles in 42 patients with CD before and after treatment with BTA or trihexyphenidyl . We regarded any needle EMG activity higher than 100 microV as the gold standard for involuntary involvement of a muscle in the dystonic posture and compared this with the results of physical examination . We calculated EMG total scores by adding the scores of the individual muscles . RESULTS: Physical examination had a low predictive value in the detection of involved muscles . There was a significant correlation between changes in EMG total scores and changes in clinical measurements . We observed increased EMG activity in 20% of noninjected muscles after BTA treatment and in 27% of noninjected muscles after trihexyphenidyl treatment . A switch from one most active muscle to another was seen equally in both groups and had no influence on clinical response . CONCLUSION: Physical examination alone is not sufficient to detect involved muscles, and repeated, simultaneous EMG-guided application of BTA may be helpful . In addition to clinical measurements, changes in EMG activity due to treatment can be used as a physiologic measure in evaluating treatment response . Increased activity of noninjected muscles and a switch from one most active muscle to another are not related to BTA treatment, but are probably pathophysiologic phenomena of CD itself.

Infect Immun, 1998 Oct, 66(10), 4817 - 22
Purification, potency, and efficacy of the botulinum neurotoxin type A binding domain from Pichia pastoris as a recombinant vaccine candidate; Byrne MP et al.; Recombinant botulinum neurotoxin serotype A binding domain {BoNT/A(Hc)}, expressed in Pichia pastoris, was developed as a vaccine candidate for preventing botulinum neurotoxin type A (BoNT/A) intoxication . After fermentation and cell disruption, BoNT/A(Hc) was purified by using a three-step chromatographic process consisting of expanded-bed chromatography, Mono S cation-exchange chromatography, and hydrophobic interaction chromatography . Two pools of immunogenic product were separated on the Mono S column and processed individually . Both products were more than 95% pure and indistinguishable by sodium dodecyl sulfate-polyacrylamide gel electrophoresis, Western blot analysis, and enzyme-linked immunosorbent assay (ELISA) . Each protein was assayed for potency in mice at immunogen doses ranging from 2.4 ng to 10 microg, followed by challenge with 1,000 mouse intraperitoneal 50% lethal doses (i.p . LD50) of BoNT/A . The calculated 50% effective dose for both peaks was approximately 0.1 microg/mouse . Peak 1 was evaluated further in a mouse efficacy assay . Mice were injected either once, twice, or three times at five different doses and subsequently challenged with 100,000 mouse i.p . LD50 of BoNT/A . In general, multiple injections protected better than one, with complete or nearly complete protection realized at doses of >/=0.5 microg/mouse . Serum neutralization and ELISA titers were also determined . Tellingly, 82 of 83 mice with antibody titers of >/=1, 600, as measured by ELISA, survived, but only 6 of 42 mice with titers of </=100 survived . This work shows that the purified BoNT/A(Hc) produced was a highly effective immunogen, able to protect against a high challenge dose of neurotoxin.

Klin Monatsbl Augenheilkd, 1998 Jul, 213(1), 15 - 22
{Protective ptosis by botulinum A toxin injection in corneal affectations}; Gusek-Schneider GC et al.; BACKGROUND: Botulinum toxin A has been introduced as a local injection therapy of different conditions with focal muscular hypercontractions . In the ophthalmologic field the toxin has proven its efficacy in the therapy of blepharospasm and hemifacial spasm . There are only few reports on the use of a botulinum toxin A to induce a protective ptosis in patients with persistent corneal ulcers . PATIENTS AND METHODS: 21 patients who failed to respond to conservative therapy of corneal erosions or ulcers of different origin received a botulinum toxin A injection into the levator palpebrae superioris muscle . RESULTS: The ptosis began after a mean of 1.5 days (1-3 days) and was complete after a mean of 5.1 days (3-12 days) after injection . Complete recovery of the levator function could be observed after a mean of 12.4 weeks (4-24 weeks) . In 13 patients (61.8%) the botulinum toxin A induced protective ptosis lead to a complete healing of indolent ulcers or erosions, in 4 patients (19%) an additional tarsorrhaphy was necessary . In 3 patients no healing could be observed during follow up, in one patient (with neuroparalytic ulcer) the injection was given prophylactically . The period of healing on average was 3.8 weeks . There was no relationship between the healing rate and the duration of the corneal disease prior to the botulinum toxin injection . The mean healing rate of younger patients was higher (75%) than that of older patients (53.8%) and higher in erosions (70%) than in ulcers (30%) . No side effects were observed besides in one patient the undesirable duration of the ptosis of a half year . CONCLUSION: The induction of a protective ptosis with botulinum toxin A injection is an efficacious treatment alternative in persistent corneal erosions and ulcers before performing a tarsorrhaphy . This method is preferrable especially in patients with lagophthalmos due to facial nerve paresis with potential recovery.

Arch Neurol, 1998 Sep, 55(9), 1233 - 7
Sensory modulation of the blink reflex in patients with blepharospasm; Gomez-Wong E et al.; OBJECTIVE: To measure the effects of a prepulse stimulus on the blink reflex responses elicited by an electrical stimulation of the supraorbital nerve in patients with blepharospasm with and without an effective sensory trick . DESIGN: Blink reflexes to supraorbital nerve stimulation were preceded in test trials by a prepulse electrical stimulus to the third finger at various leading intervals . SETTING: Ambulatory patients were treated regularly with botulinum toxin in the Neurology Department of the Hospital Clinic in Barcelona, Spain . SUBJECTS: Seventeen patients with dystonic blepharospasm and 11 age-matched control subjects . Eight of the patients with dystonic blepharospasm used a sensory trick to alleviate spasms and 9 did not . MAIN OUTCOME MEASURES: We measured amplitude of R1 and area of R2 responses elicited by the supraorbital electrical stimulus and determined the percentage of facilitation or inhibition induced by the prepulse . RESULTS: Prepulse facilitation occurred in the R1 response at intervals of 60 to 100 milliseconds and was normal in all patients . Prepulse inhibition occurred in the R2 response at intervals between 50 and 200 milliseconds and was abnormally reduced in 11 patients (64.7%), including all 9 patients who did not use a sensory trick and 2 of the 8 patients who did use a sensory trick . There was a positive correlation between absence of sensory trick and abnormality of the prepulse effects (chi(2)= 23.8; P < .001) . CONCLUSIONS: Prepulse inhibition of the trigeminofacial reflex is abnormal in a percentage of patients with blepharospasm, and this abnormality occurs more frequently in patients who do not use a sensory trick . This sensory derangement may contribute to the maintenance of the dystonic spasms by reducing the amount of physiological gating from peripheral nerve inputs on trigeminofacial reflexes.

Australas J Dermatol, 1998 Aug, 39(3), 158 - 63
Botulinum toxin for the correction of hyperkinetic facial lines; Goodman G; The present article illustrates the effects of low dose botulinum toxin (BTx) injections for the improvement of hyperkinetic facial lines and presents a grading treatment chart designed to standardize the reporting of the improvement seen . A questionnaire of patient acceptance, the patients' impression of therapy and short-term results and complications are reported . Twelve patients with 26 injected-paired regions were charted and the response to injection was graded . Patients had hyperkinetic facial lines in glabella, periorbital regions or horizontal forehead lines . Diluted BTx type A (1 IU/0.1 mL) was injected and patients were assessed at 10 days . A second follow up injection was offered to patients at this stage if required . Objectively, all patients' hyperkinetic actions and lines improved or diminished . The degree of improvement was similar in all areas injected and a symmetry of results was always observed . In a minority of cases, all movement was lost (7/26) and in others it was weakened but present (19/26) . In some injected areas the actual expression line that was visible at rest disappeared entirely (11/26): in the others it was diminished (15/26) . Complications were few . Two patients had temporary brow ptosis that spontaneously recovered within the first week . No eyelid ptosis was noted . Bruising and headaches were the most common reported complications . Low dose BTx is an effective and well-tolerated treatment for hyperkinetic facial lines with few significant complications in this small pilot study . The grading chart may allow easier comparisons of results between studies on the effects of BTx therapy.

Rev Neurol, 1998 Aug, 27(156), 258 - 63
{Clinical presentations, differential diagnosis and management of obstetric brachial palsy}; Alfonso I et al.; INTRODUCTION: The brachial plexus originates from C5 to T1 spinal segments . The brachial plexus includes the ventral ramus, trunks, divisions, cords and branches . DEVELOPMENT AND CONCLUSIONS: Brachial plexus injuries produce clinical syndromes . The Duchenne-Erb syndrome is the most frequent presentation of obstetric brachial plexus injury . The differential diagnosis of brachial plexus palsy include decreased arm movements due to pain, or weakness caused by a lesion of the nervous system outside in the brachial plexus, or by a lesion in the brachial plexus due to non-obstetrical causes . Management of these patients initially includes considering the possibility of clavicular and humeral fractures and posterior subluxation of the shoulder; and subsequently considering the possibilities of subscapularis muscle contraction or posterior shoulder subluxation in patients that develop internal rotation contracture of the shoulder; or flexion, pronation or supination contracture in patients with forearm deformation . Treatment consist of physical therapy, administration of botulinum toxin, electrical stimulation, neurolysis, nervatization, removal of neuromas and nerve grafting, treatment of fractures and subluxation, release of muscle contracture and tendon transplantation.

Dermatol Surg, 1998 Aug, 24(8), 817 - 9
Botulinum A neurotoxin for axillary hyperhidrosis . No sweat Botox; Glogau RG; BACKGROUND: Axillary hyperhidrosis causes considerable emotional stress and is associated with extraordinary costs and limitations in clothing . Existing topical and surgical therapies are either ineffective or associated with unacceptable morbidity and sequelae . Botulinum A neurotoxin (Botox) has been shown to decrease sweating in normal skin and in palmar hyperhidrosis . OBJECTIVE: The current study was undertaken to demonstrate the utility of using Botox in the treatment of axillary hyperhidrosis . METHODS: Twelve patient with axillary hyperhidrosis underwent intradermal injection with 50 units of Botox in the axillary skin bilaterally . RESULTS: All patients enjoyed relatively complete anhidrosis of the axillary skin in periods ranging from 4 to 7 months . Repeat injections produced similar results . CONCLUSION: Botulinum A neurotoxin (Botox) is an elegant and simple treatment for axillary hyperhidrosis.

Cesk Slov Oftalmol, 1998 May, 54(3), 174 - 8
{Use of botulinum toxin in the treatment of strabismus}; Gerinec A et al.; The authors present their two years experience with the administration of botulotoxin, the first observations in this country in connection with treatment of strabismus . Botulotoxin was injected by the i.m . route to 26 children mostly with residual deviations above 20 PD in concomitant strabismus . After a single injection the deviation declined to less than 20 PD in all patients . However persistence of deviations under 10 PD was not permanent and after reappearance of the deviation the administration of botulotoxin had to be repeated . The authors consider the therapeutic results satisfactory and draw attention to advantages and disadvantages of this method . They discuss in particular problems of the long-term effect of treatment.

Prostate, 1998 Sep 15, 37(1), 44 - 50
Botox-induced prostatic involution; Doggweiler R et al.; BACKGROUND: A simple approach to induced prostatic atrophy was explored . Surgical denervation is known to produce profound atrophy of the rat prostate . Because Botulinum toxin type A (Botox) produces a long-term chemical denervation, the potential to induce atrophy of the rat prostate was explored . METHODS: Thirty rat prostates were injected with varying doses of Botox . Single and serial injections were used, and rats were subsequently sacrificed after either 1 or 4 weeks, respectively . The prostate glands were harvested, weighed, and histologically studied for morphologic and apoptotic changes . RESULTS: The total prostate volume and weight were found to be reduced in all Botox-injected animals . Histologically, a generalized atrophy of the glands was observed with the H&E stain . There was also diffuse glandular apoptosis evident with the Tunel stain . There were no significant complications (e.g., urinary retention, weight loss, or hind/limb weakness) . CONCLUSIONS: Botulinum toxin type A injection into the prostate gland induces selective denervation and subsequent atrophy of the prostate . Apoptosis was seen diffusely throughout the gland . It may be possible that in the future, this long-acting neurotoxin could be used for the treatment of common pathologies of the human prostate.

Gen Hosp Psychiatry, 1998 Jul, 20(4), 255 - 9
Emotional symptoms are secondary to the voice disorder in patients with spasmodic dysphonia; Liu CY et al.; The aims of this study were to evaluate the emotional status and life quality of the patients with spasmodic dysphonia (SD) before and after botulinum toxin treatment, and to ascertain whether SD is a somatoform disorder . Ten patients with spasmodic dysphonia were injected unilaterally into the vocal cord with botulinum toxin . Before botulinum toxin treatment, two clinician's rating scales--Hamilton Depression Rating Scale (HDRS) and Hamilton Anxiety Rating Scale (HARS), and three self-rating psychometrics--Zung's Self-Rating Depression Scale (SDS), Life Quality Scale (GHQ/QL-12), and Symptom Distress Checklist (SCL-90) were applied . Self-rating scales were also administered in 20 matched normal controls . The patients were reevaluated 1 month after botulinum toxin treatment . The Clinical Global Impression Scale (CGI) was also rated by the patients themselves and a speech pathologist . The mean scores of SD patients were significantly higher than that of controls in SDS, and subscales of somatization, obsessive-compulsive symptoms, depression, anxiety, and psychoticism in SCL-90 . The mean score of GHQ/QL-12 was significantly higher in the control group . The scores of HDRS, SDS, GHQ/QL-12 and subscales of somatization, depression, and anxiety in SCL-90 showed significant improvement after botulinum treatment . In CGI, seven patients were rated as improved by patients themselves and the speech pathologist . The patients with SD had more anxiety, depression and somatization symptoms, and poor life quality than normal controls . Their emotional status and life quality improved after botulinum toxin treatment . The results suggest that the emotional symptoms of patients with SD are mainly secondary to voice disorder.

Am J Phys Med Rehabil, 1998 Jul-Aug, 77(4), 348 - 50
Botulinum toxin treatment of lumbrical spasticity: a brief report; Palmer DT et al.; Botulinum toxin A has been used to treat wrist and finger spasticity mainly through injection of the forearm flexor muscles . This case study describes its first reported use in managing spastic lumbricals of the hand . A 19-year-old male had significant flexion deformity and hypertonicity of the left wrist and hand, particularly the second through fifth metacarpophalangeal joints, after traumatic brain injury . By using the 0-4 Ashworth scale, spasticity of the lumbricals across the second to fourth metacarpophalangeal joints was rated 2, with persistent clonus of the finger flexors as confirmed by electromyography to the middle and ring fingers, even after botulinum toxin A injection of the flexor digitorum sublimis and profundus muscles . By using the electromyography-guided technique, botulinum toxin A was injected into the first lumbrical of the index finger (12 units), second and third lumbricals of the middle and ring fingers, respectively (15 units each), and fourth lumbrical of the little finger (10 units) . At follow-up, clinical and electromyographic examination revealed a significant reduction in tone and clonus of the injected lumbricals . Ashworth scores of the lumbricals from the index to little finger improved to 1 . Botulinum toxin A injection of the lumbricals can be beneficial in managing spasticity of these muscles . It is well tolerated and effective at doses of 10 to 15 units . Lumbrical injection of botulinum toxin A is a useful adjunct in our percutaneous armamentarium for managing the spastic hand.

Yale J Biol Med, 1998 Jan-Feb, 71(1), 23 - 30
Achalasia in a sixty-four-year-old man; Komisaruk EA et al.; Achalasia is an esophageal motility disorder characterized by increased lower esophageal sphincter pressure and absence of peristalsis in the lower esophagus . Patients typically present with complaints of progressive difficulty swallowing over a period of several years . Diagnosis is confirmed by esophageal manometry . Complications of achalasia include esophagitis, aspiration and possibly an increased risk of esophageal carcinoma . Medical treatment options include pneumatic dilatation, esophageal bougienage, nitrates, calcium channel blockers and botulinum toxin injections . The primary method of surgical treatment is the Heller myotomy, in which longitudinal incisions are made in the muscle fibers of the lower esophageal sphincter to reduce sphincter pressure . Frequently, a fundoplication is performed in addition to the myotomy to decrease the likelihood of development of gastroesophageal reflux . In recent years, the Heller myotomy has been performed both thoracoscopically and laparoscopically . An additional development has been the placement of an endoscope in the esophagus to provide transillumination during surgery; intraoperative endoscopy allows improved assessment of the depth of myotomy incisions and reduces the risk of esophageal perforation . The case report below describes a 64-year-old-man with achalasia who presented with persistent dysphagia despite multiple attempts at medical treatment . A laparoscopic Heller myotomy with Toupet fundoplication was performed with subsequent eradication of symptoms . A discussion of the epidemiology, etiology, clinical presentation, diagnosis and treatment of achalasia follows the case report.

Br J Ophthalmol, 1998 May, 82(5), 528 - 33
Botulinum toxin A treatment of overactive corrugator supercilii in thyroid eye disease; Olver JM; BACKGROUND/AIM: Patients with thyroid eye disease with upper eyelid retraction often develop overaction of the accessory muscles of eyelid closure, the glabellar muscles corrugator supercilii and procerus . The resultant glabellar furrowing (frown lines) contributes to the typical thyroid facies . The aim of this study was to evaluate the use of botulinum toxin A reversible chemodenervation of the glabellar muscles as adjunctive treatment in the rehabilitation of patients with thyroid eye disease . METHODS: 14 patients (13 females) ages 39-76 years (mean 52) with inactive thyroid eye disease and associated medial eyebrow ptosis and prominent glabellar frown lines were recruited . All patients had a history of upper eyelid retraction . Each patient was treated with a single botulinum toxin injection (Dysport 0.2 ml, 40 units) into each corrugator supercilii and sometimes procerus muscles as an outpatient procedure . The effectiveness and acceptability of the treatment was assessed clinically and from a patient questionnaire . RESULTS: The injections were tolerated by 13/14 (93%) patients . There was resultant flattening of the glabellar region and improvement of medial eyebrow contour in all patients, with onset of paralysis within 1 week . All patients reported a subjective improvement in appearance . Side effects included one patient (7%) with reversible partial ptosis . The beneficial effect lasted 4-6 months, with a gradual return of function . Repeat treatment was indicated where there was persistent upper eyelid retraction and protractor overaction . CONCLUSION: Botulinum toxin A chemodenervation of the glabellar muscles in these patients was effective and acceptable . Chemodenervation should be considered in the rehabilitation of patients with thyroid eye disease where there is upper eyelid retraction and overacting protractors resulting in a thyroid frown . Once the eyelid retraction has been successfully treated by surgery, the need for further glabella muscle chemodenervation is considerably reduced.

J Otolaryngol, 1998 Aug, 27(4), 213 - 6
Botulinum toxin treatment of essential palatal myoclonus tinnitus; Bryce GE et al.; OBJECTIVE: The purpose of this study was to review the use of botulinum toxin in the treatment of essential palatal myoclonus tinnitus . DESIGN: Two case series . METHOD: Four to 10 units of botulium toxin are injected into the tensor veli palatini muscle . The dose and interval between doses is titrated according to patient symptoms . With bilateral symptoms, injection is alternated between sides at sequential visits . OUTCOME MEASURES: Relief of tinnitus with cessation of palatal contractions . RESULTS: Both patients had relief of tinnitus . One patient required ventilation tube placement to relieve aural fullness . CONCLUSIONS: Tensor veli palatini botulinium toxin injection is an effective treatment for essential palatal myoclonus tinnitus.

J Clin Gastroenterol, 1998 Jul, 27(1), 21 - 35
Current therapies for achalasia: comparison and efficacy; Vaezi MF et al.; Achalasia is a primary esophageal motor disorder of unknown etiology producing complaints of dysphagia, regurgitation, and chest pain . The current treatments for achalasia involve the reduction of lower esophageal sphincter (LES) pressure resulting in improved esophageal emptying . Calcium channel blockers and nitrates, once used as initial treatment strategy for early achalasia, are now only used in patients who are not candidates for pneumatic dilation or surgery and those not responding to botulinum toxin injections . By virtue of the more rigid balloons, the current pneumatic dilators are more effective and have better efficacy than the older more compliant balloons . The graded approach to pneumatic dilation using the Rigiflex balloons (3.0, 3.5, and 4.0 cm) are now the most commonly used nonsurgical means of treating patients with achalasia, resulting in symptom improvement in up to 90% of patients . Surgical myotomy, once with high morbidity and long hospital stay, can now be performed laparoscopically with similar efficacy to the open surgical approach (94% vs . 84%, respectively), reduced morbidity, and hospitalization time . Given the advances in both balloon dilation and laparoscopic myotomy, most patients with achalasia can now choose between these two equally efficacious treatment options . Botulinum toxin injection of the LES should be reserved for patients who cannot undergo balloon dilation and are not surgical candidates.

Digestion, 1998 Aug, 59(5), 509 - 29
Endoscopic ultrasonography; Caletti G et al.; Endoscopic ultrasonography (EUS) is nowadays a clinically relevant technology and its findings can have a major impact on patient management . This technique is currently indicated for staging digestive cancers, assessment of submucosal tumors, diagnosis of intestinal wall infiltrative diseases, common bile-duct stones and gut neuroendocrine tumors . As far as neoplasms are concerned, EUS appears to be a reliable and safe technique, thus making the physician able to plan either an aggressive surgical treatment, or a conservative palliative therapy . This is of the utmost importance in order to optimize medical-related costs, and to make the best therapeutic decision for each individual patient . EUS is also helpful in monitoring the course of a disease, as it is simple and virtually without complications . When EUS findings are not sufficient for a complete diagnosis, it is now possible to perform an EUS-guided fine-needle biopsy, which can allow a cytological diagnosis . Finally, some therapeutic endosonography-guided procedures are being increasingly adopted, such as cystoenterostomy, celiac plexus neurolysis, cholangio-pancreatography and selective injection of botulinum toxin in the muscle layer of the lower esophageal sphincter.

Spine, 1998 Aug 1, 23(15), 1662 - 6; discussion 1667
A randomized, double-blind, prospective pilot study of botulinum toxin injection for refractory, unilateral, cervicothoracic, paraspinal, myofascial pain syndrome; Wheeler AH et al.; STUDY DESIGN: In a randomized, double-blind study, two dosage strengths of botulinum toxin type A were compared with normal saline injected into symptomatic trigger points in the cervicothoracic paraspinal muscles . OBJECTIVES: To compare the effect of botulinum toxin type A injections with that of normal saline to determine the former's usefulness in the management of neck pain and disability . SUMMARY OF BACKGROUND DATA: The results of several studies have suggested that botulinum toxin type A may reduce pain associated with myofascial pain syndromes . METHODS: Thirty-three participants were divided randomly to receive either 50 or 100 units of botulinum toxin type A, or normal saline . Patients were re-evaluated over a 4-month period by assessment of their pain and disability and pressure algometer readings, and then offered a second injection of 100 units of botulinum toxin type A . RESULTS: All three groups showed significant treatment effects as measured by a decline in the scores on the Neck Pain and Disability Visual Analogue Scale and an increase in the pressure algometer scores . Group differences were apparent only when the authors considered the number of patients who were asymptomatic as a result of the injections . CONCLUSIONS: Although no statistically significant benefit of botulinum toxin type A over placebo was demonstrated in this study, the high incidence of patients who were asymptomatic after a second injection suggests that further research is needed to determine whether higher dosages and sequential injections in a larger cohort might show a botulinum toxin type A effect.

J Neurosci, 1998 Aug 15, 18(16), 6103 - 12
Protein kinase C regulates the interaction between a GABA transporter and syntaxin 1A; Beckman ML et al.; Syntaxin 1A inhibits GABA uptake of an endogenous GABA transporter in neuronal cultures from rat hippocampus and in reconstitution systems expressing the cloned rat brain GABA transporter GAT1 . Evidence of interactions between syntaxin 1A and GAT1 comes from three experimental approaches: botulinum toxin cleavage of syntaxin 1A, syntaxin 1A antisense treatments, and coimmunoprecipitation of a complex containing GAT1 and syntaxin 1A . Protein kinase C (PKC), shown previously to modulate GABA transporter function, exerts its modulatory effects by regulating the availability of syntaxin 1A to interact with the transporter, and a transporter mutant that fails to interact with syntaxin 1A is not regulated by PKC . These results suggest a new target for regulation by syntaxin 1A and a novel mechanism for controlling the machinery involved in both neurotransmitter release and reuptake.

Protein Expr Purif, 1998 Aug, 13(3), 357 - 65
Production and purification of the heavy-chain fragment C of botulinum neurotoxin, serotype B, expressed in the methylotrophic yeast Pichia pastoris; Potter KJ et al.; A recombinant Hc fragment of botulinum neurotoxin, serotype B (rBoNTB(Hc)), has been successfully expressed in a Mut+ strain of the methylotrophic yeast Pichia pastoris for use as an antigen in a proposed human vaccine . The fermentation process consisted of batch phase on glycerol, followed by glycerol and methanol fed-batch phases yielding a final cell mass of 60 g/L (dcw) and was easily scaled-up to 60 L . A multistep ion-exchange chromatographic purification process was employed to produce 99% pure Hc fragment . The final yield of the purified antigen was 390 mg per kilogram of wet cell mass . The purified Hc fragment of serotype B was stable, elicited an immune response in mice, and protected upon challenge with native botulin .

J Nat Toxins, 1998 Feb, 7(1), 95 - 9
Comparative evaluation of mechanism of neuromuscular (n-m) blockade due to enhydrotoxin-A (EsNTx-a) and D-tubocurarine (d-TC); Gawade SP; Effects of major E . schistosa neurotoxin (NTx) EsNTx-a are compared with plant alkaloid d-TC for its onset (LP) and duration of action as the time required for 50% n-m blockade (DT1/2) in normal Ca2+ and modified Ca2+ Krebs Heinsleit (K-H) at two different (low and high) concentrations (conc.) . Toxin-EsNTx-a in low Ca2+ K-H and d-TC in both normal and modified Ca2+ K-H did not show LP, whereas LP is increased significantly in 2 Ca2+ K-H in high conc . of EsNTx-a . DT1/2 is increased significantly in high conc . of EsNTx-a and in low conc . of d-TC in 2 Ca2+ K-H . N-m blocking actions are further compared with alpha-bungarotoxin (alpha-BuTx), beta-bungarotoxin (beta-BuTx), and botulinum toxin (B-Tx) for their effects on tetanus, Wednesky inhibition (W.I.), and post tetanic potentiation (PTP).

Pediatr Rehabil, 1997 Oct-Dec, 1(4), 235 - 7
Treatment of cerebral palsy with botulinum toxin A: functional benefit and reduction of disability . Three case reports; Mall V et al.; Three patients with cerebral palsy are described suffering, respectively, of pes equinus, spasm of the m . teres major and flexion spasm of the hand, who were treated with botulinum toxin A . These patients demonstrate not only the local reduction of the muscular hyperactivity following treatment with botulinum toxin A but also the potential functional benefit resulting from such a treatment . Thus, local intramuscular injection of botulinum toxin A in children with cerebral palsy should be considered as part of a multidisciplinary treatment concept, since reduction of the disability and the functional improvements could have high impact on daily living activities.

Mov Disord, 1998 Jul, 13(4), 706 - 12
Treatment of cervical dystonia: a comparison of measures for outcome assessment; Lindeboom R et al.; There is little agreement on which outcome measures to use to express the efficacy of treatments for cervical dystonia . We analyzed change scores on various scales of 64 new patients with cervical dystonia before and after repeated injections with botulinum toxin . METHOD: The association between change in impairment (Tsui), and change in pain (TWSTRS-Pain) and functional health (TWSTRS-D, MOS-20) was expressed in percentages of variance explained . Effect sizes of the outcome measures from patients who continued botulinum treatment and dropouts were compared . Performance of outcome measures to distinguish patients who continued treatment and dropouts was analyzed with ROC curves and areas under the curve (AUC) . Results: Impairments explained < or =7% of the score variance in functional health . There were no differences between the effect sizes of impairment and pain of patients who continued treatment and dropouts (p > 0.60) . This suggests a poor reflection of the treatment efficacy by these outcome measures . Conversely, there were significant differences between the effect sizes of the functional status scales of the patients who continued treatment and the dropouts (p < or = 0.01) . ROC curve analysis showed that the disability, handicap, and global disease burden scale accurately distinguished between the two groups (AUCs > 0.80) . Impairments showed no discriminative accuracy (AUC = 0.46) . CONCLUSION: Neurologic impairments have a small impact on the functional health of cervical dystonia patients . Disability, handicap, and a global measure of disease burden were the most suitable outcome parameters to express the clinical efficacy of botulinum therapy.

Eye, 1998, 12 ( Pt 2), 219 - 23
A clinical algorithm for the management of facial nerve palsy from an oculoplastic perspective; Sadiq SA et al.; BACKGROUND/AIMS: Facial nerve palsy can be a sight-threatening complication . We have developed a flow diagram to aid in the management of these patients so that corneal complications may be avoided . This involves the recognition of a facial palsy and institution of treatment as guided by the flow chart . METHOD: Fifty-six patients suffered a facial nerve palsy following acoustic neuroma surgery . All received regular topical ocular lubrication, followed by either botulinum toxin A (BTXA)-induced ptosis (if corneal exposure developed despite conservative treatment) or definitive eyelid surgery . RESULTS: Twenty-one patients required regular lubrication only . Of these patients treated for corneal exposure, 20 received BTXA with good resulting corneal cover . Unfortunately, 9 of these suffered diplopia, although in 4 this resolved quickly . Twenty-four patients underwent a total of 64 eyelid procedures including levator recession, lateral tarsorraphy, lateral canthal sling, medical canthoplasty and gold weight insertion . All patients had good corneal cover post-operatively and were cosmetically improved . Of the 56 patients with a facial nerve palsy, 7 presented with a corneal epithelial defect or an infected corneal ulcer . These all responded to treatment with BTXA, topical antibiotics and/or lubrication, and eyelid surgery . CONCLUSIONS: Post-operative facial palsy may result in a significant ophthalmic workload . Although a proportion of patients with a facial nerve palsy manage well with regular lubrication, additional help with eyelid closure, either in the way of BTXA-induced ptosis in the short term or definitive eyelid surgery in the long term, is often required . Eyelid surgery seems to be the mainstay of treatment, for both function and cosmesis, with many patients requiring a combination of procedures.

J Med Assoc Thai, 1998 Jun, 81(6), 413 - 22
Botulinum treatment for post-stroke spasticity: low dose regime; Viriyavejakul A et al.; The purpose of this study was to investigate the effects of botulinum A toxin for the treatment of post-stroke spasticity patients . Twenty two post-stroke spasticity patients were recruited in the study . All patients had moderate to severe spasticity of upper and lower extremities . Botulinum toxin was injected intramuscularly according to the spasticity pattern . Injections were performed at either 2, 3, or 6 month intervals as determined by the neurologist . The total dose of each session of injection varied between 50-100 IU . Subjective and objective examinations were conducted by the physiotherapist prior to the first injection and subsequently at 1st week, 2nd week and every month after each injection . All patients were asked subjectively about their satisfaction with the treatment . The objective examinations used in this study were Ashworth scale and Fugl-Meyer Sensorimotor Assessment Form . All patients were satisfied with the treatment . Marked reduction of the spasticity was found after one to two weeks of injection . The duration of effectiveness of botulinum toxin for spasticity is from 3-6 months . The average improvement in Ashworth score was between 1 and 1.5 points . The Fugl-Meyer scores showed significant improvement in most patients for the motor function of upper and lower extremities, and balance . All patients demonstrated increase in passive range of joint motion and decrease in joint pain . This study demonstrates that botulinum toxin therapy is safe and effective in treating chronic upper and lower extremities' spasticity following stroke . The dosage used in this study is about one-half of the recommended dosage in the literature . The only drawback of this therapy is its high cost (300 US dollars for 100 I.U.).

Drug Saf, 1998 Jul, 19(1), 57 - 72
Managing antipsychotic-induced acute and tardive dystonia; Raja M; Antipsychotic-induced extrapyramidal adverse effects continue to be a serious problem in the treatment of psychotic disorders . While the pathophysiology of these adverse effects is not well understood, much recent research has focused on improving our ability to use available pharmacotherapy in the most effective and least toxic manner . Acute dystonic reactions only occur within the first days of antipsychotic treatment . They are often distressing and frightening for the patient and may even be dangerous . However, they can be effectively prevented or reversed with anticholinergics . Furthermore, the growing use of the new atypical antipsychotics will lead to a significant decrease in the rate of acute dystonic reactions . In contrast, tardive dystonia is a long-lasting menace in the course of antipsychotic treatment, for which there is no established therapy . Tardive dystonia is sometimes disabling or disfiguring and, like other tardive disorders, is potentially irreversible . Because, in most cases, patients need to continue taking the antipsychotic that has caused the adverse effect to prevent relapse of the mental illness, preventive measures are crucial . Antipsychotics should be prescribed only for patients affected by psychotic disorders, when definitely indicated and at the lowest effective dosage . The use of clozapine and other novel antipsychotic agents is also likely to represent an important step in the prevention and treatment of tardive dystonia . Compared with traditional antipsychotics, most of the new antipsychotics are characterised by a low acute extrapyramidal adverse effects liability and they also bring the hope of reducing the risk of tardive disorders . If tardive dystonia has occurred, switching to clozapine or another atypical antipsychotic and treatment with tetrabenazine, reserpine and botulinum toxin are possible options.

EMBO J, 1998 Jul 15, 17(14), 3909 - 20
Vesicle exocytosis stimulated by alpha-latrotoxin is mediated by latrophilin and requires both external and stored Ca2+; Davletov BA et al.; alpha-Latrotoxin (LTX) stimulates massive neurotransmitter release by two mechanisms: Ca2+-dependent and -independent . Our studies on norepinephrine secretion from nerve terminals now reveal the different molecular basis of these two actions . The Ca2+-dependent LTX-evoked vesicle exocytosis (abolished by botulinum neurotoxins) is 10-fold more sensitive to external Ca2+ than secretion triggered by depolarization or A23187; it does not, however, depend on the cation entry into terminals but requires intracellular Ca2+ and is blocked by drugs depleting Ca2+ stores and by inhibitors of phospholipase C (PLC) . These data, together with binding studies, prove that latrophilin, which is linked to G proteins and inositol polyphosphate production, is the major functional LTX receptor . The Ca2+-independent LTX-stimulated release is not inhibited by botulinum neurotoxins or drugs interfering with Ca2+ metabolism and occurs via pores in the presynaptic membrane, large enough to allow efflux of neurotransmitters and other small molecules from the cytoplasm . Our results unite previously contradictory data about the toxin's effects and suggest that LTX-stimulated exocytosis depends upon the co-operative action of external and intracellular Ca2+ involving G proteins and PLC, whereas the Ca2+-independent release is largely non-vesicular.

J Neurol Neurosurg Psychiatry, 1998 Jul, 65(1), 111 - 4
Botulinum toxin treatment of synkinesia and hyperlacrimation after facial palsy; Boroojerdi B et al.; OBJECTIVES: To investigate the effects of injection of botulinum toxin type A (BTX A) into the orbicularis oculi muscle and lacrimal gland in patients with aberrant regeneration after facial palsy (facial synkinesias and hyperlacrimation) . METHODS: The effect of the toxin injection (on average 75 mouse units of BTX A) into the orbicularis oculi muscle on facial synkinesias was assessed on a five point (0 to 4) scale in 10 patients with aberrant regeneration of facial nerve fibres after a peripheral facial nerve palsy . Six patients underwent a videographic control, which was assessed by a blinded independent investigator . In two patients with hyperlacrimation an extra dose of botulinum toxin (on average 20 mouse units BTX A) was injected into the lacrimal gland and the effect was assessed using the Schirmer test and on a three point scale . RESULTS: Botulinum toxin type A had a good to excellent (grades 3 and 4) effect over an average of six months after 91% of injections . In 9% the injections had a moderate (grade 2) effect . Patients with hyperlacrimation showed a nearly complete recovery . There were no systemic side effects but focal side effects due to a temporary weakness of the orbicularis oculi muscle were not uncommon . CONCLUSIONS: Botulinum toxin type A is the treatment of choice in motor and autonomic effects of aberrant regeneration of facial nerve after a peripheral palsy . The required dose is similar to or slightly lower than the dose usually recommended for hemifacial spasm.

Brain Res, 1998 Jun 29, 797(2), 357 - 60
Incorporation of synaptotagmin II to the axolemma of botulinum type-A poisoned mouse motor endings during enhanced quantal acetylcholine release; Angaut-Petit D et al.; The involvement of terminal sprouts in neurotransmitter release by in vivo botulinum type-A toxin poisoned motor endings was investigated 15 to 40 days after a single injection of the toxin onto the levator auris longus muscle of the mouse . Enhanced quantal acetylcholine release was induced by alpha-latrotoxin or La3+ in conditions that prevent endocytosis, and an antibody directed against the lumenal domain of synaptotagmin II (Syt II) was used in the presence or absence of Triton X-100 . We showed that, under resting conditions, the intravesicular domain of Syt II requires Triton X-100 to be labelled, whereas it becomes exposed to the outside of the axolemma of both the original terminal arborization and the newly formed sprouts during enhanced exocytosis . These data were taken to indicate that, when sprouting is prominent, the whole modified terminal arborization, including the original branches and the sprouts, possesses the machinery for Ca2+-independent exocytosis .

Laryngoscope, 1998 Jul, 108(7), 1055 - 61
Increased acute and chronic mitotic activity in rat laryngeal muscles after botulinum toxin injection; Inagi K et al.; OBJECTIVES: To characterize the acute and chronic cellular effects of botulinum toxin (BT) injection into rat laryngeal muscles . A complete characterization of these effects is important because patients with focal dystonias of the head and neck are commonly treated with BT injection . Further, potential muscular changes in the larynx must be carefully delineated owing to the critical phonatory and airway protective functions of these muscles . STUDY DESIGN: The acute and chronic cellular effects of BT injection were studied using 5'-bromo 2'-deoxyuridine (BrdU) following single and repeated BT injection into rat laryngeal muscles . BrdU is incorporated into mitotically active nuclei such that changes in cell proliferative behavior following BT injection can be monitored . RESULTS: Increased mitotic activity was detected in the tissue samples studied following BT injection . Differences in the times of the peak distribution of BrdU-labeled cells in each laryngeal muscle were observed . This may be related to the diffusion effects of BT . Prolonged muscle fiber changes, including splitting, were also observed as the result of repeated BT injection . CONCLUSIONS: The results of this study suggest that BT may induce a proliferative response in muscle tissue.

Laryngoscope, 1998 Jul, 108(7), 1048 - 54
Physiologic assessment of botulinum toxin effects in the rat larynx; Inagi K et al.; OBJECTIVE: Botulinum toxin (BT) is a currently used treatment for spasmodic dysphonia (SD) and other related focal dystonias . The goal of this study is to provide a basis for using the rat larynx to objectively assess physiological and histological effects of BT . STUDY DESIGN: Dosages and volumes of BT injection were varied and three physiological parameters were measured . These measures included: optical density of PAS-stained laryngeal muscle after electrical stimulation, which is an indirect measure of denervation, spontaneous laryngeal muscle activity, and laryngeal movement . METHODS: A new microlaryngoscopic technique was developed, which made it possible to observe and manipulate the rat larynx endoscopically . Laryngeal movement and electromyographic (EMG) measures were made prior to injection and 3 days following BT injections of various dosages and volumes . Optical density measures were made 3 days after injection . RESULTS: Significant reductions in vocal fold motion and spontaneous laryngeal muscle activity as a function of increased BT dosage were observed . In addition, the optical density of PAS-stained laryngeal muscle after electrical stimulation was increased following BT injection . Significant volume effects in optical density were observed in the lateral thyroarytenoid and lateral cricoarytenoid muscles on the contralateral side . CONCLUSIONS: The rat laryngeal model is suitable for assessing BT effects . In addition, the three physiological variables provided useful and reliable measures of laryngeal function . It is the authors' intention to use the rat laryngeal model to further examine the physiological and histological effects of BT with the goal of developing new methods for the treatment of patients with SD and other focal dystonias.

Headache, 1998 Jun, 38(6), 468 - 71
Botulinum toxin A, adjunctive therapy for refractory headaches associated with pericranial muscle tension; Wheeler AH; Pericranial muscle tension may contribute to the development of facial discomfort, chronic daily headache, and migraine-type headache . Elimination of pericranial muscle tension may reduce associated myalgia and counteract influences that can trigger secondary headaches which fall within the migraine continuum . Four patients with chronic, predominantly tension-type headaches and associated pericranial muscle tension failed prolonged conventional treatment and, therefore, symptomatic areas were treated with botulinum toxin A . This alleviated myalgia and reduced the severity and frequency of migraine-type headaches with a concomitant reduction in subsequent medical and physical therapy interventions . Judicious use of botulinum toxin A into defined areas of pericranial muscle tension may be useful for reducing primary myalgia and secondary headache.

Zh Mikrobiol Epidemiol Immunobiol, 1998 Mar-Apr, (2), 22 - 6
{Coagglutination test . Its improvement and use in the production of anatoxins}; Speranskaia VN et al.; The reactor technology for obtaining suspensions of Staphylococcus aureus (strain Cowan 1) with active protein A was developed . On the basis of the sensitization of bacterial suspensions with antitoxic rabbit sera staphylococcal reagents to diphtherial, gas gangrene (perfringens, oedematiens), botulinic toxins-toxoids were obtained and for the first time the coagglutination test with toxoids was carried out . More sensitive "specifically directed" reagents for the coagglutination test were obtained; for this purpose bacterial suspensions were sensitized with pure antibodies isolated from rabbit immune sera by immunosorption . The possibility of using the coagglutination test with specifically directed staphylococcal reagents for the rapid evaluation of the dynamics of toxin formation in reactors for the titration of purified toxoids, for the control of the purification of toxoids by ultrafiltration, as well as for the evaluation of the sorption-desorption of toxoids in the production of the corresponding preparations, was shown.

FEBS Lett, 1998 Jun 16, 429(3), 234 - 8
Efficacy of a novel metalloprotease inhibitor on botulinum neurotoxin B activity; Adler M et al.; The novel inhibitor 7-N-phenylcarbamoylamino-4-chloro-3-propyloxyisocoumarin (ICD 1578) was tested for its ability to antagonize the zinc metalloprotease activity of botulinum toxin B (BoNT/B) . The efficacy of this compound was tested in a cell-free system using a 50-mer synaptobrevin peptide as substrate . The peptide, designated as {Pya88} S 39-88, had a fluorescent amino acid analog, L-pyrenylalanine (Pya), substituted for the normal Phe88 of synaptobrevin-2 . Cleavage by BoNT light chain yielded fragments of 38 and 11 amino acids, respectively . The smaller fragment, containing the Pya fluorophore, was readily separated and quantified by fluorescence spectroscopy at 377 nm . In the presence of 7-200 microM ICD 1578, cleavage of {Pya88} S 39-88 was progressively reduced (IC50 = 27.6 microM), and 100 microM ICD 1578 produced >95% inhibition . For comparison, captopril, a well-known zinc metalloprotease inhibitor, generated less than 10% inhibition at a concentration of 5 mM . ICD 1578 is the most potent antagonist of BoNT/B light chain thus far described.

Mund Kiefer Gesichtschir, 1998 May, 2 Suppl 1, S125 - 9
{Botulinum toxin treatment of neurogenic dislocation of the temporomandibular joint}; Daelen B et al.; Botulinum toxin leads to paresis of the skeletal muscle lasting 2-4 months via an inhibition of acetylcholine release at the neuromuscular junction . Since 1995, botulinum toxin injections have been used in the treatment of recurrent dislocation of the temporomandibular joint (TMJ) . The chemical denervation of the external pterygoid muscle restricts the angle of mouth opening, thus helping to prevent dislocation . TMJ dislocations that occur as a result of increased tone in the protracted masticatory muscles were recently defined as neurogenic dislocations of the TMJ . We conducted a clinical study to investigate the efficacy of botulinum toxin injections into the external pterygoid muscle in five patients with recurrent neurogenic dislocations of the TMJ . In the 3 months prior to the first treatment, the patients had suffered a total of 19 dislocations . In the 3-month period following the initial treatment, only one woman experienced a dislocation . We performed the treatment a total of 25 times . Five dislocations occurred during the 6- to 36-month observation period . In the meantime, two patients remain recurrence-free 1 year after receiving treatment . All the patients had a restricted ability to open their mouths as a side effect of the weakening of the external pterygoid muscle that was completely reversible over the course of 3-4 months . All other side effects were equally well-tolerated by the patients and fully reversible after 3 weeks at the most . In the two patients who remain recurrence-free without any further treatment, the increased tone of the muscles serving the jaw normalised spontaneously over the course of the underlying neurological disease . Our results show that, in the treatment of recurrent neurogenic dislocations of the TMJ, botulinum toxin injections represent a therapeutic alternative that has few side effects.

Mund Kiefer Gesichtschir, 1998 May, 2 Suppl 1, S121 - 4
{New techniques in maxillofacial surgery: local injection treatment with botulinum toxin A}; Roser M et al.; Intramuscular injections of botulinum neurotoxin type A cause reversible chemodenervation and subsequent paralysis by blocking the presynaptic release of acetylcholine . Botulinum toxin type A has emerged as the most effective form of symptomatic treatment for abnormabilities in muscle movement (blepharospasm, hemifacial spasm, torticollis) and has been approved for use in these conditions . First results in the treatment of patients suffering from oromandibular dystonia, myogenic craniomandibular dysfunction and recurrent dislocation of the temporomandibular joint are presented . In most cases, therapeutic effects occurred within 1-6 days post-injection . Muscular hyperfunction was reliably reduced and involuntary activity patterns gradually ceased . No severe side effects of the local injections were noted.

Mol Endocrinol, 1998 Jul, 12(7), 1060 - 70
Truncated SNAP-25 (1-197), like botulinum neurotoxin A, can inhibit insulin secretion from HIT-T15 insulinoma cells; Huang X et al.; We and others have previously shown that insulin-secreting cells of the pancreas express high levels of SNAP-25 (synaptosomal-associated protein of 25 kDa), a 206-amino acid t-SNARE (target soluble N-ethylmaleimide-sensitive factor attachment protein receptors) implicated in synaptic vesicle exocytosis . In the present study, we show that SNAP-25 is required for insulin secretion by transient transfection of Botulinum Neurotoxin A (BoNT/A) into insulin-secreting HIT-T15 cells . Transient expression of BoNT/A cleaved the endogenous as well as overexpressed SNAP-25 proteins and caused significant reductions in K+ and glucose-evoked secretion of insulin . To determine whether the inhibition of release was due to the depletion of functional SNAP-25 or the accumulation of proteolytic by-products, we transfected cells with SNAP-25 proteins from which the C-terminal nine amino acids had been deleted to mimic the effects of the toxin . This modified SNAP-25 (amino acids 1-197) remained bound to the plasma membrane but was as effective as the toxin at inhibiting insulin secretion . Microfluorimetry revealed that the inhibition of secretion was due neither to changes in basal cytosolic Ca2+ levels nor in Ca2+ influx evoked by K(+)-mediated plasma membrane depolarization . Electron microscopy revealed that cells transfected with either BoNT/A or truncated SNAP-25 contained significantly higher numbers of insulin granules, many of which clustered close to the plasma membrane . Together, these results demonstrate that functional SNAP-25 proteins are required for insulin secretion and suggest that the inhibitory action of BoNT/A toxin on insulin secretion is in part caused by the production of the plasma membrane-bound cleavage product, which itself interferes with insulin granule docking and fusion.

FEBS Lett, 1998 Jun 5, 429(1), 78 - 82
Structural stabilization of botulinum neurotoxins by tyrosine phosphorylation; Encinar JA et al.; Tyrosine phosphorylation of botulinum neurotoxins augments their proteolytic activity and thermal stability, suggesting a substantial modification of the global protein conformation . We used Fourier-transform infrared (FTIR) spectroscopy to study changes of secondary structure and thermostability of tyrosine phosphorylated botulinum neurotoxins A (BoNT A) and E (BoNT E) . Changes in the conformationally-sensitive amide I band upon phosphorylation indicated an increase of the alpha-helical content with a concomitant decrease of less ordered structures such as turns and random coils, and without changes in beta-sheet content . These changes in secondary structure were accompanied by an increase in the residual amide II absorbance band remaining upon H-D exchange, consistent with a tighter packing of the phosphorylated proteins . FTIR and differential scanning calorimetry (DSC) analyses of the denaturation process show that phosphorylated neurotoxins denature at temperatures higher than those required by non-phosphorylated species . These findings indicate that tyrosine phosphorylation induced a transition to higher order and that the more compact structure presumably imparts to the phosphorylated neurotoxins the higher catalytic activity and thermostability.

Toxicon, 1998 May, 36(5), 703 - 17
Gating and permeability of ion channels produced by botulinum toxin types A and E in PC12 cell membranes; Sheridan RE; Botulinum neurotoxin (BoNT) is known to produce cationic channels in artificial bilayers . This study examined ion channels formed by BoNT in native membranes from cultured PC12 cells under conditions approximating those thought to occur during toxin internalization . Membrane patches were excised from PC12 cells using patch electrodes and exposed to symmetrical solutions containing either 200 mM CsCl, RbCl or KCl . The patch pipettes also contained 1-5 microg/ml BoNT buffered to pH 5.3 while the bath solutions were buffered to pH 7.0 . In the presence of toxin, bursts of ion channel openings were observed . These toxin-induced channels were most active with a negative voltage applied to the same side as the toxin (cis) . The increased activity at negative voltages was due to an increase in mean open time of e-fold per 120 mV and a decrease in mean closed time between bursts of e-fold per 110 mV . The shorter mean closed time within a burst was independent of membrane voltage . While BoNT-induced ion channels started as a single conductance level of 27 pS (KCl), 34 pS (RbCl) or 46 pS (CsCl) they typically increased in roughly equal steps to five or more times the original channel conductance . These higher conductance BoNT 'channels' opened and closed synchronously and could be distinguished from superposition of multiple independent channels . Despite differences in putative transmembrane sequences between BoNT/A and BoNT/E, both serotypes evidenced the same channel conductance and mean open time.

J Biol Chem, 1998 Jul 10, 273(28), 17732 - 41
SNAP-23 requirement for transferrin recycling in Streptolysin-O-permeabilized Madin-Darby canine kidney cells; Leung SM et al.; Fusion of recycling and transcytotic vesicles with the apical and basolateral plasma membrane domains of Madin-Darby canine kidney (MDCK) cells requires the N-ethylmaleimide-sensitive factor and is sensitive to botulinum neurotoxin serotype E (BoNT/E) . BoNT/E is thought to selectively proteolyze the 25,000-dalton synaptosomal associated protein (SNAP-25), a protein found in neurons or cells of neuroendocrine origin . However, SNAP-25 is not found in MDCK cells . One possible target for BoNT/E in MDCK cells is SNAP-23, a newly described SNAP-25 homolog that is found in several organs including kidney . Currently, the function of SNAP-23 is unknown . We have reconstituted transferrin recycling in permeabilized MDCK cells to assess the role of SNAP-23 in the endocytic traffic of this protein . We find that: (i) SNAP-23 is expressed in MDCK cells and is found both at the basolateral plasma membrane and associated with apical and basolateral vesicles, (ii) canine SNAP-23 is cleaved by BoNT/E, (iii) transferrin recycling is N-ethylmaleimide-sensitive factor-dependent and BoNT/E-sensitive, and (iv) addition of either exogenous SNAP-23 or anti-SNAP-23 antibodies inhibits ligand recycling . Our observations suggest that SNAP-23 may be required for fusion of recycling vesicles with the basolateral membrane of polarized MDCK cells.

J Neurosci, 1998 Jul 15, 18(14), 5212 - 24
Response of thalamocortical neurons to hypoxia: a whole-cell patch-clamp study; Erdemli G et al.; The effect of hypoxia (3-4 min of 95% N2, 5% CO2) on thalamocortical (TC) neurons was investigated using the whole-cell patch-clamp technique in rat dorsal lateral geniculate nucleus slices kept submerged at 32 degreesC . The predominant feature of the response of TC neurons to hypoxia was an increase in input conductance (DeltaGN = 117 +/- 15%, n = 33) that was accompanied by an inward shift in baseline holding current (IBH) at -65 and -57 mV (DeltaIBH = -45 +/- 6 pA, n = 18, and -25 +/- 8 pA, n = 33, respectively) but not at -40 mV . The hypoxia-induced increase in GN (as well as the shift in IBH) was abolished by procedures that are known to block Ih, i.e., bath application of 4-(N-ethyl-N-phenylamino)-1, 2-dimethyl-6-(methylamino)-pyrimidinium chloride (100-300 microM) (DeltaGN = 5 +/- 13%, n = 11) and CsCl (2-3 mM) (DeltaGN = 16 +/- 16%, n = 5), or low {Na+}o (DeltaGN = 10 +/- 10%, n = 5), whereas bath application of BaCl2 (0.1-2.0 mM) had no significant effect (DeltaGN = 128 +/- 14%, n = 8) . The hypoxic response was also abolished in low {Ca+2}o (DeltaGN = 25 +/- 16%, DeltaIBH = -6 +/- 8 pA, n = 13), but was unaffected by recording with electrodes containing EGTA (10 mM), BAPTA (10-30 mM), Cs+, or Cl-, as well as in the presence of external tetraethylammonium and 4-aminopyridine . Furthermore, preincubation of the slices with botulinum toxin A (100 nM), which is known to reduce Ca2+-dependent transmitter release, blocked the hypoxic response (DeltaGN = -3 +/- 15%, DeltaIBH = 10 +/- 5 pA, n = 4) . We suggest that a positive shift in the voltage-dependence of Ih and a change in its activation kinetics, which transforms it into a fast activating current, may be responsible for the hypoxia-induced changes in GN and IBH, probably via an increase in Ca+2-dependent transmitter release.

J Cell Physiol, 1998 Aug, 176(2), 223 - 34
Virally activated Ras cooperates with integrin to induce tubulogenesis in sinusoidal endothelial cell lines; Maru Y et al.; Four cell lines, named nonparenchymal 11 (NP11), NP26, NP31, and NP32, were established from sinusoidal endothelial cells (SECs) of rat liver . They still retained expression of receptors for vascular endothelial growth factor (VEGF), Fit-1, and kinase domain-containing receptor (KDR) . NP31 and NP32 turned out to be incapable of tubulogenesis in basement membrane matrix (Matrigel), which belongs to endothelial properties, as shown by SECs in primary culture . Expression of temperature-sensitive, virally activated Ras (ts-v-Ras) restored tubulogenic behaviors back to NP31 only at permissive temperature . Matrigel induced long-lasting tyrosine phosphorylation of Shc, with recruitment of Grb-2 and microtubule-associated protein kinase (MAPK) activation in both parental NP31 and NP31 transformed by ts-v-Ras, which was blocked by anti-beta1 integrin antibody . Tubulogenesis was inhibited by adenovirus-mediated expression of dominant-negative Ras in human umbilical vein endothelial cells (HUVECs) . PD 098059, a selective inhibitor of MAPK kinase (MEK), nearly perfectly blocked tubulogenesis by ts-v-Ras-expressing NP31 cells at permissive temperature . Furthermore, the botulinum C3 toxin, an inhibitor for Rho, caused fragmentation of branching cords in networks formed by NP31 that expressed ts-v-Ras at permissive temperature . These data suggest that the integrin-mediated Ras signals may be necessary but are not sufficient for tubulogenesis and that an artificial expression of v-Ras might substitute for the second signal required in this system.

Biochem Biophys Res Commun, 1998 Jun 29, 247(3), 888 - 93
Localization of RhoA GTPase to endothelial caveolae-enriched membrane domains; Gingras D et al.; Caveolae are small microdomains of the plasma membrane that are thought to play important roles in signal transduction processes . In this work, we have investigated the association of Rho proteins with caveolae-enriched membrane domains isolated from cultured endothelial cells . Fractionation of ECV304 cells by sucrose gradient density centrifugation in the absence of detergent resulted in the co-sedimentation of a significant proportion of RhoA and Cdc42 with known caveolae marker proteins, including caveolin, but not with other non-caveolae membrane proteins such as the angiotensin-converting enzyme . Immunoprecipitation experiments carried on crude endothelial cell lysates as well as with solubilized caveolae-enriched membrane domains showed the coimmunoprecipitation of caveolin with RhoA but not with Cdc42 . Incubation of endothelial cell lysates with a glutathione-S-transferase (GST)-RhoA fusion protein resulted in the specific precipitation of caveolin, while addition of GST-caveolin-1 to the lysates promoted the precipitation of RhoA . Moreover, incubation of bacterially expressed RhoA with GST-caveolin-1 resulted in the precipitation of RhoA, indicating that RhoA directly interacts with caveolin-1 . This interaction was found to be nucleotide-independent and was not affected by prior modification of RhoA with the C3 exoenzyme from C . botulinium or with the cytotoxic necrotinizing factor from E . coli . Taken together, these results suggest the association of RhoA with endothelial caveolae-enriched membrane domains, likely through physical interaction with caveolin-1 . These findings may provide new insights into the functions played by Rho proteins and caveolae in signal transduction events.

J Cell Biol, 1998 Jun 29, 141(7), 1503 - 13
The SNARE machinery is involved in apical plasma membrane trafficking in MDCK cells; Low SH et al.; We have investigated the controversial involvement of components of the SNARE (soluble N-ethyl maleimide-sensitive factor {NSF} attachment protein {SNAP} receptor) machinery in membrane traffic to the apical plasma membrane of polarized epithelial (MDCK) cells . Overexpression of syntaxin 3, but not of syntaxins 2 or 4, caused an inhibition of TGN to apical transport and apical recycling, and leads to an accumulation of small vesicles underneath the apical plasma membrane . All other tested transport steps were unaffected by syntaxin 3 overexpression . Botulinum neurotoxin E, which cleaves SNAP-23, and antibodies against alpha-SNAP inhibit both TGN to apical and basolateral transport in a reconstituted in vitro system . In contrast, we find no evidence for an involvement of N-ethyl maleimide-sensitive factor in TGN to apical transport, whereas basolateral transport is NSF-dependent . We conclude that syntaxin 3, SNAP-23, and alpha-SNAP are involved in apical membrane fusion . These results demonstrate that vesicle fusion with the apical plasma membrane does not use a mechanism that is entirely unrelated to other cellular membrane fusion events, but uses isoforms of components of the SNARE machinery, which suggests that they play a role in providing specificity to polarized membrane traffic.

J Neurol Neurosurg Psychiatry, 1998 Jun, 64(6), 751 - 7
Long term results of botulinum toxin type A (Dysport) in the treatment of hemifacial spasm: a report of 175 cases; Jitpimolmard S et al.; OBJECTIVE: To describe the long term efficacy and side effects of the treatment of hemifacial spasm with Dysport and to evaluate two different sites of injection to hopefully reduce side effects . METHODS: This study was designed as a prospective descriptive study . Injections were made subcutaneously around the eye . Peak improvement was subjectively assessed by using a visual analogue scale and reported in percentages (0-100%) . Duration of improvement was assessed subjectively and reported in months . RESULTS: Of 175 cases, 17 were lost to follow up and were excluded . 855 treatments were injected in the remaining 158 patients with a median of 4 treatments . The response rate was 97% . Of 855 treatments, the adjusted mean peak and duration of improvement was 77.2 (95% confidence interval (95%CI) 74.7-79.4)% and 3.4 (95%CI 3.2-3.6) months respectively . In 158 patients (complete group), the long term results from the first to the 12th treatment showed that the mean peak improvement ranged from 72.70 to 80.10% and the duration of improvement was 2.60 to 3.71 months . It remained constant throughout (p=0.40, p=0.87 respectively) . The most common side effect was ptosis . Of the 158 patients, 21 completed 12 treatments (subgroup) . A separate analysis of this group disclosed a mean peak and duration of improvement from the first to 12th treatments ranging from 70.00 to 78.10% and 2.65 to 4.31 months respectively . Analysis of variance with repeated measures showed no significant variation of peak and duration of improvement over the first to the 12th treatments (p=0.38, p=0.38 respectively) . Only 3% of the treatments were unsuccessful but responded to subsequent treatments . The incidence of ptosis was reduced from 27.17% to 9.68% by moving the injection site to the lateral part of orbital orbicularis oculi without any loss of efficacy . The yearly cost of Dysport is considerably less than Botox . CONCLUSION: This study is the first to show, in detail, the long term results of treatments of hemifacial spasm with Dysport . The efficacy is constant throughout orbicularis oculi . The efficacy of Dysport is comparable with Botox in long term follow up.

Clin Orthop, 1998 Jun, (351), 102 - 6
Focal dystonia and repetitive motion disorders; Chen R et al.; It commonly is observed that focal hand dystonias, such as writer's cramp or musician's cramp, are associated with repetitive movements, although definitive proof of a causal relationship is lacking . These focal dystonias are often task specific, with involuntary muscle contractions occurring only when patients perform specific acts such as writing or playing a musical instrument . Physiologic studies show deficiencies in spinal reciprocal inhibition and abnormalities of central sensory processing and motor output that may be related to reduced cortical inhibition . Recent studies in primates support the notion that repetitive motions can induce plasticity changes in the sensory cortex leading to degradation of topographic representations of the hand, and raise the possibility that sensory training may be beneficial . Current treatment options for focal dystonia include botulinum toxin injections, anticholinergics, baclofen, benzodiazepines, and occupational therapy.

Eur Neurol, 1998, 39(4), 204 - 10
Isolated so-called apraxia of eyelid opening: report of 10 cases and a review of the literature; Defazio G et al.; So-called apraxia of eyelid opening (scAEO) has been described chiefly in the context of extrapyramidal disorders . We described 10 new patients with scAEO developing in the absence of any other CNS sign and reviewed the 11 cases with isolated scAEO reported in the literature . Combining our patients and those from the literature, peak age at onset was in the 6th decade and there was a female preponderance of 2:1 . The characteristic inability to initiate lid elevation was frequently associated with failure to sustain lid elevation, thus suggesting that eyelid motor control may be abnormal in isolated scAEO . Antecedent events included ocular signs and symptoms consistent with diseases of eyes or face (4 cases in our series and 2 in the literature), chronic treatment with flunarizine (1 case), and family history of dystonia (1 case) . Flunarizine discontinuation led to sustained remission of the eyelid disturbance . Overall, these clues suggest the involvement of the extrapyramidal system in the pathophysiology of isolated scAEO . Familial clustering of isolated scAEO in one of our patients may be in favor of a genetic contribution . In our series, botulinum toxin administration close to the pretarsal part of the orbicularis oculi muscle significantly improved scAEO in 8/10 cases, whereas orbital/preseptal injection had no effect . We conclude that the term 'apraxia' may not be the correct descriptive term even when the eyelid disturbance occurs without any other CNS disease.

Neurology, 1998 Jun, 50(6), 1624 - 9
Mouse bioassay versus Western blot assay for botulinum toxin antibodies: correlation with clinical response; Hanna PA et al.; OBJECTIVE: To compare the mouse protection bioassay (MPB) to the Western blot assay (WBA) in detecting antibodies against botulinum toxin A (BTX-A) and to correlate the assay results with clinical responses to BTX-A injections . METHODS: MPB and WBA assay results were compared in 51 patients (34 nonresponders and 17 responders) who received BTX-A injections, most commonly for cervical dystonia . A subset of patients received a "test" injection into either the right eyebrow (14) or right frontalis (12) . RESULTS: Twelve patients with antibodies against BTX-A (Ab+) detected by WBA did not demonstrate antibodies (Ab-) by MPB . Conversely, five patients were Ab+ by MPB but Ab- by WBA . Specificity of the MPB was 100% on all three parameters (clinical, eyebrow, and frontalis injections), whereas WBA specificity was only 71% for clinical response but 100% for both eyebrow and frontalis responses . Sensitivities for both assays were low (33 to 53%) . Of the 16 patients previously Ab+ by MPB, seven became negative on retesting after a mean interval of 33 months (range, 6 to 93 months) . CONCLUSIONS: The lower specificity of the WBA compared to the MPB suggests that the WBA detects nonblocking antibodies . Eyebrow and frontalis "test" injections correlated well with MPB and WBA results and with clinical responses and may be useful in the evaluation of BTX nonresponders.

Headache, 1998 May, 38(5), 366 - 8
Headache and facial pain responsive to botulinum toxin: an unusual presentation of blepharospasm; Johnstone SJ et al.; The diagnosis of blepharospasm is rarely considered in patients complaining of face pain or headache . This patient illustrates the importance of looking for blepharospasm in patients who present with headache or face pain, as her pain and blepharospasm were successfully treated with botulinum toxin type A injections.

Aust N Z J Ophthalmol, 1998 May, 26(2), 123 - 8
Facial muscle spasms: an Australian study; Kowal L et al.; PURPOSE: A group of patients suffering from blepharospasm, hemifacial spasm and Meige's syndrome were surveyed to determine the delay from the onset of their condition until a correct diagnosis was reached, the attitudes of practitioners towards them and their condition, the effect of their condition on their lifestyle and the effects of different types of treatment on their conditions . METHODS: Questionnaires were offered to all patients with blepharospasm, hemifacial spasm and Meige's syndrome presenting to three ophthalmologists licensed to treat patients with botulinum toxin injections over a 12 month period . RESULTS: Patients consulted an average of 4.4 practitioners before a correct diagnosis was made and many waited a number of years before obtaining satisfactory treatment . Approximately two-thirds of all practitioners consulted were unaware of their condition . Ten per cent of patients reported a family history of similar conditions . Most patients received relief from their symptoms with treatment using injections of botulinum toxin . More than 55% of patients considered themselves to have psychological problems (usually relating to stress and trauma) that they associated with the onset of their condition . CONCLUSIONS: Facial muscle dystonias are rare and patient experiences suggest that they are poorly appreciated in the medical community . From the time they first see a practitioner with symptoms of facial dystonia, patients typically wait 2 years and see four practitioners before a correct diagnosis is made . Stress may be a factor in the symptomatic onset of this condition . Many patients describe pain as part of the presenting symptomatology . Botulinum toxin seems to be effective in the management of facial spasm.

Arch Phys Med Rehabil, 1998 Jun, 79(6), 715 - 7
Treatment of detrusor sphincter dyssynergia by transperineal injection of botulinum toxin; Gallien P et al.; Detrusor-sphincter dyssynergia is an involuntary contraction of the external urethral sphincter during the detrusor contraction . It causes voiding dysfunction and can lead to urologic complications such as hydroureteronephrosis and renal failure . Patients with spinal cord injuries are particularly vulnerable . Botulinum toxin has been used via cystoscopy to decrease the activity of the external urethral sphincter . This report describes the treatment of 5 tetraplegic patients by single transperineal injections of botulinum toxin for detrusor-sphincter dyssynergia, proved by a urodynamic study with electromyography . A total of 15 injections was given, resulting in improved bladder function in all patients . Urodynamic assessment after treatment showed an increase of the functional detrusor capacity and a decrease of the maximal detrusor pressure during voiding . These results confirm the consideration of botulinum toxin as a treatment for detrusor sphincter dyssynergia . A single transperineal injection is a valuable, less invasive treatment using a cystoscopic technique.

Arq Neuropsiquiatr, 1997 Sep, 55(3B), 553 - 7
{Botulinum toxin A: experience in the treatment of 115 patients}; Andrade LA et al.; Botulinum toxin A is the more efficient therapy of focal dystonias and hemifacial spasm . Our experience with botulinum toxin A injections in 115 patients is reported . Marked or total improvement was achieved in all 45 patients with hemifacial spasm, in 70% of 20 patients with essential blepharospasm and in 71.4% of 14 patients with Meige's syndrome . In 65.2% of 23 patients with cervical dystonia marked but no total improvement was obtained . The worse results were seen in the 6 patients with hand dystonia (writers cramp), in whom marked improvement was obtained in just two . Mild and transient complications occurred in up to 24.4%, eyelid ptosis and eyelid weakness being the most frequent . One patient with Meige's syndrome had an aspiration pneumonia following dysphagia . Our results are in agreement with others, showing that botulinun toxin A is a useful and safe treatment for these conditions.

Proc Natl Acad Sci U S A, 1998 Jun 9, 95(12), 7163 - 8
Modulation of an early step in the secretory machinery in hippocampal nerve terminals; Trudeau LE et al.; In hippocampal neurons, neurotransmitter release can be regulated by protein kinase A (PKA) through a direct action on the secretory machinery . To identify the site of PKA modulation, we have taken advantage of the ability of the neurotoxin Botulinum A to cleave the synaptic protein SNAP-25 . Cleavage of this protein decreases the Ca2+ responsiveness of the secretory machinery by partially uncoupling Ca2+-sensing from fusion per se . This is expressed as a shift toward higher Ca2+ levels of the Ca2+ to neurotransmitter release relationship and as a perturbation of synaptic delay under conditions where secretion induced by the Ca2+-independent secretagogue ruthenium red is unimpaired . We find that SNAP-25 cleavage also perturbs PKA-dependent modulation of secretion; facilitation of ruthenium red-evoked neurotransmitter release by the adenylyl cyclase activator forskolin is blocked completely after Botulinum toxin A action . Together with our observation that forskolin modifies the Ca2+ to neurotransmitter release relationship, our results suggest that SNAP-25 acts as a functional linker between Ca2+ detection and fusion and that PKA modulates an early step in the secretory machinery related to calcium sensing to facilitate synaptic transmission.

J Laryngol Otol, 1998 Mar, 112(3), 248 - 51
The effect of botulinum toxin type A injection for intrinsic rhinitis; Kim KS et al.; Botulinum toxin type A (BTA) is known to inhibit the release of acetylcholine from cholinergic nerve endings . Owing to the characteristics of BTA, we thought that it could be used for the treatment of intrinsic rhinitis acting as an anticholinergic drug . In a double-blind placebo-controlled study four units of BTA were injected into the middle turbinate (two units) and inferior turbinate (two units) in each nasal cavity . Rhinorrhoea, nasal obstruction, and sneezing were recorded in a symptom diary on the basis of a scale of 5 and the number of paper tissues used per day was also recorded for 24 weeks . Rhinorrhoea was significantly diminished in severity (24.1-41.5 per cent reduction) and paper tissue use (54.3 per cent reduction) in the BTA group compared with the placebo group . This effect could be maintained for four weeks . Sneezing and nasal stuffiness were not affected by BTA . These results suggest that BTA can be used to treat rhinorrhoea in intrinsic rhinitis patients, however, the effective period is short.

Plast Reconstr Surg, 1998 Jun, 101(7), 1875 - 80
Nerve injection injury with botulinum toxin; Lu L et al.; The therapeutic use of botulinum toxin (Botox) is increasing in popularity . Previous studies have shown that various drugs, especially when injected intrafascicularly, can cause major nerve damage . This study evaluates the potential for neurotoxicity of botulinum toxin in a rat sciatic nerve model . Lewis rats were randomly assigned to one of six groups (n = 10/group) . Group 1, 2, and 3 rats received, respectively, an intrafascicular, extrafascicular, and extraneural injection of 50 microl of botulinum toxin (50 UI/ml) . Group 4, 5, and 6 rats received 50 microl of 10% phenol as a positive control . Five animals received saline as a negative control . Animals were sacrificed at 2 and 7 weeks . Nerves were harvested and processed for histology and morphometry . Nerves in all botulinum toxin groups retained a normal architecture without cellular infiltration or demyelination . The number and diameter of fibers, the thickness of myelin, and the percentage of neural tissue were comparable with normal controls . Nerves injected intraneurally with phenol presented with severe damage, demyelination, and inflammation at 2 weeks and showed signs of early regeneration at 7 weeks . This study demonstrates that in a rat model, even direct intraneural injection of botulinum toxin caused no damage . This information should encourage the reconstructive surgeon to consider broader applications of this drug.

Ned Tijdschr Geneeskd, 1998 Apr 11, 142(15), 859 - 63
{Treatment of Frey's syndrome with botulinum A toxin}; Braunius WW et al.; A 74-year-old woman suffered from severe gustatory sweating and flushing of the preauricular skin following parotidectomy (Frey's syndrome) . She was treated with intracutaneous botulinum A toxin injections in the affected skin area . Minor's test was used to determine the extent of the affected area . Within one week, the symptoms disappeared . After three weeks, Minor's test was repeated and showed minimal residual hyperhidrosis . These small areas were treated again . No side effects were noted . At follow-up one year later, the patient was free of symptoms.

Ned Tijdschr Geneeskd, 1998 Mar 7, 142(10), 529 - 32
{Botulinum toxin type A treatment of cosmetically disturbing masseteric hypertrophy}; Rijsdijk BA et al.; Two patients, a woman aged 21 and a man aged 29, with asymmetrical swellings of both mandibular angles and a painful, heavy sensation in the masticatory muscles (and in the woman also round the maxillary joint), were diagnosed as having hypertrophy of the masseter muscles . Both had the habit of jaw clenching and tooth grinding . Treatment consisted not of the traditional surgical debulking which also allows correction of overdeveloped osseous mandibular angles, but of injections with botulinum toxin type A . Injection of 40-60 IU (product: Botox) per muscle was followed by some atrophy; cosmetically satisfactory results were achieved after repetition of the treatment a few months later . Reduction of muscle volume was confirmed by a quantitative volumetric assessment of MRI scans . In the female patient, the pain also abated.

J Neuroophthalmol, 1998 Jun, 18(2), 153 - 7
Drug-associated facial dyskinesias--a study of 238 patients; Mauriello JA Jr et al.; The purpose of this study was to determine whether antidepressant, antimania, antipsychotic, antihistamine, or antiparkinsonian drugs are associated with eyelid and facial dyskinesias; whether discontinuing such drugs results in improvement in the facial dyskinesias; and whether response to botulinum toxin treatment is influenced by such medications . METHODS: A retrospective review was performed on a population of 238 patients with presumed benign essential blepharospasm and Meige syndrome . Types of drugs taken before the development of disease and clinical response to botulinum toxin injections were studied . RESULTS: Fourteen of 238 patients (5.9%) with facial dyskinesias had been prescribed a variety of antidepressants, antimania medications, antipsychotics, antihistamines, antiparkinsonian drugs, or a combination of these substances before their condition developed . The onset of blepharospasm varied from 2 months to 35 years after administration of the drug . Three of seven patients who discontinued the presumed responsible drug had improvement in their facial dyskinesias . Of the 11 patients who did not improve when their drugs were stopped or whose medication could not be stopped, all but one patient had a good response to treatment with botulinum toxin A . CONCLUSIONS: Drug-induced blepharospasm should be considered in all patients who present with facial dyskinesias, and such patients should undergo withdrawal of the medication when possible . When withdrawal of medication is not possible or does not result in improvement in the facial dyskinesia, treatment with botulinum toxin injections should be initiated . The possible role in the production of facial dyskinesias of antidepressants that block reuptake of serotonin requires further evaluation.

Brain, 1998 May, 121 ( Pt 5), 977 - 88
The corticomotor representation of upper limb muscles in writer's cramp and changes following botulinum toxin injection; Byrnes ML et al.; Transcranial magnetic stimulation was used to investigate the properties of the corticomotor pathway and to map the primary motor cortex projection to hand and forearm muscles during a sustained isometric contraction in a group of subjects with writer's cramp of varying duration . Corticomotor threshold, motor evoked potential amplitude and latency, and silent-period duration were normal on both sides in all subjects . The maps of the corticomotor projection were displaced relative to normal in all subjects, and in some cases were distorted in shape, with extensions of the lateral borders and the emergence of almost discrete secondary motor areas . The degree of map distortion and displacement was greatest in subjects with long-standing writer's cramp (> 5 years), and was bilateral in some cases . Injection of botulinum toxin into affected muscles demonstrated that the alterations in map topography were not fixed, and could be temporarily reversed during the period when the clinical effects of the injection were greatest, with the maps returning to their original positions as the effects of the injection wore off . It is concluded from this study that there are slowly evolving reorganizational changes in the primary motor cortex in writer's cramp, and that these changes may be secondary to altered afferent inputs from both clinically affected and unaffected muscles.

Clin Neuropharmacol, 1998 May-Jun, 21(3), 199 - 200
Hemifacial spasm triggered by vasodilators; Micheli F et al.; Hemifacial spasm features myoclonic-like, paroxysmal, unilateral muscle twitching, attributable to vascular compression at the facial pontine root entry zone . We present the case of an 85-year-old man who presented with idiopathic hemifacial spasm with onset 23 years before . For the last 5 years, he was successfully treated with botulinum toxin injections . However, occasional nitrate intake for precordial pain promptly triggered muscle twitching . Vasodilation may exacerbate not only cases of hemifacial spasm, but even of trigeminal neuralgia, both recognized as neurovascular compressive syndromes.

Clin Neuropharmacol, 1998 May-Jun, 21(3), 196 - 8
Botulinum toxin treatment for spasmodic dysphonia: percutaneous versus transoral approach; Garcia Ruiz PJ et al.; Spasmodic dysphonia (SD) is at present defined as focal dystonia . Botulinum toxin (BT) injection is the treatment of choice for SD . BT is usually injected by a percutaneous route, but a direct, visually guided transoral approach has also been successful . It is not known whether percutaneous injection is as effective as the transoral approach . This article reviews our experience with both techniques of injection on 29 patients with adductor type SD . Since 1992, we have carried out 48 treatment sessions with the transoral technique and 76 treatment sessions with the percutaneous technique . Two patients did not respond to the percutaneous technique despite several attempts, but they did respond to the transoral approach . Globally, transoral technique was superior to percutaneous technique in terms of effectiveness (48 of 48 responses with transoral technique versus 61 of 76 responses with percutaneous approach, p < 0.01) . Dosage of BT, duration, and side effects were similar with both techniques . This article also describes a simple, inexpensive device, composed of materials on hand at every hospital, that facilitates the transoral approach.

Gut, 1998 Apr, 42(4), 507 - 10
Effects of botulinum toxin A on the sphincter of Oddi: an in vivo and in vitro study; Sand J et al.; BACKGROUND: Botulinum toxin A is a potent inhibitor of the release of acetylcholine from nerve endings . Local injection of botulinum toxin has recently been suggested to be helpful in sphincter of Oddi dyskinesia by decreasing sphincter of Oddi pressure . AIMS: To explore the mechanism of action of botulinum toxin A on sphincter of Oddi (SO) muscle . METHODS: Four piglets underwent duodenoscopy and SO manometry was performed . After obtaining a baseline pressure, the SO was injected with normal saline and the experiment repeated after one week . The SO was then injected endoscopically with botulinum toxin (40 U) with follow up manometry one week later . The sphincter of Oddi was removed from 10 pigs, cut into three rings, and placed in an organ bath . The force of contraction was measured and registered on a polygraph . Rings were stimulated by 70 V (10 Hz, 0.5 ms) electrical field stimulation for 20 seconds, exogenous acetylcholine (100 microM), and KCl (125 mM) . Botulinum toxin (0.1 U/ml) or atropine (1 microM) was added to the incubation medium and the stimulation was repeated . RESULTS: Mean basal SO pressure in the pigs remained unchanged after saline injection but decreased to about 50% of baseline value following botulinum toxin injection (p = 0.04) . The contractions induced by direct stimulation of SO smooth muscle with KCl were not significantly affected by either atropine or botulinum toxin . In all rings exogenous acetylcholine induced contractions, which were totally blocked by atropine, but not by botulinum toxin . Electrical field stimulation induced contractions that were inhibited by both atropine and botulinum toxin . CONCLUSION: Botulinum toxin inhibits pig sphincter of Oddi smooth muscle contractions by a presynaptic cholinergic mechanism, similar to that described in skeletal muscle.

Eye, 1998, 12 ( Pt 1), 51 - 3
Necrotising fasciitis as a complication of botulinum toxin injection; Latimer PR et al.; PURPOSE: To highlight the need for early diagnosis and treatment of the rare condition of necrotising fasciitis as a complication of botulinum toxin injection, and to illustrate that injections in immunocompromised patients carry a rare but serious risk . RESULTS AND METHODS: A case report is presented of an 80-year-old woman suffering from blepharospasm and chronic myeloid leukaemia, who developed necrotising fasciitis 3 days after a botulinum toxin injection . CONCLUSIONS: Chronic debilitating processes such as diabetes, alcoholism and polymyositis have been suggested as predisposing factors in the development of necrotising fasciitis . We believe this is the first reported case of necrotising fasciitis occurring secondary to a botulinum toxin injection . The fact that this infection extended through the fascial planes and led to the death of muscle was, probably, because an inoculum was introduced directly into the muscle at the time of botulinum toxin treatment . This may have led to its deep spread and difficulty in debriding the area . Chronic myeloid leukaemia does not in itself cause significant immunosuppression, but our patient was on anti-proliferative treatment and had a low leucocyte count, which may have been a predisposing factor in this case.

Am J Physiol, 1998 Jun, 274(6 Pt 1), C1496 - 500
SNAP-25 is essential for cortical granule exocytosis in mouse eggs; Ikebuchi Y et al.; Synaptosome-associated protein of 25 kDa (SNAP-25) has been shown to play an important role in Ca2+-dependent exocytosis in neurons and endocrine cells . During fertilization, sperm-egg fusion induces cytosolic Ca2+ mobilization and subsequently Ca2+-dependent cortical granule (CG) exocytosis in eggs . However, it is not yet clear whether SNAP-25 is involved in this process . In this study, we determined the expression and function of SNAP-25 in mouse eggs . mRNA and SNAP-25 were detected in metaphase II (MII) mouse eggs by RT-PCR and immunoblot analysis, respectively . Next, to determine the function of SNAP-25, we evaluated the change in CG exocytosis with a membrane dye, tetramethylammonium-1,6-diphenyl-1,3,5-hexatriene, after microinjection of a botulinum neurotoxin A (BoNT/A), which selectively cleaves SNAP-25 in MII eggs . Sperm-induced CG exocytosis was significantly inhibited in the BoNT/A-treated eggs . The inhibition was attenuated by coinjection of SNAP-25 . These results suggest that SNAP-25 may be involved in Ca2+-dependent CG exocytosis during fertilization in mouse eggs.

Mov Disord, 1998 May, 13(3), 552 - 5
Extensor truncal dystonia: successful treatment with botulinum toxin injections; Comella CL et al.; Patients with truncal extension dystonia, manifested by involuntary back arching, often associated with pain and severe motor disability, have not consistently responded to pharmacologic agents . We evaluated 4 women and 1 man (mean age, 41.8 years; dystonia duration, 9.8 years) with severe idiopathic (2 patients) or tardive (3 patients) truncal and cervical dystonia . Using electromyographic guidance, we injected botulinum toxin into the paravertebral muscles of the lumbar region in four to six sites using 25-50 U per site . We reevaluated patients 2-4 weeks after injection . The mean dose of botulinum toxin into back muscles was 210 U (range, 150-300 U) . By blinded videotape evaluation, objective improvement was found in three patients with a mean truncal dystonia score improving by 37% . Patient evaluation showed improvement in movement ranging from 20-80% (mean, 46%) after botulinum toxin . In all patients with pain as a result of dystonia, there was substantial improvement . None of the patients worsened and no adverse effects occurred . Botulinum toxin injections offer a potent new treatment for truncal dystonia.

Mov Disord, 1998 May, 13(3), 486 - 9
Clinical comparison of tardive and idiopathic cervical dystonia; Molho ES et al.; It has been suggested that tardive cervical dystonia may be clinically indistinguishable from the idiopathic form and that the diagnosis rests solely on documenting an exposure to dopamine antagonist medications . To investigate this, we performed a retrospective evaluation of patient records on 102 patients with idiopathic and 20 patients with tardive cervical dystonia seen in our Movement Disorder Clinic over the past 8 years . Several clinical and demographic variables were compared and a number of differences were observed . The presence of extracervical involvement, retrocollis, and spasmodic head movements were individually found to be predictive of tardive cervical dystonia . Torticollis, laterocollis, and trick maneuvers were predictive of idiopathic cervical dystonia . Head tremor (42.2%) and family history of dystonia (9.8%) were present only in the idiopathic group . Cervical muscle hypertrophy was significantly more common in the idiopathic group (100% versus 75%) . No difference was found between the two groups in their response to treatment with botulinum toxin A . These results indicate that clinical differences between idiopathic and tardive cervical dystonia exist . These differences may help to distinguish them in the clinical setting, improve diagnostic accuracy, and support the existence of a causal relationship between exposure to dopamine antagonist medications and chronic dystonia.

Mov Disord, 1998 May, 13(3), 481 - 5
Comparison of acute- and delayed-onset posttraumatic cervical dystonia; Tarsy D; Head, neck, or shoulder trauma is an occasional antecedent event before the appearance of cervical dystonia . A clinically distinctive syndrome of acute-onset posttraumatic cervical dystonia characterized by markedly restricted range of neck motion, absence of phasic involuntary movements, and poor response to treatment has previously been described . Patients with cervical dystonia attending a movement disorder clinic were reviewed for history of trauma before onset of symptoms . Patients with symptom onset within 4 weeks of trauma were compared with patients who developed symptoms between 3 months and 1 year after trauma . Acute-onset cervical dystonia was characterized by markedly reduced cervical mobility; prominent shoulder elevation with trapezius hypertrophy in most patients, absence of involuntary movements, sensory tricks, or activation maneuvers; and poor response to botulinum toxin injection . By contrast, delayed-onset cervical dystonia was clinically indistinguishable from nontraumatic idiopathic cervical dystonia . Acute-onset posttraumatic cervical dystonia is similar to limb dystonia after peripheral trauma and may represent a form of nondystonic muscle spasm similar to torticollis associated with musculoskeletal injuries of the cervical spine and craniocervical junction.

Br J Ophthalmol, 1998 Feb, 82(2), 110 - 4
Retreatment of children after surgery for acquired esotropia: reoperation versus botulinum injection; Tejedor J et al.; AIMS: Two viable options were compared, reoperation and botulinum toxin injection, in the management of children who need retreatment after surgery for acquired esotropia . METHODS: 47 strabismic children previously operated to correct an acquired esotropia were randomised to reoperation or botulinum toxin injection . Reoperation was undertaken in 24 of these patients and botulinum toxin injection in 23 of them . The percentage net change in distance deviation, the percentage of patients with successful motor outcome, detectable fusion, and stereopsis were compared 1 year after retreatment and at last visit (average follow up: 2.9 years in reoperation group, and 2.7 years in botulinum group) . The motor success rate relative to time elapsed from initial surgery was evaluated . RESULTS: There was no significant difference in the motor and sensory outcomes between patients reoperated and treated with botulinum injection . The frequency of correction to within 8 prism dioptres of orthotropia was, respectively: 75% versus 69.56% at 1 year; 70.83% versus 60.86% at last visit . Botulinum injection could be more effective when performed within 3 months of initial surgery . CONCLUSIONS: Botulinum injection is a rapid and safe procedure that may be as effective as reoperation in the management of children who need a secondary procedure after surgery for acquired esotropia.

Neurol Neurochir Pol, 1998, 32 Suppl 1, 85 - 93
{Botulinum toxin injections under electromyographic guidance}; Bogucki A; EMG can be used for both dystonic muscles selection and performing injections of botulinum toxin . The indications for performing injections under EMG guidance in different forms of movement disorders are discussed . There is no need of EMG control in the treatment of blepharospasm and hemifacial spasm . In cervical dystonia the use of EMG guidance can improve the results of treatment in cases of head tilt, retrocollis, shoulder elevation and in more complex forms of dystonia . The injections should be performed under EMG control in patients with limb, oro-mandibular and laryngeal dystonia and with palatal myoclonus.

Neurol Neurochir Pol, 1998, 32 Suppl 1, 71 - 84
{Botulinum toxin in spasticity treatment}; Slawek J; The author reviews the current opinions on the treatment of spasticity with special consideration given to the new method of treatment with local injections of botulinum toxin A into the spastic muscles . Botulinum toxin is the treatment of choice in focal dystonias and hemifacial spasm . The mechanism of action of the toxin is unique and is a result of dose-dependent and partial chemical denervation of the muscles, with preservation of tonus and thus its function . Recent reports have confirmed the safety and effectiveness of the method in spasticity, especially when it is focal, not diffuse or severe and without concomitant severe paresis . The author describes also the basic data of the pathophysiology of spasticity and reviews other therapeutic options and practical problems concerning the injections of botulinum toxin.

Neurol Neurochir Pol, 1998, 32 Suppl 1, 61 - 9
{Treatment of hemifacial spasm with botulinum A toxin}; Duzynski W et al.; The authors present the method of hemifacial spasm treatment with botulinum toxin discussing the results of the treatment, injection method, side effects and complications of this treatment on the basis of literature review and their own experience . Clinical features, aetiology and pathophysiology of this condition are described . Other treatment methods are briefly mentioned.

Neurol Neurochir Pol, 1998, 32 Suppl 1, 57 - 60
{Botulinum toxin in the treatment of pain}; Domzal TM; Botulinum toxin (BTx) has been administered for many years in the treatment of dystonias with great success . Its effectiveness is comparable with the best drugs . It was observed during spasmodic torticollis treatment that pain disappears as first before clinical improvement of dystonia . Different mechanisms of influence of BTx on pain are discussed . BTx was tried in tension headache, cluster headache, migraine, fibromyositis, painful cramps with varying results . It is possible that BTx will be useful in many other types of pain.

Neurol Neurochir Pol, 1998, 32 Suppl 1, 51 - 6
{Botulinum toxin in the treatment of tremor}; Domzal TM; Pharmacological treatment of essential and symptomatic tremor is not satisfactory . Introduction of botulinum toxin (BTX) has brought a new approach to tremor treatment . BTX is injected into carpal flexors and extensors about 100 i.u . into each muscle, higher doses are injected into flexors and lower into extensors . Beneficial results are observed in 50 to 67% of the patients . The author treated 5 patients with tremor of various origin with good result in 3 cases (60%), but in all cases weakness of hand muscles and middle finger dropping were observed . BTX treatment is indicated in certain cases of hand disabled by tremor.

Neurol Neurochir Pol, 1998, 32 Suppl 1, 45 - 50
{Treatment of writer's cramp and other forms of limb dystonias with botulinum toxin}; Bogucki A; All forms of limb dystonia can be treated with botulin toxin injection . The selection of dystonic muscles and performing the injections in writer's cramp are discussed in detail . Treatment strategy and outcome in other forms of limb dystonia are presented.

Neurol Neurochir Pol, 1998, 32 Suppl 1, 35 - 44
{Botulinum A toxin in the treatment of focal dystonias}; Domzal TM; There are 3 clinical groups of dystonia: generalized, segmental and focal . Spasmodic torticollis, blepharospasmus, laryngeal dystonia and graphospasmus belong to the focal dystonia . The aetiology of dystonias is not clear but genetic factors are commonly accepted . Treatment with pharmacological and surgical methods is not satisfactory . Botulinum toxin A(BTX) has brought a new approach to the effective treatment of dystonias . Effectiveness of this method is estimated as 60 to 100%, depending on clinical factors, department and author . BTX acts on neuro-muscular junction and produces chemical denervation but the effect is not persistent and after 3 or more months the treatment should be repeated . The method is harmless and can be administered in out-patients practice . Adverse events are observed in 10% patients but they are not serious and transient . Details are described the methods of BTX injections in spasmodic torticollis, blepharospasmus and laryngeal dystonia.

Neurol Neurochir Pol, 1998, 32 Suppl 1, 23 - 33
{Botulinum toxin: mechanism of action}; Bogucki A; Inhibitory effect of botulinum toxin on acetylcholine release from the neurons of peripheral nervous system and morphological changes produced in neuro-muscular junction by administration of the toxin are discussed . Other possible mechanisms of action, which can be responsible for the therapeutic effect are presented . Two clinically important problems are discussed: spreading of the toxin from the site of injection, and immunization which is responsible for non-responsiveness in some cases.

J Pediatr Orthop, 1998 May-Jun, 18(3), 304 - 11
Botulinum toxin A compared with stretching casts in the treatment of spastic equinus: a randomised prospective trial; Corry IS et al.; Conservative therapies for equinus in cerebral palsy may help to postpone calf surgery in younger children . This study reports a prospective randomised trial of intramuscular botulinum toxin A (BtA) as an alternative to serial casting in 20 children with a dynamic component to calf equinus . Outcome was assessed in the short term to show the effect of one treatment cycle . Assessments were by clinical examination, video gait analysis, and three-dimensional gait analysis . BtA was of efficacy similar to that of serial casting . Tone reduction in the BtA group allowed a more prolonged improvement in passive dorsiflexion, which may allow more opportunity for increase in muscle length . Gait analysis showed an improved mean ankle kinematic pattern in a subsection of both groups, which was maintained at 12 weeks in the BtA group, whereas the cast group relapsed . There were fewer side effects in the BtA group . Median time to reintervention was similar.

J Neurol Neurosurg Psychiatry, 1998 May, 64(5), 577 - 80
Further studies using higher doses of botulinum toxin type F for torticollis resistant to botulinum toxin type A; Houser MK et al.; OBJECTIVE: A previous study of botulinum toxin type F (BTX-F) treatment for torticollis had shown a dose of 520 MU to be effective, but for a much shorter duration than is usual with botulinum toxin type A (BTX-A) . The objective was to assess the effect of a higher dose of BTX-F . METHODS: Four of the previously treated patients, plus an additional patient, were treated with a higher dose of 780 MU BTX-F . All were secondary nonresponders to BTX-A due to neutralising antibodies . A test injection of 40 MU BTX-F was also given into the extensor digitorum brevis muscle (EDB), to examine the time course of the biological effect of the toxin electrophysiologically . Patients were followed up at two, four, eight, and 12 weeks . RESULTS: All patients reported subjective improvement lasting from seven to 11 (mean 8.6) weeks accompanied by a significant reduction in mean clinical severity scores at two weeks . Four patients had pain which was substantially reduced . The electrophysiological studies confirmed biological sensitivity to the toxin in all patients, showing a significant change beginning at two weeks and returning to baseline at 12 weeks . The time course of this effect paralleled roughly that of the clinical response . The four patients who had previously received 520 MU BTX-F reported that the response was better and longer in duration with 780 MU . Dysphagia was more common than reported with the lower dose . CONCLUSION: Better results are possible with higher doses of BTX-F but the duration of benefit is still shorter than with BTX-A, seemingly due to a shorter duration of neuromuscular junction blockade.

Arch Phys Med Rehabil, 1998 May, 79(5), 532 - 5
Low-dose botulinum toxin with ankle taping for the treatment of spastic equinovarus foot after stroke; Reiter F et al.; OBJECTIVE: To evaluate the efficacy of a combined treatment for spastic foot using selective injections of botulinum toxin (BTA) into the tibialis posterior muscle followed by ankle taping, and to compare it with current BTA treatment procedure . DESIGN: Single-blind randomized control trial . Three-month follow-up after treatment . SETTING: Neurorehabilitation clinic . SUBJECTS: Eighteen outpatients with equinovarus foot due to severe spasticity after stroke . INTERVENTIONS: (1) Injection of 190 to 320 BTA U into several calf muscles (group A); (2) injection of 100 BTA U into the tibialis posterior muscle, followed by ankle-foot taping (group B) . MAIN OUTCOME MEASURES: Ankle range of motion (ROM), Ashworth scale, gait velocity, and step length . RESULTS: Average Ashworth scores decreased 1 point in both groups, but the benefit appeared of shorter duration in group B . Changes in both foot position at rest and passive ankle ROM were observed in all patients, without treatment-related differences, except for gain in passive dorsiflexion that appeared higher in group A . Gait velocity and step length showed similar increases in both groups . CONCLUSION: The combination of selective injections of low BTA doses with ankle-foot taping is as effective as the injection of the current doses for the reduction of foot inversion with positive effects on gait parameters.

Neurology, 1998 May, 50(5), 1463 - 6
A radioimmuno-precipitation assay for antibodies to botulinum A; Palace J et al.; We quantified antibodies to botulinum A (anti-BTx) by immunoprecipitation of 125I-BTx . We tested seven bioassay-positive sera and 68 coded samples, including 18 from patients who had ceased to respond to BTx treatment . Compared with values from healthy control subjects and 42 neurologic control subjects, all bioassay-positive sera were positive (range, 258 to 2,809 pM) and 49 of 50 patients who continued to respond to BTx were negative (<130 pM) . This simple, specific, sensitive, and quantitative assay should prove helpful in the investigation of BTx resistance.

Neurology, 1998 May, 50(5), 1461 - 3
Long-term effect of botulinum toxin on impairment and functional health in cervical dystonia; Brans JW et al.; We investigated the long-term effect of botulinum toxin type A (BTA) on impairment as well as functional health in terms of disability, handicap, and quality of life in 64 patients with cervical dystonia . These patients, who first participated in a double-blind trial, were followed for another 12 months . Fifty-four patients continued treatment after 12 months of follow-up and showed improvement on all scales . Furthermore, this effectiveness appeared to increase during follow-up, which suggests a cumulative clinical effect of BTA.

Cell Mol Biol (Noisy-le-grand), 1998 Mar, 44(2), 357 - 79
The peripheral nerve and the neuromuscular junction are affected in the tenascin-C-deficient mouse; Cifuentes-Diaz C et al.; A thorough examination of the structure and plasticity of the neuromuscular system was performed in tenascin-C mutant mice deficient in tenascin-C . The study of the peripheral nerve revealed a number of abnormal features . In the motor nerve, numerous unmyelinated and myelinated fibers with degraded myelin were present . Schwann cell processes often enclosed degenerative terminals . Transgene (beta-galactosidase) expression analyzed at the ultrastructural level was found to be unequally distributed in the mutant's neuromuscular tissues . At the NMJ, preterminal disorganization was prevalent . Some axon terminals exhibited abnormal overgrowth . A surprising lack of beta-galactosidase expression at some cellular sites known to possess tenascin-C in wild type mice correlated best with marked changes in the cytoarchitecture of the peripheral nerve and NMJ . In some other -but not all- cellular sites which normally express the molecule, immunofluorescence analysis suggested the presence of significant but low levels of tenascin-C-like immunoreactivity together with beta-galactosidase expression . Messenger RNA detection by RT-PCR confirmed the presence of low amounts of tenascin-C mRNA in skeletal muscle suggesting that the mice deficient in tenascin-C are not complete knock-outs of this gene, but low-expression mutants . Following in vivo injections of botulinum type-A toxin, we observed a greatly reduced sprouting response of the motor nerves in tenascin-C mutant mice . We also observed that N-CAM and beta-catenin were overexpressed in the mutant . Our results suggest that tenascin-C is involved both in stabilization and in plasticity of the NMJ.

Exp Brain Res, 1998 Apr, 119(4), 475 - 82
Registered eye position: short- and long-term effects of botulinum toxin injected into eye muscle; Dengis CA et al.; Botulinum toxin is sometimes injected into human eye muscles as an alternative to surgery in the correction of strabismus . Within minutes of botulinum injections into ungulate eye muscles, proprioceptive discharge from muscle spindles decreases dramatically . It is only over 7-48 h, however, that surgically treated strabismus patients usually show an altered proprioceptive signal about eye position, presumably from the palisade endings attached to the global multiply innervated fibers . How quickly will botulinum toxin alter proprioceptive registration of eye position in humans? First, to examine the short-term effects, we measured open-loop pointing responses (which requires knowledge of eye position) in six strabismus patients preinjection and then over a 45 min postinjection period, and in six normal controls over the same time period . Second, to examine the long-term effects, 13 strabismus patients were tested preinjection and then daily over the next 3 weeks, and three normal controls over the same time period . We compared their open-loop pointing responses with the injected eye fixating the target to the photographically determined position of the occluded other eye (a measure of where the patient would point if eye position were determined by efference, not proprioception) . There were three groups of patients: esotropes with no previous injection, exotropes with no previous injection, and exotropes with previous injection . First, all patients showed significant correction of their tropias . Second, over the short-term, there was no difference in pointing responses found between the patients and the controls (t(18) = -1.427, P = 0.1706) . Third, over the long-term, however, the difference between the pointing responses and eye position information was compared among the four groups across four posttests and a significant difference found (F3,12 = 58.988, P < 0.00001) . Only in patients with no previous injections was there altered proprioceptive feedback about eye position . Also, injections into the medial rectus induced a significantly greater proprioceptive response than those injected into the lateral rectus . In humans, botulinum toxin alters proprioception from eye muscles only over the long-term . We suggest that the toxin temporarily affects proprioceptive feedback from palisade endings.

Rev Clin Esp, 1998 Mar, 198(3), 156 - 8
{Adduction spastic dysphonia: clinical and treatment}; Garcia Ruiz PJ et al.; Adduction spastic dystonia (SD) is currently considered a focal dystonia involving laryngeal muscles . SD is one of the most poorly known focal dystonias . We reviewed our experience with twentynine patients with adduction SD and compared the clinical and epidemiologic variables with the other focal dystonias studied at our institution in the last five years (132 patients) . Mean age of patients (47.2 +/- 13 years), sex, clinical course in years (5.7 +/- 5) and presence of circadian fluctuations did not differ significantly from those observed in patients with other focal dystonias . Likewise, there were no significant differences regarding the presence of a family history of dystonia, essential tremor, or stuttering . Our results confirm the similarity of the clinical and epidemiologic data of SD with the other focal dystonias . All patients with SD were treated with a local injection of botulinum toxin . A total of 108 treatments were performed, 41 with a visually guided transoral technique and 67 with a percutaneous technique . The transoral technique was effective in all cases (41/41) but not all treatments with the percutaneous technique were effective (53/67) . Three patients required the shift to the transoral procedure to achieve enough symptomatic alleviation.

Br J Pharmacol, 1998 Apr, 123(7), 1418 - 24
Acetylcholine sensitivity of biphasic Ca2+ mobilization induced by nicotinic receptor activation at the mouse skeletal muscle endplate; Dezaki K et al.; 1 . Acetylcholine (ACh) was locally applied onto the endplate region in a mouse phrenic nerve-diaphragm muscle preparation to measure intracellular free calcium ({Ca2+}i) entry through nicotinic ACh receptors (AChRs) by use of Ca2+-aequorin luminescence . 2 . ACh (0.1-3 mM, 20 microl) elicited biphasic elevation of {Ca2+}i (fast and slow Ca2+ mobilization) in muscle cells . The peak amplitude of the slow Ca2+ mobilization (not accompanied by twitch tension) was concentration-dependently increased by ACh, whereas that of the fast component (accompanied by twitch tension) reached a maximum response at a lower concentration (0.1 mM) of applied ACh . 3 . A pulse of nicotinic agonists, (-)-nicotine (10 mM) and 1,1-dimethyl-4-phenyl-piperazinium (10 mM), but not a muscarinic agonist pilocarpine (10 mM), also elicited a biphasic Ca2+ signal . 4 . Even though ACh release from motor nerve endings was blocked by botulinum toxin (5 microg, bolus i.p . before isolation of the tissue), the generation of both a fast and slow Ca2+ component caused by ACh application was observed . 5 . These results strongly suggest that ACh locally applied onto the endplate region of skeletal muscle induces a slow Ca2+ signal reflecting Ca2+ entry through a postsynaptic nicotinic AChR, which has a low sensitivity to transmitter ACh.

Brain, 1998 Apr, 121 ( Pt 4), 547 - 60
Current concepts on the clinical features, aetiology and management of idiopathic cervical dystonia; Dauer WT et al.; Idiopathic cervical dystonia (ICD) is the most common form of adult-onset focal dystonia . Previously, disagreement existed about whether ICD was a psychiatric illness, but the disorder is now viewed as a neurological illness and large clinical series have clarified the clinical features of the disease . At the time of diagnosis, extracervical dystonia is found in approximately 20% of patients, and there may be a concomitant head or hand tremor . Importantly, adult-onset ICD does not become generalized, although there may be segmental spread and pain may increase independently of the dystonia . While 10-20% of patients may experience remission, nearly all patients relapse within 5 years and are left with persistent disease . The aetiology of ICD is unknown, but there has been much progress in clarifying the genetic abnormality in families with inherited adult-onset cervical dystonia; linkage to chromosome 18p has been demonstrated in one family, and the DYT1 locus has been excluded in two other families . Painful trauma may be involved in the pathogenesis of ICD . Painful stimuli are received and processed by the basal ganglia, and the synaptic changes provoked by pain may lead to the abnormal physiology underlying dystonia . Consistent with this idea are experiments which demonstrate that altered sensory input leads to plasticity of the motor cortex, and those that explore the 'tonic vibration reflex' in patients with dystonia . Another theory suggests that a primary vestibular abnormality is responsible for ICD . Botulinum toxin is the most effective treatment for ICD . Roughly 75% of patients improve, and a response is generally seen within the first week . However, many questions remain regarding the optimal technique of administration . The development of neutralizing antibodies occurs in at least 5-10% of patients, and appears to be related both to dosage and to the interval between treatments . Side-effects are generally mild and result from the action of the toxin in the periphery . If the response to botulinum toxin is not adequate, anticholinergics, benzodiazepines, baclofen and other medications are used as adjunctive therapy . Surgical therapies are available for the treatment of ICD but are reserved for patients refractory to conservative measures.

Muscle Nerve, 1998 May, 21(5), 653 - 5
Evaluating motor end-plate-targeted injections of botulinum toxin type A in a canine model; Childers MK et al.; Tarsal joint forces were measured in dogs over 70 days following botulinum toxin type A (BTX-A) injections . Three dogs were injected at motor end-plates located by electromyography (EMG), while 3 dogs were similarly injected, but without EMG guidance . Extension forces were significantly (P < 0.05) smaller in limbs injected at motor end-plates than in corresponding limbs on days 14 and 35 . There were no significant differences at other times . Using these techniques, EMG end-plate targeting potentiates effects of BTX-A.

Muscle Nerve, 1998 May, 21(5), 643 - 6
The use of botulinum toxin in localizing neuromyotonia to the terminal branches of the peripheral nerve; Deymeer F et al.; In 2 patients with neuromyotonia, nerve blocks had no effect on the abnormal activity, while intramuscular injection of the botulinum toxin abolished the discharges in one and greatly diminished them in the other . Botulinum toxin thus helps to localize the origin of the neuromyotonic discharges to the terminal regions of the peripheral nerve in those cases where the more proximal portions cannot be held responsible.

Rev Med Chil, 1997 Aug, 125(8), 899 - 904
{Intrasphincteric injection of botulinum toxin in patients with esophageal achalasia}; Zapata R et al.; BACKGROUND: Intrasphincteric injection of botulinum toxin (BoTx) has demonstrated to be effective in the short-term treatment of achalasia . AIM: To assess the efficacy, safety and long-term outcome of BoTx injection into the lower esophageal sphincter (LES) of patients with achalasia . PATIENTS AND METHODS: Eight patients received 80 units of BoTx . Assessment of response was based on changes in the symptom scores (0-9) and esophageal manometric studies . RESULTS: Six out of 8 patients (75%) had sustained clinical improvement after therapy . This effect was maintained for a mean time of 17.8 months . The symptom score decreased from a mean of 6.7 to 0.5 (p < 0.01) and after treatment, LES pressure decreased from 63 to 25.5 mm Hg (p = 0.07) . There were no serious adverse effects . Five of the six responders have relapsed . Two of these patients received a second BoTx injection with satisfactory results, two went to surgery and one refused other type of therapy and died of pneumonia . CONCLUSIONS: Intrasphincteric BoTx injection is a simple, safe and effective method of treatment in patients with achalasia, with a duration of response averaging 1.5 years . Its use may be suggested in some patients with high surgical risk and those who refuse a more invasive therapy . It is also useful in malnourished patients to attain an adequate nutritional status before surgery.

Dig Dis, 1998 Jan-Feb, 16(1), 14 - 22
Use of botulinum toxin in the treatment of achalasia; Schiano TD et al.; Achalasia is a chronic esophageal motor disorder characterized by failure of the lower esophageal sphincter (LES) to relax during swallowing, aperistalsis of the esophageal body, and, often, an elevated resting LES pressure . Pneumatic dilation and Heller cardiomyotomy have been the time-honored, accepted treatments, but each may carry significant morbidity . Recently, intrasphincteric injection of botulinum toxin has been shown to be an effective treatment for achalasia, probably by reducing the excitatory cholinergic tone of the LES . Subjective and objective improvement have been reported in many patients with few reported adverse reactions . Clinical improvement generally lasts 2-6 months with patients often requiring repeat treatment . Although studies directly comparing botulinum toxin injection with pneumatic dilation and surgical myotomy are needed, botulinum toxin injection has rapidly become another therapeutic option in the treatment of achalasia.

Otolaryngol Head Neck Surg, 1998 Apr, 118(4), 452 - 7
Botulinum toxin decreases salivation from canine submandibular glands; Shaari CM et al.; The objective of this study was to determine whether botulinum toxin types A and D reduced the production of saliva from the submandibular glands of 18 dogs . The left submandibular glands of 8 dogs were injected with increasing doses of botulinum type A toxin (range 10 to 70 units), and the left glands of 10 dogs were injected with botulinum type D toxin (50 or 100 units) . The right gland of each dog was injected with equivalent volumes of saline solution to serve as control . Six days after the injection, the lingual nerve was electrically stimulated for 10 minutes (3 mAmp, 20 Hz) . The resulting volume of saliva was collected and weighed . Overall, the glands injected with types A or D toxin produced significantly less saliva than comparable glands injected with saline solution . Six of 8 dogs injected with type A toxin showed a significant decrease in saliva production (range 10.1% to 19.2%, one-sided p value = 0.0375) when compared with the controls . Nine of 10 dogs injected with type D toxin demonstrated a highly significant reduction in saliva production (total average decrease = 60%, two-sided pvalue = 0.001) when compared with the controls . We concluded that intraglandular injections of botulinum toxin types A and D significantly reduced the production of saliva from canine submandibular glands . The potential applications of intraglandular injections of botulinum toxin are discussed.

Dig Dis Sci, 1998 Apr, 43(4), 694 - 701
Effect of local injection of botulinum toxin on sphincter of Oddi cyclic motility in dogs; Wang HJ et al.; To study effects of intrasphincteric injections of botulinum toxin on the sphincter of Oddi cyclic motility and responses to motilin and cholecystokinin, four conscious dogs with duodenal cannula underwent manometry of the common bile duct, sphincter of Oddi, and duodenum . After baseline recording, each dog had intrasphincteric injections of saline or botulinum toxin . The injections of saline had no effect, whereas botulinum toxin significantly reduced mean basal pressure, amplitude, and motility index of the sphincter of Oddi . These effects took place in four to seven days and reached a maximum in seven to 10 days . The basal pressure returned to the baseline level in 28 weeks, but the amplitude and motility index remained low . The pressure parameters of motilin-induced premature phase III-like activity also decreased, but action of cholecystokinin was not affected . These results indicate that the botulinum toxin injections reduce sphincter of Oddi phasic contractile activity for a prolonged period of time.

Ann Otol Rhinol Laryngol, 1998 Apr, 107(4), 280 - 4
Unilateral versus bilateral botulinum toxin injections in adductor spasmodic dysphonia; Langeveld TP et al.; Thyroarytenoid injection of botulinum toxin is the therapy of choice in spasmodic dysphonia . However, there is no convincing evidence as to whether unilateral or bilateral injections are to be preferred . For this reason, a prospective study was designed in which voice quality, duration of effect, and side effects were assessed . Twenty-seven patients with adductor spasmodic dysphonia were treated with percutaneous injections of botulinum toxin . The first treatment consisted of injection of 5 units in the left thyroarytenoid muscle . The second treatment, 2.5 units in both sides, took place when the effect of the first procedure had completely ceased . All patients underwent both procedures . By means of self-rating scales, effects and side effects were assessed over at least 3 months . There was no difference between the procedures in duration of voice improvement, nor in the occurrence of breathy dysphonia . After a bilateral injection, statistically more patients reported swallowing problems . However, most patients preferred the bilateral injection, in spite of more and longer-lasting side effects.

Dis Colon Rectum, 1998 Feb, 41(2), 258 - 60
Involuntary contractions of the striated anal sphincters as a cause of constipation: report of a case; Jost WH et al.; PATIENT HISTORY: We present a case of anismus in a 36-year-old patient . He complained of therapy refractory constipation that had been present for 15 years, with delayed micturition and voiding by stages . METHODS AND RESULTS: During digital examination of the anal canal, we found spontaneous contractions of the sphincters at rest . The urethral pressure profile showed irregular contractions during micturition . The electromyogram, which was performed with concentric needle electrodes from the external anal sphincter, puborectalis, and external vesical sphincter, revealed synchronous contractions of these muscles . Injections of botulinum toxin into the sphincters showed good effects and no incontinence . CONCLUSION: Focal dystonia of the striated anal and vesical sphincters is a very rare cause of constipation but should be included in the differential diagnosis.

Electromyogr Clin Neurophysiol, 1998 Mar, 38(2), 75 - 9
Quantitative electromyographical changes in cervical dystonia after treatment with botulinum toxin; Fuglsang-Frederiksen A et al.; Injection of botulinum toxin (BT) into affected neck muscles gives symptomatic relief to patients with cervical dystonia by causing a presynaptic block of acetylcholine release . In a retrospective study of 19 patients, we used the turns-amplitude analysis of the EMG interference pattern for the evaluation of electrophysiological changes as a function of time after BT treatment . EMG was performed immediately before and during injection, and muscles showing abnormally increased activity (> 100 turns/s at rest) were given botulinum toxin A (Oculinum (= Botox)) 40-120 units . A second EMG was done 6-30 weeks later . At attempted rest, the sternocleidomastoid muscle contralateral to the involuntary head rotation showed the most pronounced changes, possibly due to relatively large doses of BT, and the EMG changes were related to the time after BT treatment . Six weeks after treatment the muscle showed decreased turns/s, mean amplitude and ratio (turns/amplitude) at rest . At 30 weeks, turns and mean amplitude reached values as before treatment, while ratio was increased to 175% of the pre-treatment value . This pattern may reflect a reversible and random loss of muscles fibres, due to presynaptic denervation . At maximal voluntary contractions, no correlation was seen between time after BT treatment and quantitative EMG.

Hautarzt, 1998 Feb, 49(2), 101 - 3
{Axillary hyperhidrosis: successful treatment with botulinum toxin A}; Heckmann M et al.; Severe hyperhidrosis may present as a vexing condition for the patient and a therapeutic challenge for the physician . As botulinum toxin-A (BT-A) can potently block cholinergic sympathic innervation of sweat glands it was used in an open trial for controlling severe axillary hyperhidrosis . After visualization of hyperhidrosis using the iodine-starch-test BT-A (Dysport, 400 Units) was injected intradermally in one axilla . One week later gravimetric quantification of sweat secretion revealed a reduction of sweating to 4-9% of initial values . In order to rule out daily variations as well as other factors interfering with sweat production BT-A treatment was restricted to only one axilla in each individual clearly demonstrating extensive anhidrotic efficacy on the treated side only . The treatment was well tolerated without side-effects and was assessed as 'completely satisfying' by all patients . BT-A may offer a fast, safe and highly effective therapeutic option for severe hyperhidrosis.

Hautarzt, 1998 Feb, 49(2), 87 - 90
{Botulinum toxin A in dermatology}; Heckmann M et al.; Based on its unique botulinum toxin is referred to as the most poisonous poison . Its specific inhibition of the acetyl-cholin-dependent neuromuscular transmission is used by ophthalmologists and neurologists for the relaxation of spastic or dystonic muscles, preferably in muscle groups in the head and neck area . Analogously, it is being used by dermatologists to remove facial wrinkles by paralyzing mimic muscles which account for mechanically induced wrinkling . Apart from this purely cosmetic use, botulinum toxin has gained recent attention in dermatology as a potent treatment modality for circumscribed hyperhidrosis.

Immunol Lett, 1998 Jan, 60(1), 7 - 12
Antibodies and T cells against synthetic peptides of the C-terminal domain (Hc) of botulinum neurotoxin type A and their cross-reaction with Hc; Oshima M et al.; Seventeen peptides containing T cell and/or antibody (Ab) epitopes previously localized on Hc of botulinum neurotoxin type A were used in SJL and BALB/c mice as immunogens either individually or as an equimolar mixture of groups that contained epitopes of T cells, Abs or both, to determine their abilities to generate T cells and/or Abs that recognize intact Hc . In SJL, peptide 897-915 which included both T cell and Ab epitopes, elicited Abs that cross-reacted very strongly with Hc . In BALB/c, peptides 869-887, 883-901, 981-999 and 1275-1296 which contained Ab epitopes generated Abs that cross-reacted strongly with Hc . A mixture of peptides that contained T cell and Ab epitopes was effective in both strains in eliciting T cells and Abs that cross-reacted with Hc . This mixture form gave a quicker rise (after two injections) in cross-reactive (with Hc) Ab titer as compared to other peptide mixtures or the individual peptides, and sustained in BALB/c a high Ab titer upon further booster injections . Some of the regions that elicited crossreactive immunity to Hc have sequence similarity to other clostridial toxins, suggesting that one or more of these synthetic peptides might provide cross-protection against those toxins.

Acta Ophthalmol Scand, 1998 Feb, 76(1), 27 - 7
Treatment of strabismus and nystagmus with botulinum toxin type A . An evaluation of effects and complications; Lennerstrand G et al.; PURPOSE: Injection of botulinum toxin type A into eye muscles leads to a temporary paralysis and the effects have been evaluated in strabismus or nystagmus . METHOD: A total of 112 patients with different types of concomitant and paralytic strabismus and acquired nystagmus were treated with botulinum toxin, according to well-established indications . RESULTS: The lasting effects of the injections on strabismic angle were largest in esotropia, consecutive exotropia and abducens palsy, and amounted to, on an average, 12 prism diopters or 6 degrees . The larger the strabismus the better was the effect . Repeated injections reduced the angle further . In complex nystagmus forms retrobulbar injections could be used . The side effects were mostly due to spread of botulinum toxin to the levator, producing ptosis (8%), or the inferior rectus muscle, causing vertical strabismus (10%) . On an average 42% of the patients were later operated for strabismus and nystagmus . CONCLUSION: Injection of botulinum toxin A into eye muscles is a valuable adjunct to surgery in the treatment of strabismus and nystagmus.

Br J Ophthalmol, 1998 Jan, 82(1), 67 - 71
Dissociated effects of botulinum toxin chemodenervation on ocular deviation and saccade dynamics in chronic lateral rectus palsy; Acheson JF et al.; AIM: Changes in saccade velocity/amplitude characteristics (main sequence) and attenuation of distance esotropia in response to botulinum toxin (BTX-A) chemodenervation of the antagonist medial rectus were studied in a group of nine patients with chronic lateral rectus palsy . METHODS: Serial measurements of ocular deviation and infrared oculograms of saccadic eye movements to targets at 5 degrees-20 degrees of lateral gaze were made before injection and at 2, 4, 8, 16, and 20 weeks after injection . RESULTS: At 2 weeks after injection, the ocular deviation changed by a mean of 34.5 prism dioptres and the 5 degrees and 10 degrees adduction saccades were significantly slowed (p < 0.02 Wilcoxon signed rank test) . By the second examination, however, the adducting saccade peak velocity had returned to normal while the mean ocular deviation remained significantly changed (p = 0.01 Wilcoxon matched pairs) . By 20 weeks the mean ocular deviation was not significantly different from that before injection (p = 0.14 matched pairs) . CONCLUSIONS: The ocular realignment caused by BTX-A may persist after saccadic function has been restored . This may be because toxin may have a more profound and long lasting effect on the orbital singly innervated fibres which are active tonically at rest to hold gaze whereas there is relative sparing of the additional motor units recruited during fast eye movements.

Pediatr Neurol, 1998 Feb, 18(2), 124 - 31
Use of botulinum toxin injection in 17 children with spastic cerebral palsy; Wong V; The use of botulinum toxin was studied in 17 children with spastic cerebral palsy to determine its efficacy and tolerability . Eleven ambulatory and 6 nonambulatory patients were included . All children were undergoing a physiotherapy program with monitoring of their baseline states for 3 months before botulinum toxin injection . The effect was evident within 72 hours . The peak effect was noticed by 1 to 2 weeks in the majority; the effect lasted for 3 to 10 months . All children experienced decreased spasticity scores . Their functional status improved, with three nonambulatory children becoming ambulatory with assistance and five children with assisted ambulation becoming more independently ambulatory . Measurement of joint motion showed improvement in the range of motion as compared with baseline . Video analysis of the functional state in the nonambulatory or gait in the ambulatory children revealed improvement in all . The functional status of rising from the sitting position or standing demonstrated improvement . None of the children had any untoward side effects except mild transient pain at the injection site . This study demonstrated botulinum toxin is useful as an adjunctive therapy in ameliorating spasticity in children with cerebral palsy, especially in the younger ones.

Arch Otolaryngol Head Neck Surg, 1998 Mar, 124(3), 321 - 3
Chemical browlift; Frankel AS et al.; OBJECTIVE: To determine if the medial brow can be elevated following administration of botulinum toxin type A (Botox, Allergan, Irvine, Calif) . DESIGN: A before-after interventional study comparing pretreatment and posttreatment brow height . Objective measurements and subjective comparisons of pretreatment and posttreatment slides were made by 7 independent observers unaware of treatment status . All measurements and observations were based on standardized photographs taken with identical lens settings . SETTING: Private facial plastic surgery practice . All injections were performed in office examination rooms without anesthesia or sedation . PATIENTS: Thirty adult patients electively seeking improvement of glabellar frown lines or low-positioned medial brows (angry appearance) . INTERVENTION: Twenty units of botulinum toxin type A was injected into the corrugator supercilli and procerus muscles . An electromyographic needle was used for the initial 10 injections, and a 30-gauge needle was used for the remainder . OUTCOME MEASURES: In the objective arm, change in brow height was measured from the medial canthus and midpupil directly vertical to the brow hairs; the change in interbrow distance was also measured . In the subjective arm, the number of patients who were found to have an elevated medial brow by the independent observers was noted . Objective and subjective findings were correlated . RESULTS: Objective measurements yielded a raise in the medial brow in 8 (32%) of 25 patients from the medial canthus and in 12 (48%) of 25 from the midpupil and an increase in interbrow distance in 17 (59%) of 29 patients . Subjective comparison found 18 (62%) of the 29 patients to have higher medial brows after treatment . CONCLUSIONS: Botulinum toxin type A treatment can create a chemical browlift . Further studies with more specific selection criteria are needed to better evaluate this effect.

Arch Phys Med Rehabil, 1998 Mar, 79(3), 350 - 2
Axillary hyperhidrosis: treatment with botulinum toxin A; Odderson IR; Hyperhidrosis can be emotionally challenging and socially and professionally disruptive, and there are few effective treatments . This condition was successfully treated with botulinum toxin in two men who, since their early teens, had had excessive axillary sweating, requiring frequent shirt changes . They received bilateral axillary injections with 100 units of botulinum toxin type A, and within 5 days reported cessation of excessive sweating . Quantitative measurements before and 2 to 4 weeks after the injections demonstrated an average reduction of 71% and 76% (from 11.6 to 3.4 and from 2.5 to 0.6 mL/min m2) in axillary sweating during rest . A 96% reduction (from 42.9 to 1.7 mL/min m2) was seen in one patient during mental stress . No complications developed . This study quantitates the reduced axillary sweating achieved through chemodenervation with botulinum toxin A.

Arch Dermatol, 1998 Mar, 134(3), 301 - 4
Focal hyperhidrosis: effective treatment with intracutaneous botulinum toxin; Naumann M et al.; OBJECTIVE: To evaluate the effect of intracutaneous injections of botulinum toxin type A on excessive focal hyperhidrosis . DESIGN: Therapeutic before-and-after trial over 4 months . SETTING: Neurological and dermatological university departments . PATIENTS: Eleven patients with excessive axillary, palmar, or plantar hyperhidrosis fulfilling the following criteria: (1) local and systemic drug therapy had failed to improve their symptoms; (2) the patients were severely disabled with respect to their occupation and social activities; and (3) a successful treatment by botulinum toxin would obviate the need for destructive surgical procedures . INTERVENTIONS: Three mouse units of botulinum toxin (Botox) per 4-cm2 skin area was injected intracutaneously in 16 axillae, 8 palms, and 2 soles . MAIN OUTCOME MEASURES: Reduction of hyperhidrosis as documented by the Minor iodine-starch test and gravimetrical assessment of local spontaneous sweat production measured over 1 minute . RESULTS: In all patients, botulinum toxin completely abolished sweating in the injected areas (P<.001) within 3 to 7 days . No relevant adverse effects occurred and no clinical recurrence of hyperhidrosis was observed within the follow-up period of up to 5 months . Occasionally, subclinical reactivation of sweat gland function was observed 4 months after treatment . CONCLUSIONS: Intracutaneous botulinum toxin seems preferable to any hitherto used conservative or surgical procedures and may become the therapy of choice in pathological focal hyperhidrosis.

Eur J Neurosci, 1997 Dec, 9(12), 2677 - 86
Localization of putative receptors for tetanus toxin and botulinum neurotoxin type A in rat central nervous system; Herreros J et al.; Clostridial neurotoxins (tetanus and botulinum toxins) are potent blockers of neurotransmitter release . These toxins act specifically on the nervous system by interacting with still non-identified protein receptors together with gangliosides . Whereas many biochemical data are available on their binding properties to neuronal membranes in vitro, there is poor morphological evidence of their binding to mammalian central nervous system . In the present study, the binding of tetanus and botulinum neurotoxin type A to rat brain sections is reported . Both toxins bound to nerve terminals with a broad distribution in brain . Tetanus toxin additionally bound to nerve fibres . The staining patterns were clearly shown to be due to the interaction of the heavy chains, which contain the binding moiety, with the tissue . In an attempt to investigate the nature of the acceptors present in the tissue, some sections were pre-incubated with periodic acid . This treatment resulted in the additional binding of botulinum neurotoxin type A to nerve fibres . Since the extended staining of nerve terminals was not modified by this pretreatment, it is suggested that protein receptors of clostridial neurotoxins are located at the nerve terminals, which may be common constituents of the synapses.

J Biol Chem, 1998 Feb 27, 273(9), 5146 - 54
Small GTP-binding protein Rho stimulates the actomyosin system, leading to invasion of tumor cells; Yoshioka K et al.; We have shown previously that Rho plays a pivotal role in 1-oleoyl-lysophosphatidic acid (LPA)-dependent invasion of rat hepatoma cells (MM1) . Herein we made stable transfectants of MM1 expressing active and Botulinum exoenzyme C3 (C3)-sensitive (Val14), or active and C3-insensitive (Val14/Ile41) forms of human RhoA . Both transfectants showed greatly promoted invasive ability in vitro in the absence of LPA as well as in vivo, adherence to the dish with scattered shape, and enhanced phosphorylation level of 20-kDa myosin light chain (MLC20) . A specific MLC kinase inhibitor (KT5926) could inhibit their invasion and the phosphorylation level of MLC20 . Stable active RhoA transfectants of W1 cells (low invasive counterpart of MM1) also demonstrated promoted invasive ability in vitro and in vivo, and enhanced phosphorylation level of MLC20 . C3 treatment inhibited the invasiveness of the Val14 RhoA transfectant but not that of the Val14/Ile41 RhoA transfectant . LPA enhanced the invasiveness of both transfectants, and this enhancement was abolished by the C3 treatment . These results suggested that 1) the Rho signaling pathway and actomyosin system were linked in the transmigration of tumor cells, and 2) expressed active RhoA enhanced LPA-induced tumor cell invasion via the activation of endogenous RhoA pathway, indicating a positive feedback mechanism in the activation of RhoA.

J Exp Med, 1998 Feb 16, 187(4), 497 - 503
Wegener's granulomatosis: anti-proteinase 3 antibodies are potent inductors of human endothelial cell signaling and leakage response; Sibelius U et al.; Anti-neutrophil cytoplasmic antibodies (ANCAs) targeting proteinase 3 (PR3) have a high specifity for Wegener's granulomatosis (WG), and their role in activating leukocytes is well appreciated . In this study, we investigated the influence of PR3-ANCA and murine monoclonal antibodies on human umbilical vascular endothelial cells (HUVECs) . Priming of HUVECs with tumor necrosis factor alpha induced endothelial upregulation of PR3 message and surface expression of this antigen, as measured by Cyto-ELISA, with a maximum occurrence after 2 h . Primed cells responded to low concentrations of both antibodies (25 ng-2.5 microg/ml), but not to control immunoglobulins, with pronounced, dose-dependent phosphoinositide hydrolysis, as assessed by accumulation of inositol phosphates . The signaling response peaked after 20 min, in parallel with the appearance of marked prostacyclin and platelet-activating factor synthesis . The F(ab)2 fragment of ANCA was equally potent as ANCA itself . Disrupture of the endothelial F-actin content by botulinum C2 toxin to avoid antigen-antibody internalization did not affect the response . In addition to the metabolic events, anti-PR3 challenge, in the absence of plasma components, provoked delayed, dose-dependent increase in transendothelial protein leakage . We conclude that anti-PR3 antibodies are potent inductors of the preformed phosphoinositide hydrolysis-related signal tranduction pathway in human endothelial cells . Associated metabolic events and the loss of endothelial barrier properties suggest that anti-PR3-induced activation of endothelial cells may contribute to the pathogenetic sequelae of autoimmune vasculitis characterizing WG.

Biochem Biophys Res Commun, 1998 Mar 6, 244(1), 275 - 9
Negative chronotropic effect of botulinum toxin on neonatal rat cardiac myocytes; Kimura K et al.; We demonstrated that botulinum neurotoxin attenuated the spontaneous beating rate of cultured cardiac myocytes . Primary cultured cardiac myocytes were prepared from the ventricles of neonatal Wistar rats (1-3 days old) . On 7 days after cell seeding, botulinum toxin type A incorporated into liposomes was added to the culture medium . At a final concentration of 5.0 micrograms/ml, botulinum toxin markedly attenuated the beating rate of cardiac myocytes within 2-4 hours . These results demonstrated the effect of SNARE-complex proteins on the spontaneous beating of cardiac myocytes.

Laryngoscope, 1998 Mar, 108(3), 381 - 4
Up-to-date report of botulinum toxin type A treatment in patients with gustatory sweating (Frey's syndrome); Laskawi R et al.; Several therapeutic approaches exist to treat gustatory sweating (Frey's syndrome) following parotidectomy . Because of the lack of effective treatment, a new therapeutic modality using botulinum toxin injections was presented previously by our group . The duration of the demonstrated positive effect was essentially unknown so far . Based on our experiences using this technique since December 1993, the purpose of this clinical investigation was to make an up-to-date report and demonstrate the duration of effect of BOTOX injections in patients with severe gustatory sweating . Nineteen patients with severe gustatory sweating have been treated with BOTOX by intracutaneous injections into the affected skin areas . The maximal follow-up time was 33 months . The results were obtained by interviews and controls using Minor's starch iodine test . In all treated cases (n = 19 patients, 22 treated sides) gustatory sweating ceased completely within 2 days . Side effects were absent . In 12 patients gustatory sweating reappeared . The mean duration of effect was 17.3 months (subjective personal communication of 18 patients) . Findings show that intracutaneous injection of BOTOX is a highly effective, safe, and minimally invasive treatment of Frey's syndrome with long-lasting therapeutic effect.

J Pediatr Ophthalmol Strabismus, 1998 Jan-Feb, 35(1), 9 - 16; quiz 44-5
The long-term use of botulinum toxin for adult strabismus; Horgan SE et al.; PURPOSE: To characterize patients choosing repeated botulinum toxin injection as a treatment for their strabismus, and assess their demand for it over time (up to 8 years) . METHOD: Patients who had undergone at least eight injections were identified and their clinical records analyzed for diagnosis, demographic details, and demand for toxin injections with time . To establish any predictive variables, the details for these cases were compared with those of matched controls who had undergone fewer injections . Lastly, a questionnaire was mailed to research patients' views as to the indications and preferences for regular toxin injection as a method of treatment . RESULTS: Ninety-five patients were identified (34 men, 61 women; median age 37 years), of whom 35 had consecutive exotropia and 16 had secondary exotropia . Other diagnoses represented were residual and primary deviations, restrictive exotropias, and oscillopsias . A trend of fewer injections over the attendance period was seen, and the only complication observed was upper lid ptosis in 1% of injections . Cases exhibited similar demographic composition to matched controls, but were more likely to have consecutive exotropia or secondary esotropia as a diagnosis . Univariate analysis showed evidence (p < 0.001) of an association between the number of previous operations and the odds of being a case . No evidence was found that cases and controls lived at differing distances from our hospital . The questionnaire found that 71% of patients stated appearance as the prime reason for seeking treatment, and 37% stated simplicity of toxin therapy as their reason for reattendance . Twenty-six percent of the patients were disillusioned with the results of previous surgery and preferred toxin therapy as a means of controlling their symptoms . CONCLUSION: Botulinum toxin injection is an appropriate long-term treatment for some strabismus patients who choose not to undergo further surgery . A trend toward fewer injections with time was observed, and no adverse effects were associated with long-term treatment.

Psychother Psychosom Med Psychol, 1998 Jan, 48(1), 1 - 12
{Psychosomatic aspects of idiopathic spasmodic torticollis . Results of a multicenter study}; Scheidt CE et al.; Idiopathic spasmodic torticollis (IST) is one of the most frequent dystonic movement disorders . Its classification as a focal dystonia, as well as its treatment with botulinum toxin resulted in groups of patients being regularly seen by neurologic specialists . In a multicentre study, we investigated psychosocial changes, coping and psychopathology, and their interrelations with signs, symptoms and course . 256 patients were included in the study (59.3% women, 40.7% men) . The mean age was 49.1 years . Rotating torticollis occurred more often than latero-retrocollis and antero-retrocollis . A family history of IST was seen in 3.1% of the total sample . 34% of the patients had additional dystonic symptoms . Most frequently, these affected the upper extremities (13%), less often the legs . 19.1% of the patients had experienced a period of complete remission . The General Symptom Index of the SCL 90-R in 27% of the patients ranged above the double standard deviation of the normal controls, indicating a clinically significant psychopathology.

Spinal Cord, 1998 Feb, 36(2), 91 - 4
Botulinum A toxin treatment for detrusor-sphincter dyssynergia in spinal cord disease; Petit H et al.; We studied the efficacy of endoscopic injection of Botulinum A toxin (150 I.U . Dysport) in the treatment of detrusor-sphincter dyssynergia in 17 patients with spinal cord disease . One month after the injection, the postvoiding residual urine volume (-176 ml, P < 0.001), the bladder pressure on voiding (-19 cm water, P < 0.01), and the urethral pressure (-24 cm water, P < 0.001) were significantly decreased . The modality of voiding was improved in 10 patients (i.e . micturition by suprapubic tapping was easier to induce, discontinuation of indwelling catheter use, or decrease in frequency of intermittent catheterizations) . The tolerance of the treatment was excellent . The therapeutic effect lasted 2 to 3 months on the average . The low doses used in this study probably explain in part why the treatment sometimes failed . Botulinum A toxin could become an alternative treatment for detrusorsphincter dyssynergia in certain patients, notably in those who are refractory to sphincterotomy or in patients, such as those who are tetraplegic, and who are incapable of performing intermittent self-catheterization.

Disabil Rehabil, 1998 Feb, 20(2), 62 - 5
A study of the effectiveness of botulinum toxin type A (Dysport) in the management of muscle spasticity; Watanabe Y et al.; Severe muscle spasticity is common in patients with neurological disease . It is often associated with pain and distressing spasms, and frequently leads to functional motor disability . Antispasticity drugs usually result in systemic adverse effects, and peripheral nerve blocks have some disadvantages such as sensory loss and painful dysaesthesiae . In recent years botulinum toxin type A (BT/A) has been advocated for the treatment of muscle spasticity . We studied, using a functional assessment scale, the effects of BT/A on the patients' symptoms and the functional disability due to spasticity in five children and eight adults who were referred for treatment . In 10 patients the treatment goals were achieved, and children generally had a better and more sustained response than adults . There were no adverse effects reported . The present study suggests that BT/A is safe and effective in improving the motor functional disability which is often associated with severe localized muscle spasticity.

Genes Cells, 1997 Nov, 2(11), 679 - 94
The small GTP-binding protein Rho1 is a multifunctional protein that regulates actin localization, cell polarity, and septum formation in the fission yeast Schizosaccharomyces pombe; Nakano K et al.; BACKGROUND: The small GTP-binding protein Rho has been shown to regulate the formation of the actin cytoskeleton in animal cells . We have previously isolated two rho genes, rho1+ and rho2+, from the fission yeast Schizosaccharomyces pombe in order to investigate the function of Rho using genetic techniques . In this paper, we report the cellular function of Rho1 . RESULTS: We found that Rho1 is essential for cell viability and cell polarity using gene disruption and by exogenous expression of botulinum C3 ADP-ribosyltransferase . In cells expressing either a constitutively active Rho1 or a dominant-negative Rho1, actin patches were delocalized . Both the cell wall and secondary septum were thick and stratified in cells expressing the constitutively active Rho1, while the cell wall of cells expressing the dominant-negative Rho1 seemed to be loosely organized . Furthermore, inactivation of Rho1 is apparently required for the separation of daughter cells . Cell fractionation studies suggested that Rho1 is predominantly membrane-bound . Moreover, we observed that Rho1 is localized to the cell periphery and to the septum . CONCLUSIONS: Rho1 is involved in actin patch localization, the control of cell polarity, the regulation of septation, and cell wall synthesis.

Rinsho Shinkeigaku, 1997 Oct, 37(10), 881 - 6
{A case of post-hemiplegic painful dystonia following thalamic infarction with good response to botulinus toxin}; Motoi Y et al.; We report a 67-year-old hypertensive right-handed woman who developed severe pain and dystonia in her left upper and lower extremity after a thalamic infarction . She was well until 9 months prior to the present admission to our hospital, when she had an acute onset of left hemiparesis which turned out to have been caused by a thalamic infarct . Her hemiparesis showed nearly complete recovery during the next four months . She noted an onset of severe spontaneous pain and difficulty in using her left hand four months prior to the present admission . Neurologic examination on admission revealed an alert and well oriented Japanese woman . Cranial nerves were intact . Although she did not have weakness, her left hand showed thalamic posture, and upon standing, she showed a dystonic posture in which her left forearm took pronation and flexion at the elbow joint and her left lower extremity took extension in the knee joint and planter flexion in the ankle joint . Her dystonic posture increased during walking and disappeared in the supine position . She complained of severe spontaneous pain and tingling sensation in her left extremities . Position sense was diminished in her left leg . However other sensations were intact . She had slight ataxia on the left side . Deep tendon reflexes were symmetric, but the planter response was extensor on the left side . MRI revealed a small lacunar infarct involving the right posterolateral thalamic region . EMG with surface electrodes revealed non-reciprocal tonic discharges in the left biceps brachii and forearm flexor and extensor muscles . She responded poorly to various medications . Only trihexyphenidyl showed partial alleviation of her pain and dystonic posture . We thought her pain might be caused by dystonic contraction of the skeletal muscles, at least in part . We injected 25 IU of botulinus toxin as a total dose into her biceps brachii, triceps brachii, and wrist flexor muscles . A few days after the injection, her dystonic posture began to show marked improvement; as her dystonia improved, her pain also showed marked improvement . This patient appeared to represent a case of post-hemiplegic dystonia . Her pain was initially thought to be the thalamic pain . However, as her pain disappeared with improvement of her dystonia, her pain is most likely to have been caused by the dystonic muscle contraction . Botulinus toxin treatment appears to be useful for post-hemiplegic painful dystonia.

J Biol Chem, 1998 Feb 6, 273(6), 3422 - 30
Targeting of SNAP-23 and SNAP-25 in polarized epithelial cells; Low SH et al.; SNAP-23 is the ubiquitously expressed homologue of the neuronal SNAP-25, which functions in synaptic vesicle fusion . We have investigated the subcellular localization of SNAP-23 in polarized epithelial cells . In hepatocyte-derived HepG2 cells and in Madin-Darby canine kidney (MDCK) cells, the majority of SNAP-23 was present at both the basolateral and apical plasma membrane domains with little intracellular localization . This suggests that SNAP-23 does not function in intracellular fusion events but rather as a general plasma membrane t-SNARE . Canine SNAP-23 is efficiently cleaved by the botulinum neurotoxin E, suggesting that it is the toxin-sensitive factor previously found to be involved in plasma membrane fusion in MDCK cells . The localization of SNAP-25 in transfected MDCK cells was studied for comparison and was found to be identical to SNAP-23 with the exception that SNAP-25 was transported to the primary cilia protruding from the apical plasma membrane, which suggests that subtle differences in the targeting signals of both proteins exist . In contrast to its behavior in neurons, the distribution of SNAP-25 in MDCK cells remained unaltered by treatment with dibutyryl cAMP or forskolin, which, however, caused an increased growth of the primary cilia . Finally, we found that SNAP-23/25 and syntaxin 1A, when co-expressed in MDCK cells, do not stably interact with each other but are independently targeted to the plasma membrane and lysosomes, respectively.

J Am Acad Dermatol, 1998 Feb, 38(2 Pt 1), 227 - 9
Botulinum toxin therapy for palmar hyperhidrosis; Shelley WB et al.; BACKGROUND: Severe palmar hyperhidrosis is a chronic disease, resistant to conventional therapy . Botulinum toxin inhibits sweat production by blocking release of acetylcholine from presynaptic membranes . OBJECTIVE: Our purpose was to evaluate the short- and long-term effectiveness of botulinum toxin therapy in treatment of palmar hyperhidrosis . METHODS: Four patients with severe palmar hyperhidrosis were treated with subepidermal injections of botulinum toxin . Fifty injections, 2 mouse units each, were used in each palm . Regional nerve blocks of the median and ulnar nerves were performed before the procedure . Patients were observed for 12 months after treatment . RESULTS: Botulinum toxin injections significantly reduced sweat production in the treated areas of the palms . Anhidrosis lasted for 12 months in one patient, 7 months in two patients, and 4 months in one patient . Mild weakness of the thumb lasting 3 weeks occurred in one patient . No other side effects were observed . CONCLUSION: Botulinum toxin provides an effective, safe, and long-lasting alternative therapeutic modality for treatment of severe palmar hyperhidrosis . Additional studies are needed for optimization of the technique.

Neurology, 1998 Feb, 50(2), 485 - 91
Skeletal muscle-specific immunotoxin for the treatment of focal muscle spasm; Hott JS et al.; Intramuscular injection of botulinum toxin type A (BTX) is used to treat many disorders characterized by muscular spasms . The utility of BTX, however, is limited by its short duration of action, the development of resistance after repeated injections, and cross-reactivity with autonomic neurons . To overcome these limitations, we engineered an immunotoxin (ITX) to damage skeletal muscle fibers selectively by chemically linking a monoclonal antibody against the nicotinic acetylcholine receptor to the toxin ricin . In vitro, the ITX was 20,000-fold more toxic to myotubes than myoblasts, consistent with the degree of acetylcholine receptor expression . The gastrocnemius muscles of 30 rats were unilaterally injected with a series of protein toxins at various concentrations and examined histopathologically 7 and 30 days later . ITX produced destructive myopathic changes at a dose 300-fold less than the maximum tolerated dose . Assessment of rat muscle strength after unilateral gastrocnemius injections showed that ITX was more effective and had a longer duration of action than BTX . ITXs may have potential for the treatment of involuntary muscle spasms.

Ophthalmology, 1998 Feb, 105(2), 342 - 6
Long-term efficacy of local doxorubicin chemomyectomy in patients with blepharospasm and hemifacial spasm; Wirtschafter JD et al.; OBJECTIVE: This study examines the long-term follow-up of all patients treated with doxorubicin injections in the eyelids . DESIGN: Nonrandomized clinical trial . PARTICIPANTS: Eighteen patients with blepharospasm (12 female; 6 male) and nine patients with hemifacial spasm (4 female; 5 male) . INTERVENTION: Eyelids were repeatedly injected at intervals of 10 or more weeks until the spasms were ameliorated or the patient requested discontinuation . MAIN OUTCOME MEASURE: Clinical "cure" defined as sufficient symptomatic relief to defer further paralytic treatment . All patients have been followed for more than 1 year since the last injection . RESULTS: Nine of 18 patients with blepharospasm completed the full course of treatment and are considered "cured" for more than 1 year (median, 3 years; maximum, 6 years) . Six of nine patients with hemifacial spasm completed treatment . Five of these six patients are considered "cures," lasting for more than 4.5 to 6 years . Two additional patients, one with blepharospasm and one with hemifacial spasm, had significant amelioration and were untreated for more than 3 years after the last doxorubicin injection, but occasionally request botulinum toxin supplementation . The minimum effective dose per treated eyelid ranged from 1.0 to 4.2 mg (median, 2.25 mg) . The treatment-related discontinuations and complications were related to skin inflammation . Four of the 14 "cured" patients required some surgical "touch-up" on 1 eyelid . However, all the patients who completed treatment are either cured or have had significant amelioration of symptoms . CONCLUSIONS: Doxorubicin chemomyectomy is an evolving technique and an effective treatment for essential blepharospasm and hemifacial spasms symptomatically localized to the eyelids . Sixteen (59%) of the initial series of 27 patients completed the treatment . Of these, all are apparently cured or their symptoms significantly ameliorated . In the future, an even higher proportion would be expected to complete the treatment due to improvements in the selection criteria and treatment protocols developed during this 8-year trial . While the treatment appears to be reasonably safe compared with surgical myectomy in its present form, the authors are continuing to explore and introduce additional cotreatments to minimize the acute skin changes and maximize the long-term effectiveness of the myectomy.

Magn Reson Med, 1998 Feb, 39(2), 309 - 12
Localized proton NMR spectroscopy in the striatum of patients with idiopathic spasmodic torticollis; Moller HE et al.; Single voxel proton spectroscopy was used to study brain metabolism in idiopathic spasmodic torticollis . Peak metabolite ratios in long echo time (135 ms) spectra were evaluated in the basal ganglia of 16 patients (29-65 years) . Eight of them were untreated; the other eight were examined 4-6 weeks after administration of botulinum toxin type A . As compared with 60 control spectra, patients showed a significant, therapy-resistant decrease in N-acetyl-L-aspartate (NAA)/choline (Cho) . NAA/creatine (Cr) and Cho/Cr were close to normal in the post-treatment group but significantly reduced in untreated patients . This result is consistent with the hypothesis that striatal Cr is reversibly elevated in chronic muscle stimulation . The right and left striatum were affected to the same extent.

Neurol Neurochir Pol, 1997 Mar-Apr, 31(2), 207 - 15
{The use of botulinum toxin A in the treatment of focal dystonias}; Slawek J et al.; 22 patients with focal dystonias were treated with local injections of botulinum toxin A (Botox) into muscles with involuntary, sustained movements . The method is highly effective, practically without serious side effects and now is considered the treatment of choice in this group of patients what has been also confirmed in our own material.

Rev Neurol, 1997 Sep, 25(145), 1369 - 75
{Botulinum toxin as a treatment for infantile cerebral palsy}; Pascual-Pascual SI et al.; OBJECTIVE: To review the results and adverse effects to botulinum toxin type A (BTA), Botox, in cerebral palsy (CP) spastic and/or dystonic in an open prospective study . MATERIAL AND METHODS: The first 39 cases treated were analyzed . They received 1-2 doses and were followed up to 12 months . BTA indications were wide: to improve limb function, to avoid surgical orthopedics or improve hygienics or dressing . O'Brien Global Assessment Scale (scored by neurologist, physiotherapist or parents), Ashworth spasticity scale, functional scale for dystonic upper limb (Sindou-Millet) and exam of position of foot, knee and hip, were used . RESULTS: Total doses/session was 1-10 U/kg . We observed adverse effects in 6 cases (15.4%), always mild and lasting only few days (general weakness, tiredness, instability) . Positive effects lasted 4 months in upper limbs and 4.5 months in lower limbs . In upper limbs (9 cases injected) it was observed a global positive result of mild grade in 11-40%, moderate without functional improvement in 11-22%, and moderate-important with functional improvement in 40-78% of patients, being patient's evaluation the best and physiotherapist's one the worst . Spasticity improved 2 or more grades in Ashworth scale in 7/9 cases . Dystonia improved in proportion to dose . In lower limbs gastrocnemius muscles were injected in 29 cases (55 sessions), adductors in 14 cases (33 sessions), ischiotibialis in 8 cases (27 sessions), posterior tibialis in 8 cases (12 sessions) . It was observed a global improvement null or mild in 20%, moderate without functional change in 35-44%, and moderate or important with functional improvement in 35-44%, with significative correlation between parent's, physiotherapist's and neurologist's scores . Spasticity was also significatively reduced after treatment . It went down 2 or more grades in Ashworth scale in 40% of ischiotibialis, 60% of adductors and 65% of gastrocnemius, in general with a doses-effect association . Foot position in walking improved from moderate to important grade in 2/3 of cases, as improved foot position while standing . Knee flexion and hip hyperadduction were reduced moderate-importantly in 60% and 40% of cases respectively . CONCLUSION: BTA is highly effective in the treatment of CP, and if associate with physiotherapy long and even permanent effect can be achieved.

Curr Opin Rheumatol, 1997 Nov, 9(6), 486 - 95
Evaluation and treatment of speech and swallowing disorders associated with myopathies; Sonies BC; Dysphagia, or disordered swallowing, can be demonstrated at any time over the course of many myopathies . Ability to swallow may be impaired because of weakness, inflammation, or dysfunction of the oropharyngeal, laryngeal, and esophageal musculature . Dysphagia may occur during the progression of disease regardless of whether the patient is properly treated . The presentation of signs of dysphagia can vary among patients because of differing patterns of weakness or incoordination of the facial muscles, lips, tongue, palate, pharyngeal constrictors, or smooth and striated muscles of the esophagus . Although the literature has focused on problems in the esophagus, scant attention has been paid to the oropharynx, which is often equally affected . Studies suggest that surgical myotomy and botulinum toxin injection may provide benefits for some patients with esophageal dysfunction . Although the condition is pervasive, there is little information on the incidence of dysphagia in muscular disorders . Because a major complication of dysphagia is aspiration, any sign of swallowing impairment demands medical attention and treatment.

Biol Chem, 1997 Oct, 378(10), 1171 - 6
SNAP-25 can self-associate to form a disulfide-linked complex; Sadoul K et al.; SNAP-25 is expressed in neurons and endocrine cells and is essential for exocytosis of neurotransmitters and peptide hormones . It has been shown to be involved in several interactions with other proteins of the secretion machinery . Here we show that SNAP-25 can self-associate to form a disulfide-linked complex . Complex formation is facilitated in vitro (in concentrated extracts or by immunoprecipitation) . SNAP-25 complexes, however, also form when intact cells are treated with a membrane-permeable crosslinker indicating that SNAP-25 molecules exist in close proximity in vivo and could form complexes spontaneously . We also show that monomeric SNAP-25 and disulfide-linked SNAP-25 complexes are palmitoylated and that both can be cleaved by botulinum neurotoxin E.

Neuropediatrics, 1997 Dec, 28(6), 307 - 13
Interventional neuropediatrics: treatment of dystonic and spastic muscular hyperactivity with botulinum toxin A; Heinen F et al.; Therapeutic effect of botulinum toxin A was studied in a group of pediatric patients (n = 28) aged between 6 months and 18 years . The patients were diagnosed with cervical dystonia (n = 6), adductor spasm of the hip (n = 8), spastic drop foot (n = 7) and various other focal motor problems associated with spastic muscular hyperactivity (n = 7) . The mean dose of botulinum toxin A (Dysport) used to inject into the affected muscle was 22 U/kg body weight . Reduced muscular hyperactivity with a significant increase in joint mobility was achieved for dystonic (p < 0.0001) as well as for spastic conditions in patients with adductor spasm (p < 0.0002) . For these patients the improved joint mobility represented a significant benefit for both daily activities and nursing care . Local paresis and local hematoma were observed in 1/28 and 1/28 patients, respectively; 1/28 patients developed a secondary non-response . However, apart from these side effects, no other adverse reactions to botulinum toxin A treatment were recorded during the treatment and observation period (12-64 months) . Our results suggest that botulinum toxin A represents an effective and safe therapeutic substance for the treatment of pediatric patients suffering of focal motor problems due to dystonic or spastic muscular hyperactivity.

Rev Chir Orthop Reparatrice Appar Mot, 1997, 83(4), 368 - 71
{Muscular lengthening of the triceps by successive casts in children with cerebral palsy}; Cottalorda J et al.; PURPOSE OF THE STUDY: Twenty children with cerebral palsy who underwent elongation of the triceps surae using successive plaster-casts (28 short triceps) were reviewed . This study was retrospective . MATERIAL AND METHODS: Among the eighteen children, 10 were hemiplegic, 8 were diplegic and 2 were spastic quadriparetic . All of them except one were ambulatory children . The authors describe their elongation technique by plaster-casts and the treatment they lead . The mean age at time of elongation was 4 years and 6 months (range 2 years 4 months to 8 years) . The passive dorsiflexion of the foot before elongation was of 0 degree (range -20 degrees to +10 degrees) knee in extension, and of 5 degrees (range -15 degrees to +15 degrees) knee in flexion . RESULTS: The passive dorsiflexion of the foot after elongation was of 23 degrees (range +10 degrees to +30 degrees) knee in extension, and of 27 degrees (range +10 degrees to +35 degrees) knee in flexion . One major complication was noted: the persistence of a varus foot in child after elongation . 24 elongations were reviewed with a mean follow-up of 21 months (range 12 months to 30 months) . The passive dorsiflexion of the foot was of 10 degrees (range 0 degree to +20 degrees) knee in extension and of 17 degrees (range -5 degrees to +25 degrees) knee in flexion . DISCUSSION: Compared to different procedures (surgical lengthening, botulinum-A toxin) elongation by successive plaster-casts is a quick, safe, complication-free, and simple technique, whose results are equivalent . Even if recurrence of equinus is probable, a surgical procedure of lengthening could be made on an operative-free tendon . CONCLUSION: Elongation of the triceps surae muscle by successive plaster-casts constitutes a safe alternative technique compared to surgical procedure.

J Surg Res, 1997 Dec, 73(2), 113 - 6
Histology and function of the internal anal sphincter after injection of botulinum toxin; Langer JC et al.; BACKGROUND: Children with Hirschsprung's disease may have persistent obstructive symptoms due to internal anal sphincter hypertonicity, even after definitive surgery . Anal myectomy is not universally effective and may result in permanent sphincter injury . Botulinum toxin injection has been used to selectively weaken a variety of muscles and could theoretically represent a less invasive option for children with this difficult problem . We evaluated the efficacy and safety of botulinum toxin in an immature porcine model . MATERIALS AND METHODS: Six-week-old piglets underwent four-quadrant intrasphincteric injection of botulinum toxin or saline . Under ketamine sedation, internal sphincter resting pressure was measured using a water-perfused system before injection and 4 weeks later . Animals were sacrificed 4 weeks after injection . Histological evidence of neuromuscular changes or inflammation in the internal sphincter was documented . All analysis was done blindly . RESULTS: Internal anal sphincter pressure increased in control animals, likely due to growth over the 4-week period . Conversely, botulinum toxin injection was associated with a significant decrease in internal sphincter pressure . There were no significant differences between the botulinum toxin and control groups with respect to histologic evaluation of neuronal size and number, nerve bundle size and number, inflammation, or muscle atrophy . CONCLUSIONS: These data suggest that botulinum toxin is effective in decreasing internal anal sphincter pressure without histologically evident adverse effects . A clinical trial using botulinum toxin for persistent obstructive symptoms following surgery for Hirschsprung's disease is therefore justified .

J Neurol Sci, 1997 Nov 25, 152(2), 193 - 7
Delayed segmental axial dystonia of the trunk on standing after lumbar disk operation; Ghika J et al.; We report four patients with various degrees of chronic, tonic, mildly painful, or non-painful, kyphoscolioses in orthostatism, which developed weeks, or months, after one or several laminectomies for lumbar disk hernia, in the absence of recurring radicular pain or acute lumbar pain . No family history or personal antecedent, of focal or generalized dystonia was found and the dystonia was not seen in any of the four patients pre-operatively, or during the immediate post-operative period . Only ill-defined lumbar 'discomfort', unlike their pre-operative lumbago, was reported by the patients, before and during the occurrence of the pathologic trunk posture on standing . Asymmetric lumbar muscle tonic contraction and hypertrophy was found on physical examination . In all patients, the kyphoscoliosis was maximal when standing, partially disappeared when seated, and completely when lying down . One patient responded well to clonazepam, but the other three showed no improvement with either clonazepam or local injections of botulinum toxin; L-dopa was ineffective in all cases, and trihexiphenidyle in three.

J Neurol Sci, 1997 Nov 25, 152(2), 132 - 5
The mechanism of action of botulinum toxin type A in focal dystonia is most probably through its dual effect on efferent (motor) and afferent pathways at the injected site; Giladi N; OBJECTIVE: To highlight some clinical and physiological features related to treatment with botulinum toxin type A (BTX-A) injections for focal dystonia that may suggest an effect through efferent (alpha motoneuron) and afferent pathways . DATA SOURCES: This review is based on published clinical and physiological studies as well as personal experience regarding the effect of BTX-A in focal dystonia . DATA SYNTHESIS: Long or short lag period between BTX-A injections and clinical improvement, remote effect, an effect on the basic physiological characteristics of dystonia, poor correlation between the local weakness and the clinical improvement and alleviation of pain are clinical observations which are difficult to explain on the basis of the known effect of BTX-A on the neuromuscular junction of the alpha motoneuron . These observations as well as recent scientific reports are used to discuss a hypothesis that in addition to its effect as local muscle relaxant, BTX-A acts at the level of the central nervous system (CNS) for 'reorganization' . Such an effect on CNS activity can be mediated through afferent pathways coming from the injected site--possibly originated in muscle spindles . Its effect through afferent pathways on the CNS may be considered as a long-term 'sensory trick'.

Proc Natl Acad Sci U S A, 1997 Dec 23, 94(26), 14871 - 6
Block of transmitter release by botulinum C1 action on syntaxin at the squid giant synapse; Marsal J et al.; Electrophysiological, morphological, and biochemical approaches were combined to study the effect of the presynaptic injection of the light chain of botulinum toxin C1 into the squid giant synapse . Presynaptic injection was accompanied by synaptic block that occurred progressively as the toxin filled the presynaptic terminal . Neither the presynaptic action potential nor the Ca2+ currents in the presynaptic terminal were affected by the toxin . Biochemical analysis of syntaxin moiety in squid indicates that the light chain of botulinum toxin C1 lyses syntaxin in vitro, suggesting that this was the mechanism responsible for synaptic block . Ultrastructure of the injected synapses demonstrates an enormous increase in the number of presynaptic vesicles, suggesting that the release rather than the docking of vesicles is affected by biochemical lysing of the syntaxin molecule.

Mov Disord, 1998 Jan, 13(1), 158 - 61
Comparison of treatment of tardive dystonia and idiopathic cervical dystonia with botulinum toxin type A; Brashear A et al.; To compare clinical parameters of patients treated with botulinum toxin type A (BTX) for treatment of idiopathic cervical dystonia (ICD) and for tardive cervical dystonia (TCD), we studied 156 patients (149 with ICD and 7 with TCD) who were treated with serial injections of BTX over 5 years . We hypothesized that patients with TCD and ICD would demonstrate similar improvement in severity scores after treatment with BTX . The diagnosis, dates, dosages, and frequency of BTX injected and severity assessments were recorded into a computerized database . Nonparametric Wilcoxon rank sum and signed-rank tests were used to assess statistical significance . The change in severity scores between the first treatment and last treatment in both groups was not statistically significant (p = 0.4859), indicating similar improvement . The difference in BTX doses was significant (p = 0.0045) . ICD patients (n = 149) received an average of 219.8 +/- 63.5 units and those with TCD (n = 7) were treated with an average dose of 287.4 +/- 60.3 units . The average number of days between treatments for individuals with ICD was 142.9 +/- 85.8, similar to that for persons with TCD (144.7 +/- 64.5) (p = 0.6075) . Our analysis provides preliminary evidence that the improvement from the administration of BTX for patients with ICD and TCD is similar.

Mov Disord, 1998 Jan, 13(1), 150 - 4
Variability of the immunologic and clinical response in dystonic patients immunoresistant to botulinum toxin injections; Sankhla C et al.; Immunoresistance (Ab+) to botulinum toxin type A (BTX-A) has been a serious concern since the introduction of BTX-A in the treatment of dystonia and other disorders associated with abnormal muscle contractions . We studied seven patients who developed Ab+ and later reverted to antibody-negative (Ab-) status . These seven patients, six women (mean age, 56 years; range, 41-80 years), with an average duration of dystonia for all patients of 197 months (range, 84-360 months), received a total mean cumulative dose of 1659 units (U) (range, 810-1975 U), with an average dose of 207 U per visit . All of these patients became unresponsive to BTX-A treatment and became Ab+ as determined by mouse bioassay . Their response to BTX-A after they reverted to Ab- was analyzed . The average latency between the initial BTX-A treatment and development of Ab+ was 27 months (range, 1543 months) . The average duration between the detection of Ab+ status and subsequent reversal to Ab- status was 30 months (range, 10-78 months) . Six of these Ab- patients were reinjected with BTX-A, and all six benefited from repeat injections comparable with their earlier response . Three patients lost their clinical response to subsequent injections and were found to be again Ab+ . Two of the five patients who became immunoresistant to BTX-A received botulinum toxin type F (BTX-F) injections and one patient received a single session of BTX-B with improvement in their symptoms . In conclusion, this unique group of patients who were Ab+ and became Ab- responded favorably to repeat BTX-A injections, but some lost the benefit with subsequent injections . These observations suggest that the anamnestic immunologic response to BTX-A can wane, but can be reactivated by repeat BTX-A treatments . The presence of antibodies did not interfere with the response to BTX-F or BTX-B injections, thus confirming the antigenic specificity of various BTX serotypes.

Mov Disord, 1998 Jan, 13(1), 108 - 17
Change in lateralization of the P22/N30 cortical component of median nerve somatosensory evoked potentials in patients with cervical dystonia after successful treatment with botulinum toxin A; Kanovsky P et al.; The precentral P22/N30 cortical component of the median nerve somatosensory evoked potentials (SEPs) was recorded in 16 patients (11 women and five men) suffering from cervical dystonia before and after botulinum toxin therapy . Cervical dystonia was diagnosed as idiopathic in all patients: 13 patients suffered from right-sided torticollis, and three suffered from left-sided torticollis . The amplitude of the P22/N30 component and the side-to-side ratio of amplitude values were measured . Normal values were obtained by acquiring measurements in two groups of healthy volunteers (n1 = 20 and n2 = 20) . The recordings in the first control group were done with the patient's head in a normal position, whereas, in the second control group, the patient kept the head intentionally rotated 60 degrees to the right . Patients were treated with local injections of botulinum toxin A (BTX-A) . The mean duration of treatment was 8.3 months, and the mean total amount of BTX injected was 295 U . The P22/N30 precentral component was repeatedly recorded in patients after head posture had been corrected to the normal plane by BTX-A treatment . The recordings showed that the amplitude of the P22/N30 precentral component recorded contralaterally to the direction of head deviation was significantly higher in patients before treatment than after treatment . Contralateral pretreatment amplitudes were also significantly higher (p < 0.01 and p < 0.05, respectively) than amplitudes in both groups of healthy volunteers . The mean side-to-side ratio of precentral P22/N30 component amplitudes was significantly higher in patients before treatment compared with after treatment and also compared with both control groups . These changes in dystonic patients probably reflect the direction of head rotation, the muscle pattern of torticollis, and the change in force of dystonic contraction after the treatment . The changes presumably could be the result of higher excitability of the precentral cortex contralateral to head rotation in patients with cervical dystonia and its change after successful BTX-A treatment.

J Neurosurg, 1998 Feb, 88(2), 328 - 30
Preoperative treatment with botulinum toxin to facilitate cervical fusion in dystonic cerebral palsy . Report of two cases; Racette BA et al.; The authors report the use of high-dose botulinum toxin A for muscle relaxation prior to surgery for cervical spine fixation in two patients with dystonic cerebral palsy that included severe cervical dystonia . Both patients had recently developed progressive cervical myelopathy and surgery was planned to halt the insidious progressive weakness . However, marked dystonic posturing of the neck would have compromised their tolerance of halo fixation and subsequently impeded postoperative fusion . Preoperative chemodenervation of selected cervical muscles with injections of high-dose botulinum toxin A eliminated all involuntary neck movements, permitting the patients to tolerate halo fixation and facilitating postoperative spinal fusion . It is concluded that botulinum toxin A can be used safely and effectively in the preoperative management of patients with cervical dystonia and cervical spondylitic myelopathy.

Otolaryngol Head Neck Surg, 1998 Jan, 118(1), 74 - 81
An anatomic study of the rat larynx: establishing the rat model for neuromuscular function; Inagi K et al.; The gross and microscopic anatomy of the rat larynx was studied with particular attention to myology and neuromuscular structures to further validate it as a model to evaluate morphologic and functional changes induced by botulinum injection . A laryngeal alar cartilage (LAIC), alar cricoarytenoid (ACA) muscle, and a superior cricoarytenoid muscle (SCA) were identified as anatomic structures not previously described . Two portions (medial and lateral) of the thyroarytenoid muscle (TA) were distinguished . The function of the ACA was suggested to be similar to the aryepiglottis muscle in humans and the function of the SCA was suggested to be similar to the human interarytenoid muscle . The predominant pattern of motor endplate (MEP) distribution in rat laryngeal muscles (posterior cricoarytenoid, lateral cricoarytenoid, cricothyroid, and SCA) was to have MEPs concentrated mostly at the midbelly of muscle where they were distributed throughout the cross-sectional area of the midbelly . The TA and ACA differed from this pattern . The lateral TA had MEPs concentrated at the anterior third of its belly and those of the medial TA were located at the midbelly . Motor endplates in the ACA were located mostly at the posterior portion of muscle . Muscle fiber-typing showed subtle differences between the intrinsic laryngeal muscles . Fast fibers were predominant in the rat laryngeal muscles . This study supports the expanded use of rats in studies of laryngeal neuromuscular function and disease in humans.

J Appl Microbiol, 1997 Dec, 83(6), 678 - 84
Specific peptides of casein pancreatic digestion enhance the production of tetanus toxin; Porfirio Z et al.; Casein pancreatic digest is the basic bacterial growth medium used for diphtheria, botulinum and tetanus toxin vaccine production . It is known that the variation in the peptide content of the casein digest directly affects final toxin yields . In this study, the identification and sequences of eight peptides, four to eight amino acids in length, of casein pancreatic digestion, which seem to be involved in the enhancement of tetanus toxin production, are described . They all contain one or two residues of proline/molecule and a predominance of hydrophobic amino acid residues . The most active peptides show a general structure of Pro-aromatic-Pro, and this pattern resembled the motif displayed by bradykinin-potentiating peptides found in snake venoms . By analogy with the mechanism of bradykinin potentiation through inhibition of the proteolytic degradation of bradykinin, it is suggested that the six peptides identified here could protect the tetanus toxin from proteolysis, once secreted by the bacteria.

Br Dent J, 1997 Dec 13-27, 183(11-12), 415 - 7
Medical treatment of recurrent temporomandibular joint dislocation using botulinum toxin A; Moore AP et al.; This paper describes a new technique for prophylactic treatment of recurrent mandibular dislocation using injection of botulinum toxin A (BtA) into the lateral pterygoid muscles . BtA temporarily weakens muscles by blocking acetylcholine release, and thus operates through a principle different from established treatments such as joint sclerosant therapy, eminectomy or Dautry's procedure . The patient suffered recurrent mandibular dislocations caused by tardive dystonia . We injected 75 mu BtA percutaneously into each lateral pterygoid muscle under electromyographic guidance . No further dislocations occurred over the subsequent 10 months, and follow-up continues . There were no immediate or delayed side effects . More experience is required before this becomes an established treatment . BtA is usually given in outpatients, and is less invasive or destructive than previous options . It may not be suitable if dislocation is due to lax ligaments or weak muscles . Operators must be aware that other BtA preparations require a different dose.

Laryngoscope, 1998 Jan, 108(1 Pt 1), 55 - 63
Supraglottal injection of botulinum toxin type A in adductor type spasmodic dysphonia with both intrinsic and extrinsic hyperfunction; Schonweiler R et al.; Patients with adductor type spasmodic dysphonia (SD) often exhibit both glottal and supraglottal hyperfunction . Based on the hypothesis that a "ventricular muscle" may contribute to the hyperfunction in these cases, eight patients with adductor type SD were treated with bilateral injection of botulinum toxin type A into the ventricular folds . Four weeks after injection, ventricular fold hyperfunction was absent in all cases . Number of voice breaks, standard deviation of fundamental frequency, and shimmer were significantly improved . Voice range profiles of the speaking voice were significantly extended in dynamic and frequency range . Side effects were a breathy phonation and mild swallowing difficulties without aspiration for about 1 week . Patients' self-rating concerning strangled and breathy voicing demonstrated an interval of acceptable voice quality between 1 week and 4 months after injection in all cases . Results suggest that supraglottal injection in patients with SD of both glottal and supraglottal hyperfunction, as a new approach, can normalize supraglottal activity and improve glottal voicing . Based on our experience with other patients with adductor type of SD, this injection technique is as efficient as injection into the thyroarytenoid muscle . Nevertheless, it remains to be proved that a pathologic ventricular muscle activity is addressed by this technique or if it is based on spreading to the thyroarytenoid muscle.

J Biol Chem, 1997 Dec 26, 272(52), 33023 - 7
SNAP-23 is not cleaved by botulinum neurotoxin E and can replace SNAP-25 in the process of insulin secretion; Sadoul K et al.; The synaptosomal-associated protein of 25 kDa (SNAP-25) is expressed in neurons and endocrine cells . It has been shown to play an important role in the release mechanism of neurotransmitters and peptide hormones, including insulin . Thus, when insulin-secreting cells are permeabilized and treated with botulinum neurotoxin E (BoNT/E), SNAP-25 is hydrolyzed, and insulin secretion is inhibited . Recently SNAP-23, a more generally expressed isoform of SNAP-25, has been described . The functional role of SNAP-23 has not been investigated to date . It is now shown that SNAP-23 is resistant to cleavage by BoNT/E . It was therefore possible to test whether transfection of HIT (transformed pancreatic B-) cells with SNAP-23 reconstitutes insulin release from BoNT/E treated cells, in which SNAP-25 is inactivated by the toxin . The results show that SNAP-23 is able to replace SNAP-25 when it is overexpressed . While these results demonstrate that SNAP-23 is a functional homologue of SNAP-25, able to function in regulated exocytosis, they indicate that SNAP-23 may be inefficient in this process . This suggests that both isoforms may have their own specific binding partners and discrete, albeit mechanistically similar, functional roles within the cell.

Mayo Clin Proc, 1998 Jan, 73(1), 67 - 71
Hemifacial spasm and other craniofacial movement disorders; Evidente VG et al.; Craniofacial dyskinesias encompass a variety of abnormal spontaneous craniofacial movements that often appear similar in morphology but are, in fact, of varied cause and nature . Although hemifacial spasm and blepharospasm are the two most common abnormal craniofacial movements, the clinician should be cognizant of other dyskinesias, particularly craniofacial dystonias, tremor, tic, chorea, and stereotypies . Most craniofacial dyskinesias respond favorably to injections of botulinum toxin type A or oral medications . Surgical treatment may be beneficial for refractory cases.

Ann Otol Rhinol Laryngol, 1998 Jan, 107(1), 52 - 5
Botulinum toxin type A for Frey's syndrome: a preliminary prospective study; Laccourreye O et al.; Fourteen patients with severe Frey's syndrome (occurring after conservative parotidectomy) managed with intracutaneous injection of botulinum toxin type A were prospectively evaluated . Results were analyzed for effectiveness, complications, and adverse effects . Complications were not encountered . The only adverse effect noted was a temporary and slight partial paresis of the upper lip of 3 months' duration in 2 patients . Permanent paresis was not encountered . Frey's syndrome was always controlled within 2 days following the intracutaneous injection of botulinum toxin A . Frey's syndrome recurrence was not encountered with a follow-up duration that varied from 3 to 9 months (mean follow-up 7 months) . This preliminary report confirmed that in patients who have Frey's syndrome after conservative parotidectomy, the intracutaneous injection of botulinum toxin is a valuable treatment option that should be further investigated.

J Neurosci, 1998 Jan 1, 18(1), 70 - 80
Synaptic transmission deficits in Caenorhabditis elegans synaptobrevin mutants; Nonet ML et al.; Synaptobrevins are vesicle-associated proteins implicated in neurotransmitter release by both biochemical studies and perturbation experiments that use botulinum toxins . To test these models in vivo, we have isolated and characterized the first synaptobrevin mutants in metazoans and show that neurotransmission is severely disrupted in mutant animals . Mutants lacking snb-1 die just after completing embryogenesis . The dying animals retain some capability for movement, although they are extremely uncoordinated and incapable of feeding . We also have isolated and characterized several hypomorphic snb-1 mutants . Although fully viable, these mutants exhibit a variety of behavioral abnormalities that are consistent with a general defect in the efficacy of synaptic transmission . The viable mutants are resistant to the acetylcholinesterase inhibitor aldicarb, indicating that cholinergic transmission is impaired . Extracellular recordings from pharyngeal muscle also demonstrate severe defects in synaptic transmission in the mutants . The molecular lesions in the hypomorphic alleles reside on the hydrophobic face of a proposed amphipathic-helical region implicated biochemically in interacting with the t-SNAREs syntaxin and SNAP-25 . Finally, we demonstrate that double mutants lacking both the v-SNAREs synaptotagmin and snb-1 are phenotypically similar to snb-1 mutants and less severe than syntaxin mutants . Our work demonstrates that synaptobrevin is essential for viability and is required for functional synaptic transmission . However, our analysis also suggests that transmitter release is not completely eliminated by removal of either one or both v-SNAREs.

Ophthalmologica, 1998, 212(1), 53 - 60
Morphological changes in the orbital surface layer muscle of the rabbit eye produced by botulinum toxin; Ohtsuki H et al.; We quantitated the morphological changes in the orbital surface layer muscles in the rabbit following the single injection of botulinum A toxin . Experiments were performed in 9 white rabbits (1.6-3.0 kg) . They were administered 5 units (5 rabbits) or 10 units (4 rabbits) of botulinum toxin injected into the superior rectus muscle of one eye . The diameter of myofibers of the orbital and intermediate layer zones was measured with an ocular micrometer on histological sections 3 days and 1, 3 and 5 weeks after injection . Quantitative changes were noted in the muscle fibers of the orbital surface layer zone following the injection of 10 units of botulinum toxin . At 1 week, the diameter of myofibers in the orbital layer was reduced, but it was increased at 5 weeks compared to that in the control eyes; in contrast, no change in the diameter of muscle fibers was found in the intermediate layer zone.

J Neurol Neurosurg Psychiatry, 1998 Jan, 64(1), 13 - 7
What is the optimal dose of botulinum toxin A in the treatment of cervical dystonia? Results of a double blind, placebo controlled, dose ranging study using Dysport . German Dystonia Study Group; Poewe W et al.; OBJECTIVES: Botulinum toxin injections have become a first line therapeutic approach in cervical dystonia . Nevertheless, published dosing schedules, responder rates, and frequency of adverse events vary widely . The present prospective multicentre placebo controlled double blind dose ranging study was performed in a homogenous group of previously untreated patients with rotational torticollis to obtain objective data on dose-response relations . METHODS: Seventy five patients were randomly assigned to receive treatment with placebo or total doses of 250, 500, and 1000 Dysport units divided between one splenius capitis (0, 175, 350, 700 units) and the contralateral sternocleidomastoid (0, 75, 150, 300 units) muscle . Assessments were obtained at baseline and weeks 2, 4, and 8 after treatment and comprised a modified Tsui scale, a four point pain scale, a checklist of adverse events, global assessment of improvement, and a global rating taking into account efficacy and adverse events . At week 8 the need for retreatment was assessed and then the code was unblinded . For those still responding, there was an open follow up until retreatment to assess the duration of effect . RESULTS: Seventy nine per cent reported subjective improvement at one or more follow up visits . Decreases in the modified Tsui score were significant at week 4 for the 500 and 1000 unit groups versus placebo (p<0.05) . Additionally positive dose-response relations were found for the degree of subjective improvement, duration of improvement, improvement on clinical global rating, and need for reinjection at eight weeks . A significant dose relation was also established for the number of adverse events overall and for the incidence of neck muscle weakness and voice changes . CONCLUSION: Magnitude and duration of improvement was greatest after injections of 1000 units Dysport; however, at the cost of significantly more adverse events . Therefore a lower starting dose of 500 units Dysport is recommended in patients with cervical dystonia, with upward titration at subsequent injection sessions if clinically necessary.

J Neurol Neurosurg Psychiatry, 1998 Jan, 64(1), 6 - 12
A double blind, randomised, parallel group study to investigate the dose equivalence of Dysport and Botox in the treatment of cervical dystonia; Odergren T et al.; OBJECTIVE: This study was designed to establish whether a ratio of three units of Dysport is equivalent to one unit of Botox for the treatment of cervical dystonia . METHODS: Patients with predominantly rotational cervical dystonia, and a minimum of four previous Botox treatments, were randomised to receive either the clinically indicated dose of Botox or three times that dose in Dysport units . Study botulinum toxin was administered in a double blind fashion, to one or more clinically indicated muscles, at one or more sites per muscle . Patients returned for assessment two, four, eight, and 12 weeks after treatment . RESULTS: A total of 73 patients (Dysport, 38; Botox, 35) were entered . The Dysport group received a mean (SD) dose of 477 (131) (range 240-720) Dysport units, and the Botox group received a mean (SD) dose of 152 (45) (range 70-240) Botox units . The mean (SEM) post-treatment Tsui scores for the Dysport group (4.8 (0.3)) and the Botox group (5.0 (0.3)) were not statistically different (p=0.66) . The study had 91% power to detect a clinically significant difference of two points . Both groups showed substantial improvement in Tsui score by week 2 (mean (SD); Dysport, 46 (28)%; Botox, 37 (28)%), with a peak effect at week 4 (mean (SD); Dysport, 49 (29)%; Botox, 44 (28)%) . A similar response profile was seen for other assessments of efficacy . The duration of effect, assessed by time to retreatment, was also similar (mean (SD); Dysport, 83.9 (13.6) days; Botox, 80.7 (14.4) days; p=0.85) . During the study 22 of 38 (58%) Dysport patients reported 39 adverse events, and 24 of 35 (69%) Botox patients reported 56 adverse events (p=0.35) . A global assessment of efficacy and safety considered that 29 of 38 (76%) Dysport patients and 23 of 35 (66%) Botox patients were treatment successes (p=0.32) . CONCLUSION: Patients with predominantly rotational cervical dystonia treated with the clinically indicated dose of Botox or three times that dose in Dysport units show similar improvements and do not have significantly different safety profiles.

Am J Physiol, 1997 Dec, 273(6 Pt 2), F1054 - 7
H+ secretion is inhibited by clostridial toxins in an inner medullary collecting duct cell line; Alexander EA et al.; Renal epithelial cell H+ secretion is an exocytic-endocytic phenomenon . In the inner medullary collecting duct (IMCD) cell line, which we have utilized as a model of renal epithelial cell acid secretion, we found previously that acidification increased exocytosis and alkalinization increased endocytosis . It is likely, therefore, that the rate of proton secretion is regulated by the membrane insertion and retrieval of proton pumps . There is abundant evidence from studies in the nerve terminal and the chromaffin cell that vesicle docking, membrane fusion, and discharge of vesicular contents (exocytosis) involve a series of interactions among so-called trafficking proteins . The clostridial toxins, botulinum and tetanus are proteases that specifically inactivate some of these proteins . In these experiments we demonstrated, by immunoblot and immunoprecipitation, the presence in this IMCD cell line of the specific protein targets of these toxins, synaptobrevin/vesicle-associated membrane proteins (VAMP), syntaxin, and synaptosomal-associated protein-25 (SNAP-25) . Furthermore, we showed that these toxins markedly inhibit the capacity of these cells to realkalinize after an acid load . Thus these data provide new insight into the mechanism for H+ secretion in the IMCD.

N Engl J Med, 1998 Jan 22, 338(4), 217 - 20
A comparison of botulinum toxin and saline for the treatment of chronic anal fissure; Maria G et al.; BACKGROUND: Chronic anal fissure is a tear in the lower half of the anal canal that is maintained by contraction of the internal anal sphincter . Sphincterotomy, the most widely used treatment, is a surgical procedure that permanently weakens the internal sphincter and may lead to anal deformity and incontinence . METHODS: We conducted a double-blind, placebo-controlled study of botulinum toxin for the treatment of chronic anal fissure in 30 consecutive symptomatic adults . All the patients received two injections (total volume, 0.4 ml) into the internal anal sphincter; the treated group (15 patients) received 20 U of botulinum toxin A, and the control group (15 patients) received saline . Success was defined as healing of the fissure (formation of a scar), and symptomatic improvement was defined as the presence of a persistent fissure without symptoms . RESULTS: After two months, 11 patients in the treated group and 2 in the control group had healed fissures (P=0.003); 13 in the treated group and 4 in the control group had symptomatic relief (P=0.003) . The maximal voluntary pressures were similar to those at base line in both groups, and the resting anal pressure was reduced by 25 percent in the treated group but not in the control group . Three patients in the control group later underwent sphincterotomy, and 10 received botulinum-toxin injections (20 U) . Of the latter, seven had healed fissures after two months; the other three left the study and underwent surgery . Four patients in the treated group were later re-treated (with 25 U of botulinum toxin); all had healed fissures after two months . One patient in the control group had temporary flatus incontinence after treatment with botulinum toxin . No relapses occurred during an average of 16 months of follow-up . CONCLUSIONS: Local infiltration of botulinum toxin into the internal anal sphincter is an effective treatment of chronic anal fissure.

Ophthal Plast Reconstr Surg, 1997 Dec, 13(4), 259 - 64
Use of botulinum A toxin in patients at risk of wound complications following eyelid reconstruction; Choi JC et al.; Our purpose was to determine the efficacy of botulinum A toxin (BOTOX) in promoting wound immobilization and preventing wound dehiscence in patients at risk of wound-healing complications following eyelid reconstruction . In 11 patients at risk of postoperative wound complications, we injected BOTOX into the periocular musculature in addition to standard suture tarsorrhaphy . Each patient experienced excellent wound immobilization and wound healing . There were no complications . Adjuvant use of BOTOX, in conjunction with suture tarsorrhaphy, immobilizes the eyelids and promotes wound healing in patients at risk of wound complications following eyelid reconstruction.

FEBS Lett, 1997 Dec 8, 419(1), 13 - 7
Transient expression of botulinum neurotoxin C1 light chain differentially inhibits calcium and glucose induced insulin secretion in clonal beta-cells; Land J et al.; We have investigated the effect of botulinum neurotoxin (BoNT) C1 light chain (LC) on insulin exocytosis from the clonal beta-cell line HIT-T15 . In streptolysin-O permeabilized cells, the beta-cell impermeant BoNT C1 cleaved mainly syntaxin 1 and inhibited Ca2+ as well as GTPgammaS induced exocytosis . To study the effect of BoNTs in intact cells, we transiently coexpressed the BoNT LC together with a reporter gene for insulin release . BoNT C1 inhibited K+ induced insulin secretion by 95% but reduced insulin release stimulated by glucose only by 25% . Thus a component of glucose stimulated insulin release is insensitive to BoNT C1.

Curr Opin Neurol, 1997 Dec, 10(6), 498 - 501
Management of spasticity; Hesse S et al.; Recent open studies and two placebo-controlled studies confirm the potential role of Botulinum toxin A in the treatment of focal spasticity in adults and children . The effect of the toxin might not only be mediated by the paresis of extrafusal, but also intrafusal muscle fibres, thereby altering the afferent discharge . To enhance its effectiveness, an additional electrical stimulation seems promising . Most patients tolerate the neurolytic agent well . Two individuals, however, suffered from an intermittent tetraparesis after treatment . The repetitive magnetic stimulation and the use of gabapentin might be other new therapeutic options in the management of spasticity.

Eye, 1997, 11 ( Pt 4), 472 - 5
Botulinum toxin for the temporary treatment of involutional lower lid entropion: a clinical and morphological study; Steel DH et al.; PURPOSE: A prospective study was designed to evaluate the use of botulinum toxin as a temporary treatment in patients awaiting surgical repair for involutional entropion and to compare its use with lid taping . METHODS: Botulinum toxin was administered to 30 patients with involutional entropion (35 eyelids) . These patients had all previously been using lid taping and lubricant ointment as a temporary measure whilst awaiting lid surgery . Patients' symptoms and signs were assessed before and after toxin injection . The date of entropion recurrence was recorded . Eyelid tissue from 8 patients treated with toxin and 3 control patients who had not been given toxin was obtained after surgical entropion repair and examined histologically to ensure the botulinum toxin had no potential detrimental effects on the results of surgery . RESULTS: The toxin was simple and quick to administer . Anatomical success was achieved in 33 of the 35 eyelids with significant improvements in symptoms and signs . The mean duration of action of the toxin was 12.5 weeks . Lower lid laxity was inversely correlated with duration of toxin action . There were no consistent changes in orbicularis oculi morphology after toxin injection . CONCLUSION: Botulinum toxin is a highly effective temporary treatment for involutional entropion with few complications and no adverse effects on the results of surgical entropion repair.

Ann Otol Rhinol Laryngol, 1997 Dec, 106(12), 1012 - 9
Efficacy of repeated botulinum toxin injections as a function of timing; Inagi K et al.; This pilot study was designed to determine if the interval between repeated botulinum toxin injections influenced physiologic and histologic effects on laryngeal muscles in a rat model . The physiologic measurements included digitized videomicroscopic recording of vocal fold movement and electromyography . The histologic measurements included muscle fiber size and digitized optical density of laryngeal muscles after glycogen depletion by electrical stimulation . The results demonstrated that the effect of timing of the second injection was strongly correlated to laryngeal changes . Most notable were results in the subjects that underwent injections 6 weeks apart . We hypothesize that these findings might be related to terminal axonal sprouting with reinnervation . The results from this study help confirm and expand the validity of using the rat laryngeal model to understand the effect of botulinum toxin . Moreover, we believe that the data might be extrapolated to prove useful in predicting human responses to botulinum toxin treatment for functional dystonias such as spasmodic dysphonia.

Int J Oral Maxillofac Surg, 1997 Dec, 26(6), 458 - 60
Treatment of recurrent dislocation of the temporomandibular joint with type A botulinum toxin; Daelen B et al.; A case is reported of a 56-year-old woman who suffered from recurrent dislocations of the temporomandibular joint (TMJ) secondary to an exacerbated tetraspastic syndrome of multiple sclerosis . Following chemical denervation of the masseter and pterygoid muscles with injections of type A botulinum toxin, no further dislocations occurred for periods of up to four months . The treatment has been repeated five times . Some of the indications and possible adverse reactions to this therapy are discussed and comparisons made with other, conventional methods for managing recurrent dislocation of the TMJ.

Protein Expr Purif, 1997 Nov, 11(2), 195 - 200
Recombinant expression and purification of the botulinum neurotoxin type A translocation domain; Lacy DB et al.; Botulinum neurotoxin type A in its fully activated form exists as a dichain protein consisting of a 50-kDa light chain and a 100-kDa heavy chain linked by a disulfide bond (B . R . DasGupta and H . Sugiyama, Biochem . Biophys . Res . Commun . 48, 108-112, 1972) . The protein can be further subdivided into three functional domains: a catalytic domain corresponding to the light chain, a translocation domain associated with the N-terminal half of the heavy chain, and a binding domain as the C-terminal half . To facilitate further structural and functional studies on the mechanism of toxin translocation, we report here the recombinant Escherichia coli expression and purification of the isolated translocation domain with a yield of 1 mg pure protein per 1 g cell paste . Circular dichroism, enzyme-linked immunosorbent assays, and preliminary crystallization experiments verify proper protein folding . This reagent should serve as a key tool in elucidating the mechanism of translocation and in determining how the catalytic domain, a large 50-kDa metalloprotease, is delivered to the cytosol .

J Neuroimmunol, 1997 Dec, 80(1-2), 1 - 5
Lack of effect of Miller Fisher sera/plasmas on transmitter release from PC12 cells; Benatar MG et al.; IgG antibodies to GQ1b ganglioside are found in > 90% of patients with the Miller Fisher Syndrome (MFS) . MFS sera or IgG preparations have marked effects on neurotransmitter release at the neuromuscular junction, but their mode(s) of action remain unclear . To establish a cell-based system for investigating the mechanism of action of MFS serum preparations, we looked at neurotransmitter release from three cell lines . We failed to demonstrate substantial 14C-acetylcholine release from two motor-neuronal cell lines, VSC4.1 and NSC19, and therefore studied 3H-noradrenaline release from NGF-differentiated PC12 cells, a neural-crest derived catecholaminergic cell line . K(+)-induced release was inhibited by botulinum toxin and basal release was enhanced by alpha-latrotoxin, resembling that at the neuromuscular junction, although K(+)-induced release was dependent on L-type rather than P/Q-type calcium channels . The cells expressed polysialylated gangliosides on the cell surface . Incubation in heat-inactivated or untreated MFS preparations did not, however, affect basal or K(+)-induced release . Thus the PC12 cells do not appear to be sensitive to the effects of serum antibodies from MFS patients.

FEBS Lett, 1997 Nov 24, 418(1-2), 1 - 5
Botulinum neurotoxin types A and E require the SNARE motif in SNAP-25 for proteolysis; Washbourne P et al.; Botulinum neurotoxins type A and E (BoNT/A and BoNT/E) are metalloproteases with a unique specificity for SNAP-25 (synaptosome-associated protein of 25 kDa), an essential protein component of the neuroexocytotic machinery . It has been suggested that this specificity is directed through the recognition of a nine residue sequence, termed SNARE motif, that is common to the other two SNARE proteins: VAMP (vesicle-associated membrane protein) and syntaxin, the only known substrates of the other six clostridial neurotoxins . Here we analyse the involvement of the four copies of the SNARE motif present in SNAP-25 in its interaction with BoNT/A and BoNT/E by following the kinetics of proteolysis of SNAP-25 mutants deleted of SNARE motifs . We show that a single copy of the motif is sufficient for BoNT/A and BoNT/E to recognise SNAP-25 . While the copy of the motif proximal to the cleavage site is clearly involved in recognition, in its absence, other more distant copies of the motif are able to support proteolysis . Also, a non-neuronal isoform of SNAP-25, Syndet, is shown to be sensitive to BoNT/E, but not BoNT/A, whilst the SNAP-25 isoforms from Torpedo marmorata and Drosophila melanogaster were demonstrated not to be substrates of these metalloproteases.

Ital J Neurol Sci, 1997 Oct, 18(5), 261 - 9
Guidelines for the therapeutic use of botulinum toxin in movement disorders . Italian Study Group for Movement Disorders, Italian Society of Neurology; Berardelli A et al.; Since its introduction in the early '80s the use of botulinum toxin has improved the quality of life of the patients affected by movement disorders . Toxin's neuromuscular blocking action allows a symptomatic treatment of those clinical conditions characterised by excessive muscular activity . Although the dosages used are safe and the side-effects are reversible, a correct use of botulinum toxin depends on the knowledge of its clinical pharmacology and of the anatomy of the body segments to be injected . In addition, the treatment of more complex conditions, i.e . laringeal dystonia, imposes an inter-disciplinary approach and specialised injection techniques . In this review, the Italian Study Group on Movement Disorders presents the consensus guidelines for the therapeutic use of botulinum toxin in movement disorders . The main toxin types, their use and administration modalities, and the training guidelines will be presented.

Clin Rehabil, 1997 Nov, 11(4), 288 - 92
The effect of botulinum toxin on hand function after incomplete spinal cord injury at the level of C5/6: a case report; Richardson D et al.; OBJECTIVE: To investigate the benefits of the focal use of botulinum toxin in spasticity in the forearm seen after incomplete spinal cord injury . DESIGN: A single case study with standardized assessment before and at three-week intervals after injection . INTERVENTION: EMG-guided selective injection of botulinum toxin . SUBJECT: A 23-year-old man, 18 months post injury . MEASURES: Rivermead Motor Assessment; grip strength; Jebsen hand tests; visual analogue scale; Ashworth spasticity scale . RESULTS: Weakness was seen as expected with some functional losses, but the patient made gains in the areas of concern: shaking hands, typing, using the hand to drink . These gains were sustained at 12 weeks . CONCLUSION: Selective use of botulinum toxin to weaken muscles can lead to functional benefit.

Ophthalmology, 1997 Nov, 104(11), 1762 - 7
Botulinum toxin management of childhood intermittent exotropia; Spencer RF et al.; OBJECTIVE: Intermittent exotropia is a common form of childhood strabismus that has a late onset and presents a difficult and frustrating management dilemma . Surgical treatments have a high recurrence rate, and multiple surgeries often are required to achieve a desirable motor outcome . This study presents long-term observations on the use of botulinum toxin for the treatment of intermittent exotropia in children . DESIGN: This study is a nonrandomized, case-controlled study of consecutive pediatric patients who had intermittent exotropia . PARTICIPANTS: Thirty-two neurologically normal children ranging from 3 to 144 months in age were diagnosed with intermittent exotropia with a minimum distance deviation of 15 prism diopters (PD) . INTERVENTION: Simultaneous bilateral injections of 2.5 units botulinum toxin type A were made into the lateral rectus muscles with the patient receiving nitrous oxide-ethrane inhalation anesthesia . Patients were observed for 12 to 44 months after the initial injection . MAIN OUTCOME MEASURES: A satisfactory outcome was considered to be stable binocular alignment of the eyes to an orthophoric range of +/-10 PD . RESULTS: Bilateral lateral rectus muscle injections of botulinum toxin were effective in reducing the mean preinjection deviation of -29 PD to an average exotropic angle of -6 PD . Stable orthophoria (+/-10 PD) was achieved in 22 patients (69%) . Overall, male patients required significantly fewer injections than did female patients . All patients between 24 and 56 months of age, irrespective of gender, required only a single bilateral injection to achieve a favorable motor outcome . CONCLUSIONS: Botulinum toxin is at least as effective as surgical outcomes reported previously for the treatment of intermittent exotropia in children . This treatment method is particularly effective in children between 2 and 4.5 years of age irrespective of the initial strabismic angle and is not associated with any secondary abnormalities.

Ann Otol Rhinol Laryngol, 1997 Nov, 106(11), 956 - 64
Transoral electromyographic recordings in botulinum toxin-injected rat larynges; Inagi K et al.; Objective assessment of muscle function following botulinum toxin injections in laryngeal muscles is difficult in human subjects . We developed a rat laryngeal model for the study of botulinum toxin injection . A new laryngoscopic technique has made it possible to observe the rat larynx endoscopically and to obtain electromyographic measurements during and after injection of toxin . The electromyographic interference pattern, fibrillation potentials, and vocal fold movement were used for analyzing dose and volume effects of injected toxin . We conclude that the lowest dosage able to produce the maximal duration of functional laryngeal impairment is 0.07 U in a volume of 0.4 microL . This model will enable us to obtain physiologic and histologic parameters that can be used to assess the selection of optimal treatment regimens with botulinum toxin for the treatment of patients with spasmodic dysphonia.

Toxicon, 1997 Sep, 35(9), 1439 - 51
Structural features of aminoquinolines necessary for antagonist activity against botulinum neurotoxin; Sheridan RE et al.; Certain aminoquinoline antimalarial compounds, such as chloroquine, antagonize the paralytic actions of botulinum neurotoxins (BoNT) . These studies have been extended to determine the critical structural groups necessary for synthetic aminoquinolines to have antagonist activity against BoNT . Isolated mouse hemidiaphragms were maintained at 36 degrees C and indirectly stimulated; the resulting isometric twitch tensions were recorded as a measure of synaptic function . The muscles were exposed to the test compounds before being treated with a challenge concentration of BoNT (typically 0.2 nM of serotype A) . The time to onset of 50% muscle paralysis due to BoNT was used to assess quantitatively the efficacy of the test compounds, which were then ranked on the basis of the concentrations necessary to delay paralysis by a specified time increment . Of the compounds tested, those having a 7-chloro-4-aminoquinoline configuration, similar to chloroquine (or the structurally similar 6-chloro-9-amino acridine group in quinacrine), were most effective . Truncation of the alkyl-amino-alkyl group from chloroquine and conversion of the 4-amino nitrogen to a primary amine did not significantly alter its effectiveness as a BoNT antagonist . However, the 6-chloro- or 8-chloro- isomers of chloroquine were essentially ineffective . These results suggest that aminoquinolines antagonize the paralytic actions of BoNT through interaction with a selective, stereospecific site that is not well correlated with antimalarial activity.

Toxicon, 1997 Sep, 35(9), 1373 - 412
Pharmacologic characterization of botulinum toxin for basic science and medicine; Pearce LB et al.; The use of Botulinum neurotoxin (BoNT) is increasing in both clinical and basic science . Clinically, intramuscular injection of nanogram quantities of BoNT is fast becoming the treatment of choice for a spectrum of disorders including movement disorders such as torticollis, blepharospasm, Meige Disease, and hemifacial spasm (Borodic et al., 1991, 1994a; Jankovic and Brin, 1991; Clarke, 1992) . Neuroscientists are using BoNTs as tools to develop a better understanding of the mechanisms underlying the neurotransmitter release process . Consequently, our ability to accurately and reliably quantify the biologic activity of botulinum toxin has become more important than ever . The accurate measurement of the pharmacologic activity of BoNTs has become somewhat problematic with the most significant problems occurring with the clinical use of the toxins . The biologic activity of BoNTs has been measured using a variety of techniques including assessment of whole animal responses to in vitro effects on neurotransmitter release . The purpose of this review is to examine the approaches employed to characterize, quantify and investigate the actions of the BoNTs and to provide a guide to aid investigators in determining which of these methods is most appropriate for their particular application or use.

Ann Neurol, 1997 Dec, 42(6), 973 - 5
Treatment of gustatory sweating with botulinum toxin; Naumann M et al.; Gustatory sweating is an autonomic disorder that frequently occurs after parotid gland surgery . We investigated the action of intracutaneous injections of botulinum toxin (BTX) (1.0-2.0 mouse units/2.25-cm2 skin area) in 45 patients (mean age, 52 years) with gustatory sweating . The area of hyperhidrosis was determined by Minor's iodine test before and up to 24 weeks after the injection . The effect of BTX was assessed by measuring the hyperhidrotic area . The maximum BTX-induced reduction of gustatory sweating was seen at 7.4 +/- 4.5 days after injection . The area of sweating decreased from 17.6 +/- 8.6 cm2 before BTX to 1.3 +/- 1.6 cm2 after BTX (p < 0.0001) . Half the patients rated gustatory sweating subjectively as completely abolished, and the remainder felt pronounced improvement . No toxic effects were observed . In none of the patients did hyperhidrosis recur over a 6-month follow-up . We conclude that BTX is a safe and effective treatment that can be recommended as the therapy of choice in gustatory sweating.

Br J Pharmacol, 1997 Nov, 122(6), 1043 - 6
Nitrergic modulation of cholinergic responses in the opossum lower oesophageal sphincter; Cellek S et al.; 1 . Electrical field stimulation (EFS) of the superfused lower oesophageal sphincter from opossum (Monodelphis domestica) elicited biphasic responses . The first phase (relaxation) was strictly dependent on the duration of the EFS . The second phase (contraction) started following termination of the EFS (< or = 15 Hz) . EFS at frequencies above 15 Hz led only to contraction, which started immediately upon initiation of the stimulation . 2 . In the presence of NG-nitro-L-arginine (L-NOARG; 0.1-300 microM), the relaxation phase was abolished and the contractile response started with the initiation of EFS (at all frequencies) and was greater in magnitude . The contractile response to EFS was completely blocked with scopolamine (10 microM) . 3 . Exogenous acetylcholine (1-100 microM) elicited concentration-dependent contractions of the sphincter in the presence of botulinum toxin . These contractions were abolished when EFS was applied during administration of acetylcholine . This inhibitory effect of EFS was completely reversed when the tissue was treated with L-NOARG (100 microM) . 4 . These results suggest that the cholinergic response in the opossum lower oesophageal sphincter is under nitrergic control.

Mov Disord, 1997 Nov, 12(6), 1064 - 7
Idiosyncratic adverse reactions to intramuscular botulinum toxin type A injection; LeWitt PA et al.; Three cases of adverse reactions to repeated intramuscular botulinum toxin A (BTA) injections are described: a persistent rash on the face at the site of injection, a localized anaphylactic reaction following BTA injection into one leg, and bilateral ptosis repeatedly following BTA injection into neck muscles . The mechanisms for these idiosyncratic adverse responses are not known.

Mov Disord, 1997 Nov, 12(6), 1060 - 3
Botulinum toxin A improves muscle spasms and rigidity in stiff-person syndrome; Liguori R et al.; We studied the effect of botulinum toxin A (BTA) on painful muscular spasms and rigidity in two bedridden patients with clinical, electrophysiologic, and immunologic evidence of stiff-person syndrome . We injected BTA or saline solution into several limb muscles with both the rater and patient blinded to the order of the injections . A physician, unaware of the treatment order, used an objective rating scale for rigidity and spasm frequency scale and independently assessed the treatment results . BTA administration significantly reduced rigidity and stopped the spasms in all limbs . Following BTA injection on one side, the spasm frequency decreased bilaterally possibly because of the spread of hematogenous toxin.

Mov Disord, 1997 Nov, 12(6), 1013 - 8
DYSBOT: a single-blind, randomized parallel study to determine whether any differences can be detected in the efficacy and tolerability of two formulations of botulinum toxin type A--Dysport and Botox--assuming a ratio of 4:1; Sampaio C et al.; BACKGROUND: Elston and Russell discovered a difference in the biological potency of the English formulation of botulinum toxin type A or BTX-A (Dysport) and the American formulation (Botox) . Potency of both is expressed in LD50 mouse units, but because of assay differences, these units are not equivalent . Since the first warning by Quinn and Hallet on the clinical importance of this issue, it has been impossible to reach a consensus on the conversion factor for the potency of these formulations . OBJECTIVE: To test the hypothesis that the conversion factor for the clinical potency of Dysport to Botox is approximately 4:1 . DYSBOT is an acronym that results from adding "DYS" from Dysport with "BOT" from Botox . PATIENTS AND METHODS: Design: A single-blind, randomized, parallel comparison . A total of 91 patients with blepharospasm or hemifacial spasm were randomized to treatment with Dysport or Botox using a fixed potency ratio of 4:1 . Clinical evaluations: The patients were evaluated at baseline (day of the treatment) . 1 month after treatment, and whenever the effect was judged to be fading . Objective and functional rating scales were used as quantitative measures of the change in clinical status . Adverse reactions were collected using a systematic questionnaire . RESULTS: Using this ratio between products, both Dysport and Botox groups produced similar clinical efficacy and tolerability . For patients showing a positive response without the need of a booster, the duration of effect was 13.3 +/- 5.9 weeks for the Dysport group and 11.2 +/- 5.8 weeks for the Botox group . Of 48 patients, 11 (23%) needed booster treatment in the Dysport group compared with five (12%) of 43 in Botox group . Adverse events were noted in 24 (50%) of 48 patients in the Dysport group and 20 (47%) of 43 of the Botox-treated group . CONCLUSIONS: Using a 4:1 conversion ratio for Dysport and Botox, similar results were obtained for the two treatments in an appropriately powered study, suggesting that this conversion factor is a good estimate of their comparative clinical potencies.

Brain, 1997 Nov, 120 ( Pt 11), 1975 - 87
Clinical and neurophysiological features of tick paralysis; Grattan-Smith PJ et al.; The clinical and neurophysiological findings in six Australian children with generalized tick paralysis are described . Paralysis is usually caused by the mature female of the species Ixodes holocyclus . It most frequently occurs in the spring and summer months but can be seen at any time of year . Children aged 1-5 years are most commonly affected . The tick is usually found in the scalp, often behind the ear . The typical presentation is a prodrome followed by the development of an unsteady gait, and then ascending, symmetrical, flaccid paralysis . Early cranial nerve involvement is a feature, particularly the presence of both internal and external ophthalmoplegia . In contrast to the experience with North American ticks, worsening of paralysis in the 24-48 h following tick removal is common and the child must be carefully observed over this period . Death from respiratory failure was relatively common in the first half of the century and tick paralysis remains a potentially fatal condition . Respiratory support may be required for > 1 week but full recovery occurs . This is slow with several weeks passing before the child can walk unaided . Anti-toxin has a role in the treatment of seriously ill children but there is a high incidence of acute allergy and serum sickness . Neurophysiological studies reveal low-amplitude compound muscle action potentials with normal motor conduction velocities, normal sensory studies and normal response to repetitive stimulation . The biochemical structure of the toxin of I . holocyclus has not been fully characterized but there are many clinical, neurophysiological and experimental similarities to botulinum toxin.

Dermatol Nurs, 1997 Oct, 9(5), 329 - 33, 365
Facial rejuvenation with botulinum; Ellis DA et al.; Botulinum toxin type A (Botox) blocks the release of neurotransmitter acetylcholine at the presynaptic neuromuscular junction leading to an irreversible, but temporary muscular paralysis and weakness . This can produce a significant improvement of wrinkling in the upper face caused by the actions of the facial muscles . A prospective clinical study representing a 15-month experience with this new technique is presented . Patient selection and evaluation, classification of animation lines, techniques, results, and complications are discussed.

Endocrinology, 1997 Dec, 138(12), 5518 - 26
Functional importance of synaptobrevin and SNAP-25 during exocytosis of histamine by rat gastric enterochromaffin-like cells; Hohne-Zell B et al.; Gastric enterochromaffin-like (ECL) cells release histamine upon stimulation with gastrin in a calcium-dependent manner . The intracellular mechanisms and proteins mediating exocytosis of histamine-containing vesicles in ECL cells have not been determined yet . We used immunocytochemistry to show the localization of SNAP-25 (synaptosome-associated protein of 25 kDa) and synaptobrevin VAMP (vesicle-associated membrane protein) in ECL cells of the rat gastric mucosa and in isolated, highly enriched ECL cells, which were identified with an antibody directed against the marker enzyme histidine decarboxylase . Immunoblots of isolated ECL cells demonstrated the presence of SNAP-25, synaptobrevin, synaptophysin, synaptotagmin, and syntaxin . Histamine release from isolated ECL cells permeabilized with 8 microM digitonin (2 min) was stimulated approximately 2.5-fold upon exposure to calcium (30 microM; 10-min incubation) . Preincubation with 1 microM tetanus toxin light chain for 15 min attenuated calcium-induced histamine release by 40-50% and almost completely cleaved synaptobrevin . Botulinum neurotoxin A (100 nM) totally blocked calcium-induced histamine release and cleaved SNAP-25 . We conclude that synaptobrevin, synaptophysin, synaptotagmin, SNAP-25, and syntaxin are present in gastric ECL cells . Inhibition of histamine secretion by clostridial neurotoxins associated with the cleavage of synaptobrevin and SNAP-25 implicates the functional importance of these proteins in the docking and fusion of histamine vesicles.

Otolaryngol Head Neck Surg, 1997 Nov, 117(5), 487 - 92
A comparison of methods of botulinum toxin injection for abductory spasmodic dysphonia; Meleca RJ et al.; Treatment of abductory spasmodic dysphonia with botulinum toxin injection into the posterior cricoarytenoid muscles often results in only partial symptom relief . In contrast, excellent results can be achieved after thyroarytenoid injection for the adductory type of spasmodic dysphonia . One reason for disappointing results may be inaccurate placement of the botulinum toxin into the posterior cricoarytenoid muscles . We describe a new approach to posterior cricoarytenoid injection used in 18 patients for treatment of abductory spasmodic dysphonia . Of the 30 patients treated for abductory spasmodic dysphonia at Loyola University-Chicago, 6 underwent both a retrocricoid approach and the newer transcricoid method, thus allowing patient and clinician comparison of techniques . We and all six of our patients preferred the transcricoid approach because of less discomfort, equivalent or better voice results, and fewer side effects.

Ann Plast Surg, 1997 Nov, 39(5), 447 - 53
Local injection into mimetic muscles of botulinum toxin A for the treatment of facial lines; Guerrissi J et al.; The purpose of this clinical investigation is to confirm the efficacy of eliminating facial wrinkles by injecting botulinum toxin A into mimetic muscles . Fifty-four patients were injected with BOTOX A-14 in the corrugator superciliaris, 19 in the frontalis muscles, and 13 in the orbicularis oculis . Dilution was obtained by adding 4 ml preservative-free saline to 100 IU of BOTOX A . The dose used varied according to the patient . The severity of wrinkles and the intensity of muscle contraction (facial expression) were taken into account . The paralysis obtained in the mimetic muscles was effective for 6 months in 39 patients, 8 months in 10 patients, and 9 months in 1 patient . The results were documented by photographs, videotape, and electromyographies pre- and postinjection . To preserve the results, 21 patients (39%) demanded a second infiltration to achieve satisfactory results . Neither local nor general adverse effects were noted, except transitory eyebrow palsy in 2 patients, and edema and ecchymosis in 4 patients . The improvement obtained in facial mimetic wrinkles was satisfactory to the patient and to us.

J Laryngol Otol, 1997 Sep, 111(9), 839 - 44
Frey's syndrome: treatment with botulinum toxin; Bjerkhoel A et al.; Frey's syndrome, i.e . gustatory sweating on the cheek, is a fairly common embarrassment after parotid gland surgery . New surgical techniques have been proposed to avoid this complication, but are not widely in use . Hence, there is need for treatment of Frey's syndrome . All surgical and topical treatments have drawbacks . This study was set up in order to evaluate a recently described treatment . One hundred and two patients were interviewed after parotidectomy . Thirty-one of them had noticed gustatory sweating and 15 patients underwent Minor's starch iodine test before, and after, treatment with intracutaneous injections of botulinum toxin A (Botox, Allergan Inc., USA) . Thirteen of the patients did not experience any gustatory sweating at follow-up (one to 13 months) . Minor's starch test showed total disappearance of gustatory sweating in 12 of the 15 treated patients . The only side effect was a discreet, transitory affection of the orbicularis oris muscle in one patient . As this treatment is minimally invasive it could be an attractive treatment for Frey's syndrome if the effect is maintained . Complaints of local hypoaesthesia and pain were also common after parotid surgery.

Arch Ophthalmol, 1997 Nov, 115(11), 1411 - 8
Botulinum toxin management of essential infantile esotropia in children; McNeer KW et al.; BACKGROUND: Infantile esotropia has an onset during early infancy when visual cortical connections are established for binocular fusion and stereopsis . The goal of early treatment is to achieve normal binocular alignment and a favorable sensory outcome . OBJECTIVE: To determine the long-term effects of the use of botulinum toxin for the management of infantile esotropia in children . PATIENTS: Seventy-six neurologically normal children ranging from 4 to 48 months of age were entered consecutively into the study after being given the initial diagnosis of infantile esotropia with a mean strabismic angle of 33 prism diopters . INTERVENTIONS: Simultaneous bilateral injections of 2.5 U of botulinum toxin type A were made into the medial rectus muscles under nitrous oxide and ethrane anesthesia . Patients were followed up for 12 to 95 months after the last injection . Forty patients required 1 bilateral injection and 36 patients required multiple bilateral injections to achieve a favorable motor outcome . RESULTS: Bilateral medial rectus muscle injections of botulinum toxin were effective in reducing the mean preinjection deviation of 33 PD to an average esotropic angle of 2 PD . Binocular alignment (+/- 10 PD) was achieved in 68 patients (89%) . Boys required significantly fewer injections than did girls . The secondary incidence of overacting inferior oblique muscles was significantly greater in boys, while girls had a significantly greater incidence of late-onset refractive errors . CONCLUSION: Botulinum toxin is an effective treatment modality for the management of infantile esotropia in infants and children, producing binocular alignment of the visual axes.

Schizophr Bull, 1997, 23(4), 583 - 609
Treatment of tardive dyskinesia; Egan MF et al.; Although the new generation of atypical antipsychotic agents could some day eliminate concerns about tardive dyskinesia (TD), this disorder remains a significant clinical problem for both patients and physicians . Fortunately, many, if not most, cases of TD are mild . For patients with mild to moderate TD, therapeutic efforts are primarily directed at minimizing neuroleptic exposure or, when possible, changing to atypical agents . Most cases of TD do not seem to progress, suggesting that the risk of remaining on typical neuroleptics is probably small . Patients with moderate to severe forms of TD present greater challenges . These patients frequently require medication to suppress their dyskinesias . A variety of suppressive agents have been tried with limited success . No treatment strategy has emerged that is clearly superior or even successful in most patients . Increasing doses of typical neuroleptics may be useful for short-term suppression; however, the long-term efficacy and risk of this strategy have not been studied carefully . Data on atypical neuroleptics are scant . Clozapine's short-term suppressive effects seem, at best, weak, but patients may improve with long-term treatment . Medications with relatively few side effects that may have suppressive efficacy for some patients include calcium channel blockers, adrenergic antagonists, and vitamin E . Gamma-amino-butyric acid agonists agents and dopamine depleters are frequently useful, but have troubling side effects of their own . A variety of other medications have been employed, but are not well studied . For patients with tardive dystonia, anticholinergic agents or botulinum toxin has been particularly effective . Efforts to understand the neurobiology of TD may shed light on this persistent clinical conundrum.

Arch Phys Med Rehabil, 1997 Nov, 78(11), 1272 - 3
Bruxism after brain injury: successful treatment with botulinum toxin-A; Ivanhoe CB et al.; Bruxism, the rhythmic grinding of teeth--usually during sleep--is not an infrequent complication of traumatic brain injury . Its prevalence in the general population is 21%, but its incidence after brain injury is unknown . Untreated, bruxism causes masseter hypertrophy, headache, temporomandibular joint destruction, and total dental wear . We report a case of complete resolution of postanoxic bruxism after treatment with botulinum toxin-A (BTX-A) . The patient was a 28-year-old man with no history of bruxism who sustained an anoxic brain injury secondary to cardiac arrest of unknown etiology . On admission to our rehabilitation unit 2 months after the injury, the patient presented with severe bruxism and heavy dental wear . The patient was injected with a total of 200 units of BTX-A to each masseter and temporalis . There was total resolution of bruxism 2 days after injection, with no complications . On follow-up 3 months after injection, the patient remained free of bruxism . We propose that botulinum toxin be considered as a treatment for bruxism secondary to anoxic brain injury . Further studies regarding muscle selection and medication dosage are warranted to elucidate the toxin's efficacy in this condition.

FEBS Lett, 1997 Oct 6, 415(3), 325 - 8
Arachidonic acid, a principal product of Rac-activated phospholipase A2, stimulates c-fos serum response element via Rho-dependent mechanism; Kim BC et al.; Previously, we have reported that phospholipase A2 (PLA2) is one of the major downstream targets by which Rac GTPase mediates the activation of c-fos serum response element (SRE) in response to agonists such as EGF {FEBS Lett . 407 (1997) 7-12} . Thus, the potential activity of arachidonic acid (AA), a principal product of Rac-activated PLA2, on c-fos SRE stimulation has been suggested . Here, we provide evidence about the biological activity of AA on c-fos SRE activation . Further, we observed that co-transfection with expression plasmid of either RhoN19, a dominant negative RhoA mutant, or botulinum C3 transferase which inhibits Rho via ADP ribosylation, selectively repressed AA- or Rac-induced SRE activation, suggesting that Rho activity is critical for the signaling cascade of 'Rac-PLA2-AA' to c-fos SRE . Thus, Rac signaling to the nucleus appears to be, at least partly, mediated by a Rho-linked pathway and this Rac-Rho signaling connection is mediated by AA . In accordance with the role of Rho as a potential mediator of AA signaling to the nucleus, AA induces a rapid translocation of RhoA.

J Struct Biol, 1997 Oct, 120(1), 78 - 84
Electron density projection map of the botulinum neurotoxin 900-kilodalton complex by electron crystallography; Burkard F et al.; The 900-kDa botulinum neurotoxin complex serotype A has been crystallized by the lipid-layer two-dimensional crystallization technique . Based on the binding characteristics of the hemagglutinating portion of the complex, a number of ganglioside/ lipid mixtures were tested but only lactosyl ceramide/1-palmityl-2-oleoyl-sn-glycero-3-phosphocholine was found to crystallize the complex . The optimum lipid mixture contained 75 mass % lactosyl ceramide and 25 mass % 1-palmityl-2-oleoyl-sn-glycero-3-phosphocholine . Using protein concentrations from 5 to 500 micrograms/ml and pH and 5 acetate buffer, we have obtained crystals that diffract to better than 15 A when prepared in negative stain . A projection map with a resolution of 30 A was calculated with unit cell dimensions of a = b = 157 A and P3 symmetry . The complex is triangular in shape with six distinct lobes observed . Additionally, six smaller structures protrude from the triangular core.

Infect Immun, 1997 Nov, 65(11), 4586 - 91
Induction of an immune response by oral administration of recombinant botulinum toxin; Kiyatkin N et al.; A gene encoding the full-size botulinum neurotoxin serotype C was reconstructed in vector pQE-30 and expressed at high levels in Escherichia coli . Three amino acid mutations (H229-->G, E230-->T, and H233-->N) were generated in the zinc-binding motif, resulting in complete detoxification of the modified recombinant holotoxin . The PCR-amplified wild-type light chain of botulinum neurotoxin serotype C was also expressed in E . coli and used as a control in all experiments . Modified recombinant holotoxin and light chain contained a histidine affinity tag at the amino terminus, which was used for detection and purification . Recombinant proteins were purified on nickel affinity resin and analyzed by Western blotting with the anti-histidine tag and anti-neurotoxin C antibodies . The results indicated that the 150-kDa molecule of modified recombinant holotoxin and the 50-kDa recombinant light chain were synthesized without degradation; however, E . coli did not provide for efficient nicking of modified recombinant toxin . Modified recombinant holotoxin was not toxic to mice, had no effect on nerve-evoked muscle twitch in vitro, and was not able to cleave syntaxin in crude synaptosome preparations . The recombinant light chain was also nontoxic in vivo, had no effect on evoked muscle twitch, but was able to cleave syntaxin . Modified recombinant neurotoxin and light chain were administered to animals either orally or subcutaneously . Both oral administration and subcutaneous administration of modified recombinant neurotoxin evoked high levels of serum antibodies and protective immunity . Oral administration of recombinant light chain evoked no systemic response, whereas subcutaneous administration evoked antibody production and immunity.

J Biochem (Tokyo), 1997 Sep, 122(3), 531 - 6
Purification of bovine soluble guanylate cyclase and ADP-ribosylation on its small subunit by bacterial toxins; Tomita T et al.; Soluble guanylate cyclase (sGC) consisting of two different subunits (alpha: Mr = 74,000, beta: Mr = 69,000) was purified more than 12,000-fold in terms of specific activity from the supernatant of bovine lung homogenates and characterized . The heme content determined with the pyridine hemochromogen method and Bradford's protein assay was 0.8 heme per dimer . Cholera, pertussis, and botulinum C3 toxins modified exclusively the beta-subunit of sGC, yielding the ADP-ribose-bound compound with 1:1 stoichiometry, and Vmax for the cyclase reaction was increased 10 times by this modification . When the ADP-ribosylation of sGC was performed simultaneously with two or three bacterial toxins which have distinct amino acid specificities, the resultant enzyme had only one ADP-ribose, and the activity was the same as that of the enzyme modified with one toxin . When NO was incorporated into the reaction mixture containing the ADP-ribosylated sGC, the cyclase activity noticeably increased by approximately the same amount as that seen for the unmodified enzyme . Such effects were not seen with CO . When ADP-ribosylated sGC was incubated with Mn2+, the enzyme activity was synergistically increased . The heme-deleted sGC was also ADP-ribosylated by bacterial toxins and its activity was raised . These findings suggest that sGC has an ADP-ribosylation site near the GTP binding site, like other GTP-binding proteins, and that the beta-subunit regulates the activity.

Surg Clin North Am, 1997 Oct, 77(5), 971 - 92
Pathophysiology and endoscopic/balloon treatment of esophageal motility disorders; Koshy SS et al.; Diagnostic and therapeutic dilemmas associated with esophageal dysmotility syndromes continue to confront physicians managing these patient populations . Although modern manometric systems have allowed us to better define normal parameters of esophageal motility, with the exception of primary achalasia, the clinical relevance of many aberrant motor patterns remains unclear . The novel use of botulinum toxin in idiopathic achalasia stems from increased understanding of the pathogenesis of the disease . Similarly, as our knowledge of the pathophysiology of other esophageal motor disorders grows, in conjunction with improved diagnostic capabilities, more effective management strategies may be used in the future.

Biochem Biophys Res Commun, 1997 Oct 20, 239(2), 592 - 7
Intracellular location of SNAP-25 in human neutrophils; Nabokina S et al.; Exocytosis plays an essential role in the physiological functions of human neutrophils . Although SNAP-25 is considered to play a key role in vesicle-membrane fusion, it has been detected almost exclusively in the neuronal system . Using different specific antibodies to SNAP-25, we have identified in the membrane fraction of resting human neutrophils an immunoreactive band with the same molecular mass observed in brain homogenates . Immunoblot analysis of subcellular fractions of neutrophils revealed that SNAP-25 protein was found in the granule membrane fraction, but not in the cytosolic and plasma membrane fractions . Granule localization for neutrophil SNAP-25 was further demonstrated by confocal and immunoelectron microscopy . Furthermore, SNAP-25 was mainly located in the morphologically defined neutrophil peroxidase-negative granules, which are mobilizable upon cell activation . In addition, the protein was specifically cleaved by botulinal neurotoxin A, as observed in brain homogenate . These findings reveal the presence of SNAP-25 in the granule membranes of human neutrophils .

Exp Neurol, 1997 Oct, 147(2), 452 - 62
Sensory and motor denervation influence epidermal thickness in rat foot glabrous skin; Li Y et al.; Denervation in man often results in shiny, dry, thin skin . A previous study has shown that the epidermis of glabrous skin in the rat becomes approximately 40% thinner within 1 week following sciatic nerve transection, but which nerve fiber type or types influence epidermal thickness is unknown . In this study, we compared the effects on the epidermis of selective sensory, motor, and sympathetic denervation . Protein gene product 9.5 and calcitonin gene-related peptide immunocytochemical staining were used to determine the extent of denervation of epidermis, dermis, and sweat glands in the footpads . Epidermal thickness of the glabrous plantar skin of the foot was measured . To verify the specificity and reliability of each animal model, the relevant regions of the peripheral nervous system were examined by light or electron microscopy or both . Epidermal thickness decreased significantly following sciatic nerve transection (58% of control, P < 0.05) and dorsal root ganglionectomy (59%; P < 0.05) . The thickness also decreased following lumbar ventral rhizotomy (61%; P < 0.01), destruction of lumbar spinal motor neurons (66%; P < 0.05), and botulinum toxin-induced paralysis of the tibialis anterior and gastrocnemius muscles (70%; P < 0.05) . A slight decrease followed dorsal rhizotomy (84%; P < 0.01) . In contrast, no significant alterations in epidermal thickness were detected following sham operation and sympathectomy . Epidermal thinning was paralleled by reductions in the amounts of transcripts for glyceraldehyde-3-phosphate dehydrogenase and beta-actin . These results suggest that selective loss of both sensory and motor fibers to the hind limb can contribute to reducing epidermal thickness in rat foot glabrous skin.

J Biol Chem, 1997 Oct 10, 272(41), 26005 - 8
Regulated secretion is impaired in AtT-20 endocrine cells stably transfected with botulinum neurotoxin type A light chain; Aguado F et al.; Botulinum neurotoxin type A (BoNT/A) inhibits neurotransmitter release by specific cleavage of SNAP-25, a synaptosome-associated protein also expressed in the ACTH secretory cell line AtT-20 . Expression of light chain BoNT/A (L-BoNT/A) gene transfected into AtT-20 cells resulted in a cleaved form of SNAP-25 indistinguishable from that generated by bona fide BoNT/A . L-BoNT/A-transfected cells showed no difference in replication rate, viability, or phenotype, compared with control AtT-20 cells . In contrast, L-BoNT/A-transfected cells could not be induced to secrete ACTH upon stimulation by 8-bromo-cAMP or KCl . In addition, alpha-latrotoxin induced ACTH release from control cells, but not from L-BoNT/A-transfected cells . These experiments suggest an important role for SNAP-25 in regulated secretion from AtT-20 cells and underline the usefulness of this cell system as a tool for the study of the molecular mechanism of peptide hormone secretion.

Klin Monatsbl Augenheilkd, 1997 May, 210(5), 289 - 92
{Use of botulinum toxin in ophthalmology}; Huber A; BACKGROUND: Botulinum Toxin A produces muscle palsies by blocking the neuromuscular transmissions . The numerous applications of Botulinum-chemodenervation in ophthalmology are demonstrated . RESULTS: In blepharospasm und facial hemispasm Botulinum Toxin A injections represent an excellent alternative to medical and surgical therapy . They have to be repeated after several weeks or month . Other indications are spastic entropium and lagophthalmos . In paralytic strabismus Botulinum Toxin injections (intramuscular under EMG control) serve to prevent contracture of the homolateral antagonist and thus to facilitate recovery of the agonist with restauration of binocular single vision or in non recovering cases to simplify the surgical treatment by making no more necessary the usual recession of the homolateral antagonist . In concomitant strabismus Botulinum-chemodenervation is applicable above alle in small angle deviations under 25 degrees, in sensory strabismus, in residual squint angles after surgery and in contraindications against surgery of any cause . Botulinum Toxin can also be used to stimulate a weakening procedure with control of resulting binocular function or disturbing diplopia . CONCLUSIONS: Botulinum Toxin A injections are of considerable therapeutic value in blepharospasm, spastic entropion, lagophthalmus, as well in paralytic strabismus and certain cases of concomitant strabismus.

Ophthalmologica, 1997, 211(6), 387 - 90
Chemodenervation in treatment of upper eyelid retraction; Ozkan SB et al.; Upper-eyelid retraction is a common sign of thyroid-associated eye disease (TAED), and these patients are highly bothered by the appearance of their eyes . In this study, botulinum toxin A (BTA) was injected into the levator palpebrae superioris muscle in 8 eyes of 4 patients in an attempt to control the abnormal elevation of the upper eyelid . BTA provided control of the upper-eyelid retraction, and the cosmetically acceptable effect lasted for 3-4 months . It was concluded that BTA is an effective method of treatment in this condition . Since it has a temporary effect, it can safely be used to provide relief of symptoms related to upper-eyelid retraction during unstabilized periods of TAED, which may last as long as several years in some patients.

Pharmacoeconomics, 1997 Dec, 12(6), 695 - 706
Costs of treating dystonias and hemifacial spasm with botulinum toxin A; Dodel RC et al.; Botulinum toxin (BTX) has become a safe and effective therapeutic tool in the treatment of a variety of neurological disorders, especially dystonias . One major disadvantage, however, is the high cost of a single injection of BTX . In this study of 835 patients, we calculated the cost of treatment with BTX serotype A (BTX-A) for different dystonias and hemifacial spasm . The annual expenditure per patient for BTX-A injections in this cohort totalled (mean +/- standard deviation) 1030 Deutschmarks (DM) {1996 values} +/- DM610 {$US570 +/- $US340; 230 +/- 130 pounds sterling (Pound)} for blepharospasm (n = 158), DM1450 +/- DM1520 ($US800 +/- $US830; 310 Pounds +/- 280 Pounds) for craniocervical dystonia (n = 148), and DM1480 +/- DM780 ($US810 +/- $US430; 330 Pounds +/- 180 Pounds) for oromandibular dystonia (n = 16), while the treatment of cervical dystonia consumed DM4590 +/- DM2060 ($US2520 +/- $US1130; 960 Pounds +/- 420 Pounds) {n = 362} per patient . In order to alleviate symptoms in patients with hemifacial spasm (n = 151), DM510 +/- DM270 ($US280 +/- $US150; 110 Pounds +/- 60 Pounds) had to be spent annually . The expenses for surgical therapy for cervical dystonia were DM10,120 +/- DM1900 (n = 54) . No major differences concerning expenditure could be found in this study between the 2 available preparations of BTX . However, there appeared to be a lower rate of adverse effects with the Botox formulation, compared with the Dysport formulation, of BTX-A (this difference was statistically significant, i.e . p < 0.001) . Although the cost of an individual injection is high, other cost factors also substantially contribute to the societal costs of adult-onset dystonias . Some of these costs may be attenuated with the use of BTX . The subjective and objective relief of these socially devastating and sometimes painful conditions rewards the expenditure associated with the use of BTX-A.

Pharmacoeconomics, 1997 Dec, 12(6), 675 - 84
Measuring patient benefit from botulinum toxin in the treatment of dystonia . Feasibility of cost-utility analysis; Gudex CM et al.; The dystonias are a group of movement disorders arising from CNS dysfunction and characterised by involuntary and prolonged spasms of muscle contraction . Recently there has been increasing demand for treatment with botulinum toxin (BT), a relatively expensive neurological paralytic agent . As there has been no systematic assessment of patient benefit from BT, this study was undertaken to develop and test a methodology for assessing the cost utility of BT therapy for patients with dystonias . A generic health status instrument, the EuroQOL, was completed at regular intervals over at least 6 months by 130 patients with a current diagnosis of dystonia . A general population tariff was used to calculate quality-adjusted life-year (QALY) gains from BT treatment, and relevant cost data were obtained from patients and medical records . The cost-per-QALY estimates ranged considerably, depending on the type of dystonia, the duration of BT treatment, type of health-related quality-of-life (HR-QOL) tariff used and baseline characteristics of participants . The study findings reflect the general clinical impression of BT: that it can benefit patients with dystonia, but the benefit may be small compared with many treatments for other diseases . The nature of the disease and its cyclical treatment caused practical difficulties in recruiting participants, administering questionnaires and in estimating QALY gains.

J Neurol Neurosurg Psychiatry, 1997 Oct, 63(4), 474 - 6
Botulinum A toxin as a treatment of detrusor-sphincter dyssynergia in patients with spinal cord injury: MRI controlled transperineal injections; Schurch B et al.; OBJECTIVES: To correlate clinical and urodynamic findings with MRI in patients with spinal cord injury and detrusor-sphincter dyssynergia who were consecutively treated with transperineal injections of botulinum-A toxin (BTX-A) under EMG control . METHODS: Six patients with spinal cord injury and upper motor neuron bladder dysfunction associated with detrusor-sphincter dyssynergia were prospectively analysed . One hundred international units (IU) BTX-A (Botox in 1 ml normal saline without preservative) diluted 1 to 1 with 1 ml gadopentetate were injected transperineally under EMG control . MRI was started immediately after needle withdrawal . RESULTS: In all six patients gadopentetate was located in the external urethral sphincter on MRI . In no patient did traces of gadopentetate appear in the perineal musculature located in the vicinity of the external urethral sphincter . No patient developed resistance to BTX-A . All patients showed an (ongoing) improvement of their voiding function after BTX-A injections . CONCLUSIONS: Transperineal injections of BTX-A under EMG control are efficient in the release or amelioration of lower urinary tract obstruction due to detrusor sphincter dyssynergia in patients with spinal cord injury . Despite well described methods, EMG of the external urethral sphincter is difficult and it is not possible to definitively exclude false recordings of the surrounding perineal musculature . By the use of MRI it was shown that both the EMG recordings and transperineal injection method are precise.

Proc Natl Acad Sci U S A, 1997 Oct 28, 94(22), 12186 - 91
Disruption of syntaxin-mediated protein interactions blocks neurotransmitter secretion; O'Connor V et al.; The membrane protein syntaxin participates in several protein-protein interactions that have been implicated in neurotransmitter release . To probe the physiological importance of these interactions, we microinjected into the squid giant presynaptic terminal botulinum toxin C1, which cleaves syntaxin, and the H3 domain of syntaxin, which mediates binding to other proteins . Both reagents inhibited synaptic transmission yet did not affect the number or distribution of synaptic vesicles at the presynaptic active zone . Recombinant H3 domain inhibited the interactions between syntaxin and SNAP-25 that underlie the formation of stable SNARE complexes in vitro . These data support the notion that syntaxin-mediated SNARE complexes are necessary for docked synaptic vesicles to fuse.

Otolaryngol Head Neck Surg, 1997 Oct, 117(4), 303 - 7
Refinement in the rehabilitation of the paralyzed face using botulinum toxin; Bikhazi NB et al.; A number of surgical procedures exist to improve facial symmetry for patients with facial paralysis . Whereas static symmetry is often improved, dynamic asymmetry frequently persists because of the imbalance of complex coordinated movements of facial expression . The paralyzed face is often distorted by the excessive pull of the normal contralateral face during emotional expression . This study reports an expanded clinical indication for botulinum toxin in patients with unilateral facial paralysis . Ten patients with facial paralysis and markedly asymmetric smiles were treated with botulinum toxin A injections into the contralateral zygomaticus major, levators labii superioris and angulii oris, or risorius muscles . Eight of the 10 patients noted improvement in the symmetry of their smiles and underwent repeat injections . The onset and duration of effect averaged 5.9 days and 3 months, respectively . Botulinum toxin therapy provides a safe and efficacious modality for refining the appearance of the paralyzed face during mimetic activity.

S Afr Med J, 1997 Aug, 87(8), 1001 - 3
Experience with botulinum toxin in the treatment of cerebral palsy; Arens LJ et al.; OBJECTIVES: To assess the effect of botulinum toxin on dynamic spasticity and dystonic posturing in children with cerebral palsy . DESIGN: Assessment and documentation of the motor disability of children with cerebral palsy followed by injection of botulinum toxin into selected muscle groups . Reassessment of motor function after injection . SUBJECTS: Fifteen children with cerebral palsy: 5 with dynamic spasticity, 5 with dystonia and 5 with a mixed picture . RESULTS: On a standard scoring system, 13 of the children showed improved function at reassessment . CONCLUSION: Intramuscular injection of botulinum toxin is effective in the treatment of selected children with spastic and dystonic forms of cerebral palsy . Improvement is not permanent, but the injection can be repeated.

Am J Gastroenterol, 1997 Oct, 92(10), 1812 - 7
Prospective study of esophageal botulinum toxin injection in high-risk achalasia patients; Gordon JM et al.; OBJECTIVES: Intrasphincteric injection of botulinum toxin has been reported as a safer treatment alternative to balloon dilation or myotomy in achalasia . We studied botulinum toxin injection in achalasia patients who are at high surgical risk because of age or concomitant medical problems . METHODS: Consecutive patients who were elderly (age > 60 yr) or who had significant medical problems or both were enrolled after confirming achalasia by history, manometry, and esophageal scintigraphy . Patients underwent esophagogastroduodenoscopy, and 20 units of botulinum toxin were injected into each of four quadrants of the lower esophageal sphincter . Patients were interviewed at 1, 3, 5, and 6 months, and esophageal scintigraphy was repeated at 1 month . RESULTS: Sixteen patients with increased surgical risks were studied: many had serious coronary heart disease, diabetes, or obstructive lung disease . At 1 month, 12 of 16 patients had a clinical response but 5 developed recurrent symptoms within 6 months . One developed reflux, and two were found to have esophageal wall inflammation, loss of tissue planes, and mediastinal adhesions at subsequent myotomy . CONCLUSIONS: Intrasphincteric botulinum toxin injection may be appropriate in those achalasia patients who are elderly or have concomitant medical problems but concern persists regarding the length of the response and untoward side effects.

Eur Arch Otorhinolaryngol, 1997, 254(8), 391 - 5
Effects of botulinum toxin on vocal tract steadiness in patients with spasmodic dysphonia; Zwirner P et al.; Since laryngeal botulinum toxin (BTX) injections have become the treatment of choice for spasmodic dysphonia, the purpose of this study was to examine its effects on the stability of the upper vocal tract as compared to the effects on glottic stability . Two different acoustic methods were used to analyze voice samples from 16 patients with adductor-type spasmodic dysphonias before and after BTX therapy and from a normal control group . Independent acoustic analyses were used to determine laryngeal and upper vocal tract stability . The results showed significantly higher values for the standard deviation of fundamental frequency (SDF0), reflecting laryngeal instability, for the patient group than for the control group and an impressive improvement for the patients after BTX therapy . Further, the equally high values of SDF0 for the initial second and a second from the midsegment of phonation were differentially reduced by BTX therapy, resulting in a normal pattern of laryngeal stability during sustained phonation . The variability of the first and second formants, reflecting upper vocal tract instability, showed higher values for the patients compared with the control group, but this difference was not statistically significant . The present findings showed that BTX injections to the thyroarytenoid muscle had no discernible effect on stability of the upper vocal tract.

Neuroreport, 1997 Sep 29, 8(14), 3039 - 44
Botulinum toxin in upper limb spasticity: study of reciprocal inhibition between forearm muscles; Girlanda P et al.; To establish whether botulinum A toxin (BTX-A) acts on modifying reciprocal inhibition between forearm muscles in spasticity, 20 patients with post-stroke upper limb spasticity lasting for more than 1 year were studied . Clinical examination, physiotherapeutic evaluation, standardized video-tape assessment and electrophysiological testing (flexor carpi radialis muscle M and H responses with study of reciprocal inhibition) were performed at baseline and 2 weeks, 1, 2, 3, 4 months after BTX-A treatment . BTX-A induced a significant decrease of tone and an improvement of motility and functional status, with a significant decrease of the M wave and the H reflex . The reduction in both inhibitory phases of reciprocal inhibition did not change after BTX-A treatment differently from that reported in upper limb dystonia . These findings indicate that the efficacy of BTX-A in upper limb spasticity is mainly due to peripheral effects.

No Shinkei Geka, 1997 Oct, 25(10), 927 - 32
{Objective evaluation of selective peripheral denervation for spasmodic torticollis}; Taira T et al.; The authors evaluated the results of selective peripheral denervation (SPD) of posterior rami of the cervical spinal nerves and/or the accessory nerve for spasmodic torticollis . Five patients underwent seven operations in total and the results were evaluated with the modified Tsui's score which was used in the clinical trial of botulinum toxin (BTX) for torticollis in Japan . The preoperative score was 10.8 +/- 2.2 (mean +/- S.D.) and the postoperative score was 1.4 +/- 1.7 . The score changes indicated the effects of the operation as "excellent" in four cases and "good" in one case . These results indicate that SPD is superior to BTX in terms of control of symptoms in spasmodic torticollis . After the initial operation, however, two patients showed the so-called "mole-hitting game phenomenon" in which normal muscles develop abnormal contraction after denervation of abnormal muscles . This forced us to perform the second operations . Although this phenomenon was first described in botulinum toxin treatment, this is probably the first report in surgically denervated cases.

Clin Neuropharmacol, 1994 Jun, 17(3), 229 - 35
Treatment with botulinum toxin injections does not change brainstem interneuronal excitability in patients with cervical dystonia; Valls-Sole J et al.; Brainstem interneuronal excitability is enhanced in patients with cervical dystonia . Treatment with local botulinum toxin (BTX) injections temporarily alleviates the pain and weakens the muscle spasms, characteristics of this condition . In 10 patients with cervical dystonia, we studied whether the clinical improvement induced by BTX was associated with modification of the blink reflex excitability recovery curve to paired supraorbital nerve electrical shocks . We found that the mean percentage recovery of the R2 to the test stimulus was abnormally enhanced before treatment and that it did not significantly change after treatment, at the time of maximal clinical improvement, in any of the interstimulus intervals tested . We conclude that the clinical improvement induced by BTX in patients with cervical dystonia is largely symptomatic and is not related to any change of the known abnormalities in brainstem interneuronal excitability that possibly underlie the pathophysiology of cervical dystonia.

Nervenarzt, 1997 Jun, 68(6), 485 - 95
{Prognosis of traumatic spinal cord lesions . Significance of clinical and electrophysiological findings}; Curt A et al.; The clinical examination of patients with spinal cord injury can be supplemented by electrophysiological techniques (somatosensory-evoked potentials (SSEP), motor-evoked potentials (MEP), electroneurography) to assess the extent and severity of a spinal cord injury . As essential advantage of these techniques in comparison with the clinical examination is that they can be reliably applied even in uncooperative patients . These techniques allow an early prognosis of the functional deficit in patients with acute spinal cord injury . Recordings of tibial nerve SSEP and MEP of the anterior tibial muscle allow to predict the outcome of ambulatory capacity, while recordings of pudendal nerve SSEP allow prognosis of the bladder function to be assessed . In tetraplegic patients median and ulnar nerve SSEP and MEP of the abductor digiti minimi muscle can indicate the development of hand function . Electroneurography allows to differentiate between the proportion of peripheral and central nervous lesions underlying the muscle paresis . This is of prognostic value with regard to the development of muscle tone and consequently for planning therapy . The electrophysiological examinations are of complementary value in the diagnostic assessment of spinal cord lesions, in the prediction of functional outcome, and in monitoring the course of neurological deficits . This is helpful for planning and selection of appropriate therapeutic approaches (e.g . functional electrical stimulation, application of botulinum toxin, splinting procedures) within the rehabilitation programme.

Mov Disord, 1997 Sep, 12(5), 772 - 5
BotB (botulinum toxin type B): evaluation of safety and tolerability in botulinum toxin type A-resistant cervical dystonia patients (preliminary study); Truong DD et al.; Botulinum toxin (BTX) injection is considered the treatment of choice for patients with cervical dystonia (torticollis) . We conducted a pilot, open-label, dose-escalation study with BTX type B in 12 patients who no longer responded clinically to injections with BTX type A . At the doses tested, BTX type B was safe and well tolerated without evidence of dose-limiting toxicity in this patient population . Mild-to-moderate adverse events generally resolved quickly and included asthenia, pain, nausea, dysphagia, hypertonia, and tremor . No serious adverse events or antibodies to type-B treatment were reported . Low-dosing-session (100-899 units) and high-dosing-session (900-1,500 units) groups were defined based on units administered per dosing session . Toronto Western Spasmodic Torticollis Rating Scale-Severity Scale (TWSTRS-Severity), Patient Analogue Pain Scale, and Physician and Patient Global Assessment Scales were measured during this study . The TWSTRS-Severity mean maximum percent improvement from baseline demonstrated a 9.9% versus 28.8% difference between the low-dose and high-dose groups, respectively . EFfectiveness was noted for the high-dose group on the Patient Analogue Pain Scale but not on the Global Assessment Scales.

Mov Disord, 1997 Sep, 12(5), 764 - 6
Severe constipation in Parkinson's disease relieved by botulinum toxin; Albanese A et al.; A parkinsonian patient with severe outlet-type constipation was treated with injection of botulinum toxin into the puborectalis muscle . A total of 30 units (Botox) was injected in two sites . Resting anal pressure, maximum voluntary contraction, and pressure on straining were evaluated before treatment and 4, 8, 12, and 16 weeks afterward . Pressure values declined following treatment, the decline of pressure on straining ending by week 12 . Proctography performed 8 weeks after treatment showed improvement in the anorectal angle and evacuation of barium paste . The clinical benefit lasted for approximately 12 weeks . The present data show that botulinum toxin is a promising tool for treating outlet-type constipation in Parkinson's disease.

Mov Disord, 1997 Sep, 12(5), 722 - 6
Quantitative assessment of botulinum toxin treatment in 43 patients with head tremor; Wissel J et al.; We treated 43 patients who had head tremor as the major complaint with local botulinum toxin type A (Btx A) injections into neck muscles: 29 patients were classified as suffering from tremulous cervical dystonia (TCD), and 14 had head tremor without dystonia (HT) . All patients were clinically assessed by means of the Tsui scale and a 4-point pain scale at baseline and follow-up visit . Quantitative recordings of head tremor with a bidirectional accelerometer system (horizontal and vertical planes) placed on the forehead were obtained before and 2-3 weeks after Btx A injections . Muscle selection for an injection was based on the visible and palpable tremor oscillation in the involved neck muscles and on analysis of standardized simultaneous electromyographic recordings of six cervical muscles . Patients with HT received mean total doses of 400 units (U) of Dysport (Btx A) (range, 160-560 U) distributed between the two splenius capitis muscles . Patients with TCD received a mean total dose of 500 U Dysport (range, 320-720 U) injected into a mean of 3 muscles (range, 2-4 muscles) . The condition of all patients with HT and of 26 of the 29 patients with TCD improved subjectively . The total on the Tsui scale as well as pain scores decreased significantly (p < 0.05) following treatment . Latency of onset, duration of improvement, and side effects showed no significant difference in HT and TCD . Amplitude of HT decreased significantly for both groups following treatment . The mean dominant peak frequency in TCD and HT was slightly less than 5 Hz and did not change significantly after treatment.

Neurology, 1997 Sep, 49(3), 701 - 7
Botulinum toxin type B: a double-blind, placebo-controlled, safety and efficacy study in cervical dystonia; Lew MF et al.; We enrolled and treated 122 patients with idiopathic cervical dystonia in a double-blind, placebo-controlled safety and efficacy study of botulinum toxin type B (BotB) . Both A-responsive and A-resistant patients were enrolled . Patients received intramuscular injections of either BotB (2,500 U, 5,000 U, or 10,000 U) or placebo . The primary outcome measure of efficacy was the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS)-Total score at 4 weeks following study drug administration . Secondary measures of efficacy were TWSTRS-Severity, -Disability, and -Pain subscale scores, and Analog Pain Assessment, Investigator Global Assessment, Patient Global Assessment, and Sickness Impact Profile scores . Duration of effect was estimated with an intent-to-treat analysis of responders . Safety measures included clinical parameters, laboratory tests, and adverse events . The primary and most of the secondary analyses indicated a statistically significant treatment effect and a dose response . BotB is safe, well tolerated, and efficacious in the treatment of cervical dystonia at the doses tested.

Neuroscience, 1997 Nov, 81(2), 457 - 78
Effects of botulinum neurotoxin type A on abducens motoneurons in the cat: ultrastructural and synaptic alterations; Pastor AM et al.; The synaptic alterations induced in abducens motoneurons by the injection of 3 ng/kg of botulinum neurotoxin type A into the lateral rectus muscle were studied using ultrastructural and electrophysiological techniques . Motoneurons identified by the retrograde transport of horseradish peroxidase showed a progressive synaptic stripping already noticeable by four days post-injection which increased over the study period . By 35 days post-injection, the normal coverage of motoneurons by synaptic boutons (66.4 +/- 4.0%) significantly decreased to 27.2 +/- 4.0% . Synaptic boutons detached by a widening of the subsynaptic space but remained apposed by synaptic contacts and desmosomes to the motoneuron . Detachment did not affect equally flat and round vesicle-containing boutons . The control motoneuron had almost equal numbers of both types of boutons, but after 35 days post-injection the ratio of round to flat vesicle-containing boutons was 1.20 +/- 0.01 . Synaptic boutons impinging on motoneurons showed signs of alterations in membrane turnover, as indicated by an increase in the number of synaptic vesicles and a decrease in the number of coated vesicles and synaptic vesicles near the active zone . Abducens motoneurons had a transient increase in soma size by 15 days that returned to normal at 35 days, but no signs of chromatolysis or organelle degeneration were seen . Accompanying the swelling of motoneurons, a 15-fold increase in the number of spines, very infrequent in controls, was observed . Spines located in the soma and proximal dendritic trunk received synaptic contacts from both flat and round vesicle-containing boutons that could be either partly detached or completely attached to the motoneuron . An increased turnover of the plasmatic membrane of the motoneuron was observed, as indicated by a four-fold increase in the number of somatic coated vesicles . Animals were implanted with bipolar electrodes in the ampulla of both horizontal semicircular canals for evoking contralateral excitatory and ipsilateral inhibitory postsynaptic potentials . Motoneurons were antidromically identified from the lateral rectus muscle . Synaptic potentials of vestibular origin were recorded in abducens motoneurons . In the period between two and six days post-injection, a complete abolition of inhibitory synaptic potentials was observed . By contrast, excitatory synaptic potentials remained, but were reduced by 82% . The imbalance between excitatory and inhibitory inputs to motoneurons induced a progressive increase of firing frequency within a few stimuli applied to the contralateral canal . Between 7 and 15 days post-injection, both excitatory and inhibitory postsynaptic potentials were virtually abolished and remained so up to the longest time checked (105 days) . Some motoneurons recorded beyond 60 days post-injection showed signs of recovery of excitatory postsynaptic potentials . During the whole time-span studied, presynaptic wavelets were present, indicating no affecting of the conduction of afferent volleys to the abducens nucleus . Taken together, these data indicate that botulinum neurotoxin at high doses causes profound synaptic alterations in motoneurons responsible for the effects seen in the behavior of motoneurons recorded in alert animals.

Neuroscience, 1997 Nov, 81(2), 437 - 55
Effects of botulinum neurotoxin type A on abducens motoneurons in the cat: alterations of the discharge pattern; Moreno-Lopez B et al.; The discharge characteristics that abducens motoneurons exhibit after paralysis of the lateral rectus muscle with botulinum neurotoxin type A were studied in the alert cat . Antidromically identified motoneurons were recorded during both spontaneous and vestibularly induced eye movements . A single injection of 0.3 ng/kg produced a complete paralysis of the lateral rectus muscle lasting for about 12-15 days, whereas after 3 ng/kg the paralysis was still complete at the longest time checked, three months . Motoneurons recorded under the effect of the low dose showed differences in their sensitivities to both eye position and velocity according to the direction of the previous and ongoing movements, respectively . These directional differences could be explained by post-saccadic adaptation of the non-injected eye in the appropriate direction for reducing ocular misalignment . Thus, backward and forward post-saccadic drifts accompanied on- and off-directed saccades, respectively . The magnitude of the drift was similar to the magnitude of changes in eye position sensitivity . The discharge of the high-dose-treated motoneurons could be described in a three-stage sequence . During the initial 10-12 days, motoneuronal discharge resembled the effects of axotomy, particularly in the loss of tonic signals and the presence of exponential-like decay of firing after saccades . In this stage, the conduction velocity of abducens motoneurons was reduced by 21.4% . The second stage was characterized by an overall reduction in firing rate towards a tonic firing at 15-70 spikes/s . Motoneurons remained almost unmodulated for all types of eye movement and thus eye position and velocity sensitivities were significantly reduced . Tonic firing ceased only when the animal became drowsy, but was restored by alerting stimuli . In addition, the inhibition of firing for off-directed saccades was more affected than the burst excitation during on-directed saccades, since in many cells pauses were almost negligible . These alterations could not be explained by adaptational changes in the movement of the non-injected eye . Finally, after 60 days the initial stages of recovery were observed . The present results indicate that the high dose of botulinum neurotoxin produces effects on the motoneuron not attributable to the functional disconnection alone, but to a direct effect of the neurotoxin in the motoneuron and/or its synaptic inputs.

Regul Pept, 1997 Jul 23, 71(1), 37 - 44
Botulinum neurotoxin F, a VAMP-specific endopeptidase, inhibits Ca(2+)-stimulated GH secretion from rat pituitary cells; Jacobsson G et al.; Botulinum neurotoxin F (BoNTx F) is a zinc-dependent endopeptidase that causes proteolytic cleavage of the vesicle protein VAMP (vesicle-associated membrane protein) . VAMP is an important component of the molecular machinery regulating docking and fusion of secretory vesicles with the target membrane . We have investigated presence of VAMP protein in cultured rat anterior pituitary cells . Confocal laser microscopy revealed presence of VAMP-like immunoreactivity in secretory granules of GH-containing cultured rat anterior pituitary cells . Using BoNTx F, we have investigated whether VAMP is involved in growth hormone (GH) secretion . Treatment of streptolysin-O permeabilized GH-secreting cells with BoNTx F (2.0 and 20 nM) significantly inhibited Ca(2+)-induced GH release . The results show that the secretory granules of rat anterior pituitary cell contain VAMP protein and suggest that VAMP is of importance in regulating Ca(2+)-mediated GH secretion.

Med Pregl, 1997 May-Jun, 50(5-6), 194 - 200
{Treatment of spasms of visceral smooth muscles}; Milovanovic DR et al.; A lot of pathophysiological factors can cause increased activation of smooth muscle contractile mechanisms resulting in long-lasting contractions-spasms . They significantly increase the intercellular concentration of calcium ions and/or increase the affinity of thin contractile filaments for them . The most frequently used drugs in the therapy of visceral smooth muscle spasms are substances that relax smooth muscles (with antimuscarinic activity/atropine-like/or with non-specific activity/papaverine-like direct spasmolytics) and analgesics (opioids or nonsteroid antiinflammatory drugs-NSAID) . In the treatment of biliary and renal colics NSAIDs for parenteral use were equally or more efficient than spasmolytics or opioid analgesics . Organic nitrates relax smooth muscles efficiently, but this effect is short-lasting due to their rapid liver metabolism . Experiences with other drugs that could be useful in spastic visceral conditions are still scarce (calcium channel blockers, botulinum toxin, metoclopramide etc) . Due to diversity of mechanisms of action of spasmogenic factors, further investigations are directed to discovery of more efficient and more selective drugs than these currently used.

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