What Is Botulism?

Botulism (from Latin botulus, "sausage") is a rare but serious paralytic illness caused by a nerve toxin, botulin, that is produced by the bacterium Clostridium botulinum. Botulin is the most potent known toxin, blocking nerve function and leading to respiratory and musculoskeletal paralysis.

There are three main kinds of botulism:

Foodborne botulism is a form of foodborne illness and is caused by eating foods that contain the botulism toxin. Wound botulism is caused by toxin produced from a wound infected with Clostridium botulinum. Infant botulism is caused by consuming the spores of the botulinum bacteria, which then grow in the intestines and release toxin. All forms of botulism can be fatal and are considered medical emergencies. Foodborne botulism can be especially dangerous as a public health problem because many people can be poisoned from a single contaminated food source.

In the United States an average of 110 cases of botulism are reported each year. Of these, approximately 25% are foodborne, 72% are infant botulism, and the rest are wound botulism. Outbreaks of foodborne botulism involving two or more persons occur during most years and usually are caused by eating contaminated home-canned foods. The number of cases of foodborne and infant botulism has changed little in recent years, but wound botulism has increased because of the use of black-tar heroin, especially in California.

Clostridium botulinum is a spore-forming, anaerobic bacillus which produces a toxin that causes botulism. C. botulinum was first recognized and isolated in 1896 by Van Ermengem and is commonly found in soil.

These rod-shaped organisms grow best in low oxygen conditions. The bacteria form spores which allow them to survive in a dormant state until exposed to conditions that can support their growth.

Subtypes Each of the seven subtypes of C. botulinum produce seven different botulinum toxins (one per subtype). These are labeled with letters and are called A-G types (types C and D are not human pathogens). A "mouse protection" test determines the type of C. botulinum present (monoclonal antibodies used). In the United States, outbreaks are primarily due to types A, B (which are found in soil) or E (which is found in fish).š

š Optimum temperature for types A & B is 35-40° C. Minimum pH is 4.6. It takes 25 min at 100°C to kill these types. Optimum temperature for type E is 18-25°C. Minimum pH is 5.0. It takes about 0.1 minute at 100°C to kill type E C. botulinum.

Clostridium botulinum is also used to prepare Botox, used to selectively paralyze muscles to temporarily relieve wrinkles. It has other "off-label" medical purposes, such as treating headaches.

Botulin toxin or botox is the toxic compound produced by the bacterium Clostridium botulinum. It is an enzyme that breaks down one of the fusion proteins that allow neurons to release acetylcholine at a neuromuscular junction. By interfering with nerve impulses in this way, it causes paralysis of muscles in botulism. The toxin itself is a two-chain polypeptide with a 100 kDa heavy chain joined by a disulphide bond to a 50-kD light chain. It is possibly the most toxic substance known, with a lethal dose of about 300 pg/kg, meaning that somewhat over a hundred grams could kill every human living on the earth.

Botulin toxin is used (usually under a trademarked name such as "Botox") for producing long-term (months) paralysis of muscles. This was intended for the relief of uncontrollable muscle spasms, but is increasingly being used for cosmetic purposes, to paralyse facial muscles as a means of concealing wrinkles.

Botulin toxin has always been considered an ideal agent for chemical warfare (though, given its origins, the distinction from biological warfare is a thin one), since it oxidises rapidly on exposure to air, so an area attacked with a toxin aerosol would be safe to enter within a day or so. There are no documented cases of the toxin actually being used in warfare. There has been concern over the use of botulin toxin as a terrorist weapon, but it appears to not be ideal for this purpose. The vials of toxin used therapeutically are considered impractical for use by terrorists because each vial has only an extremely small fraction of the lethal dose for humans.

The toxin's properties did not escape the attention of the Aum Supreme Truth cult in Japan, who actually set up a plant for bulk production of this agent, though their terrorist and assassination attacks used the nerve agent sarin instead, it being easier to disperse and faster acting.

The CIA once prepared some cigars of Fidel Castro's favorite brand which had been saturated with botulinum toxin, against the possibility of an assassination attempt. The cigars were never used, but when tested years later were still found to be effective. See [1] (http://www.parascope.com/mx/articles/castroreport.htm).

Botox is also used as a treatment against hyperhydrosis (excessive sweating).

The heavy chain of the toxin is particularly important for targetting the toxin to specific types of axon terminals. The toxin must get inside the axon terminals in order to cause paralysis. Following the attachment of the toxin heavy chain to proteins on the surface of axon terminals, the toxin can be taken into neurons by endocytosis. The light chain is able to leave endocytotic vesicles and reach the cytoplasm. The light chain of the toxin has protease activity. The type A toxin proteolytically degrades the SNAP-25 protein. The SNAP-25 protein is required for the release of neurotransmitter from the axon endings

Symptoms (foodborne and wound forms) Classic symptoms of botulism occur between 12-36 hours after uptake of the botulinum toxin, but they can occur as early as 6 hours or as late as 10 days. Those symptoms usually include dry mouth, difficulty swallowing, slurred speech, muscle weakness, double vision, vomiting, and severe diarrhea, along with a progressive muscle paralysis. These are all symptoms of the muscle paralysis caused by the bacterial toxin. If untreated, these symptoms may progress to cause paralysis of the arms, legs, trunk, and respiratory muscles. In all cases the toxin made by C. botulinum causes illness, not the bacterium itself.

Infant botulism Infant botulism is the most common form of the ailment in the United States. The mode of action of this form is through actual infection by germinating spores in the gut of an infant. Infection results in constipation, general weakness, loss of head control and difficulty feeding. Because of these symptoms, infant botulism is often referred to as floppy baby syndrome.

Honey, corn syrup, and other sweeteners are potentially dangerous for infants. This is because, when mixed with the non-acidic digestive juices of an infant, the human body temperature, and anaerobic environment, creates an ideal medium for botulinum spores to grow and produce toxin. Botulinum spores are among the few bacteria that survive in honey, but they also are widely present in the environment. While these spores are harmless to adults, because of stomach acidity, an infant's digestive system is not yet developed enough to destroy them, and the spores could potentially cause infant botulism. For this reason, it is advised that neither honey, nor any other sweetener, should be given to children until they are weaned.

The leading explanation for why some infants become infected with C. botulinum, is that infants do not yet have sufficient numbers of resident microbiota in their guts to competitively exclude C. botulinum. Thus, without competition, C. botulinum is able to establish itself in the gut of an infant.

Botulinum toxin Botulinum toxin blocks the release of acetylcholine from nerve endings thus arresting their function. This toxin is unstable to heating, or on prolonged exposure to oxygen, so poisoning generally occurs from the use of improperly bottled or canned foods: typical instances of botulism would be home-bottled preserves used in salads. An unusual example of botulism occurred in Britain in the unusually hot, dry summer of 1976, when river levels dropped so low in some areas that feeding swans accidentally ingested material from anaerobic layers in a river (normally out of their reach), and were struck by botulism symptoms.

Diagnosis: Physicians may consider the diagnosis if the patient's history and physical examination suggest botulism. However, these clues are usually not enough to allow a diagnosis of botulism. Other diseases such as Guillain-Barré syndrome, stroke, and myasthenia gravis can appear similar to botulism, and special tests may be needed to exclude these other conditions. These tests may include a brain scan, spinal fluid examination, nerve conduction test (electromyography, or EMG), and a tension test for myasthenia gravis. The most direct way to confirm the diagnosis is to demonstrate the botulinum toxin in the patient's serum or stool by injecting serum or stool into mice and looking for signs of botulism. The bacteria can also be isolated from the stool of persons with foodborne and infant botulism.

Acta Med Port, 2004 Jan-Feb, 17(1), 54 - 8 Epub 2004 Feb 27.
{Food-borne botulism: review of five cases.}; Cardoso T et al.; Food-borne botulism is a disease caused by the ingestion of food contaminated with botulinum toxin, often present in smoked meat, canned food and preserved food; it can occur as sporadic case or as an outbreak . In the last decades there has been an increasing incidence of food-borne botulism in Portugal . The authors do a review of five cases of food-borne botulism, three isolated cases and 2 familiar . Four were associated with the ingestion of smoked ham and one of canned tunafish . The incubation period was 48 hours in one patient and 4 days in another, in the remaining patients it was not possible to determine this period . The clinical picture was dominated in all patients by diplopy, dysphagia, dizziness, blurred vision, dry mouth and constipation, and in two patients there were gastrointestinal complains . In one patient the electromyography findings were compatible with pre-synaptic neuromuscular blockage . A toxin type B was found in the serum of one patient and in the food involved in the two familiar cases . All patients experienced complete recovery with only symptomatic treatment . With this article the authors intend to call attention to this diagnosis, which is not rare, but difficult for someone not familiar with its presentation, being of notice that the diagnosis is essentially clinic with a strong epidemiological history, confirmed by typical electromyography findings and by the identification of the toxin involved . In Portugal there is only descriptions of clinical cases associated with the type B and the type E toxins, not being necessary the resource to the antitoxin therapy.

Nature, 2004 Dec 16, 432(7019), 925 - 9 Epub 2004 Dec 12.
Substrate recognition strategy for botulinum neurotoxin serotype A; Breidenbach MA et al.; Clostridal neurotoxins (CNTs) are the causative agents of the neuroparalytic diseases botulism and tetanus . CNTs impair neuronal exocytosis through specific proteolysis of essential proteins called SNAREs . SNARE assembly into a low-energy ternary complex is believed to catalyse membrane fusion, precipitating neurotransmitter release; this process is attenuated in response to SNARE proteolysis . Site-specific SNARE hydrolysis is catalysed by the CNT light chains, a unique group of zinc-dependent endopeptidases . The means by which a CNT properly identifies and cleaves its target SNARE has been a subject of much speculation; it is thought to use one or more regions of enzyme-substrate interaction remote from the active site (exosites) . Here we report the first structure of a CNT endopeptidase in complex with its target SNARE at a resolution of 2.1 A: botulinum neurotoxin serotype A (BoNT/A) protease bound to human SNAP-25 . The structure, together with enzyme kinetic data, reveals an array of exosites that determine substrate specificity . Substrate orientation is similar to that of the general zinc-dependent metalloprotease thermolysin . We observe significant structural changes near the toxin's catalytic pocket upon substrate binding, probably serving to render the protease competent for catalysis . The novel structures of the substrate-recognition exosites could be used for designing inhibitors specific to BoNT/A.

Biosecur Bioterror, 2004, 2(3), 216 - 23
Public perceptions and risk communications for botulism; Glik D et al.; Formative research findings from 10 focus group interviews on botulism are described . Data were collected from a diverse sample of people throughout the United States in 2003, as part of a collaborative multisite initiative sponsored by the Centers for Disease Control and Prevention to improve communications materials on bioterrorism agents . Focus group guides included questions on knowledge, action, emotions, and information seeking in response to a series of scenarios on a hypothetical terrorist attack using botulinum toxin . Data were collected, transcribed, coded, and analyzed using content domains based on risk and health communications theories . Initial participant responses to scenarios were emotional, changing into immediate health and survival concerns conceptualized as information specific to the agent and event . Knowledge about botulism was low, and participants wanted clear, concise, and actionable messages . Broadcast media, the internet, and community-based sources were cited as sources of information . Findings have implications for botulism preparedness messages and for general public risk communications.

Curr Med Chem, 2004 Dec, 11(23), 3085 - 92
Botulinum toxin: a successful therapeutic protein; Aoki KR; Botulinum toxin serotype A has proven to be a successful and valuable therapeutic protein when dosage, frequency of treatment and variety of treated clinical conditions are considered . This modern therapeutic protein was predicted by Justinus Kerner, a 19th century German physician, who provided the first detailed clinical description of botulism and its association with faulty sausage production . Kerner was preceded by Paracelsus, who described the duality of a drug as "only the dose makes a remedy poisonous" . This concept is well known to modern medicinal chemists, pharmacologists and clinicians worldwide . Because botulinum toxin is an enzyme and specifically delivered to its target cell/neuron, exceedingly small doses are needed to exert its pharmacological effect . Botulinum toxin therapy is successful because of the local administration of nanogram quantities of this highly selective and long-lasting (months) therapeutic effect, which leads to symptomatic relief of numerous disease conditions . These minute therapeutic doses are dramatically lower than the doses needed to cause systemic disease (e.g . botulism) . This review will focus on the current understanding of the mechanism of action of botulinum neurotoxins and the pharmacology of the various approved-marketed products and the direction of future research.

Emerg Infect Dis, 2004 Sep, 10(9), 1685 - 7
Botulism type E outbreak associated with eating a beached whale, Alaska; McLaughlin JB; We report an outbreak of botulism that occurred in July 2002 in a group of 12 Alaskan Yu'pik Eskimos who ate blubber and skin from a beached beluga whale . Botulism death rates among Alaska Natives have declined in the last 20 years, yet incidence has increased.

Emerg Infect Dis, 2004 Sep, 10(9), 1601 - 5
Foodborne botulism in the Republic of Georgia; Varma JK et al.; Foodborne botulism is a potentially fatal, paralytic illness that can cause large outbreaks . A possible increase in botulism incidence during 2001 in the Republic of Georgia prompted this study . We reviewed surveillance data and abstracted records of patients with botulism who were hospitalized from 1980 to 2002 . During this period, 879 botulism cases were detected . The median annual incidence increased from 0.3 per 100,000 during 1980 to 1990 to 0.9 per 100,000 during 1991 to 2002 . For 706 botulism patients hospitalized from 1980 to 2002, 80% of their cases were attributed to home-preserved vegetables . Surveillance evaluation verified that botulism incidence varied greatly by region . Georgia has the highest nationally reported rate of foodborne botulism in the world . A strategy addressing individual behaviors in the home is needed to improve food safety; developing this strategy requires a deeper understanding of why botulism has increased and varies by region.

J Toxicol Clin Toxicol, 2004, 42(4), 383 - 7
A case of type F botulism in southern California; Richardson WH et al.; BACKGROUND: Botulism caused by type F botulinum toxin accounts for less than 0.1% of all human botulism cases and is rarely reported in the literature . CASE REPORT: A 45-year-old woman presented to an emergency department complaining of blurred vision, difficulty focusing, and dysphagia . The treating physician initially considered the possibility of paralytic shellfish poisoning due to a report of shellfish ingestion, which was later determined to be frozen shrimp and a can of tuna, but no gastroenteritis or paresthesias were present . During the emergency department observation, the patient developed respiratory distress with hypercapnea and required intubation and mechanical ventilation . Within hours, ptosis, mydriasis, and weakness in the arms and legs developed . Bivalent (A, B) botulinum antitoxin was administered approximately 24 h from the onset of initial symptoms, but over the next two days complete paralysis progressed to the upper and lower extremities . Shortly thereafter a stool toxin assay demonstrated the presence of type F botulinum toxin . The patient subsequently received an experimental heptavalent botulinum antitoxin on hospital day 7 but paralysis was already complete . Her three-week hospital course was complicated by nosocomial pneumonia and a urinary tract infection, but she gradually improved and was discharged to a rehabilitation facility . Anaerobic cultures and toxin assays have yet to elucidate the source of exposure . CONCLUSION: We report a rare case of type F botulism believed to be foodborne in etiology . Administration of bivalent botulinum antitoxin did not halt progression of paralysis.

Protein Expr Purif, 2004 Oct, 37(2), 399 - 408
Production and purification of a chimeric monoclonal antibody against botulinum neurotoxin serotype A; Mowry MC et al.; Production of recombinant antibodies against botulinum neurotoxin is necessary for the development of a post-exposure treatment . CHO-DG44 cells were transfected with a plasmid encoding the light and heavy chains of a chimeric monoclonal antibody (S25) against botulism neurotoxin serotype A . Stable cell lines were obtained by dilution cloning and clones were shown to produce nearly equivalent levels of light and heavy chain antibody by an enzyme-linked immunosorbent assay (ELISA) . In suspension culture, cells produced 35 microg/ml of chimeric antibody after 6 days, corresponding to a specific antibody productivity of 3.1 pg/cell/day . A method for the harvest and recovery of an antibody against botulism neurotoxin serotype A was investigated utilizing ethylenediamine-N,N'-tetra(methylphosphonic) acid (EDTPA) modified zirconia and MEP-hypercel, a hydrophobic charge interaction chromatography resin . Purification of the S25 antibody was compared to that achieved using rProtein A-Sepharose Fast Flow resin . After the direct load of culture supernatant, analysis by ELISA and gel electrophoresis showed that S25 antibody could be recovered at purities of 41 and 44%, from the EDTPA modified zirconia and MEP-hypercel columns, respectively . Although the purity obtained from each of these columns was low, the ability to withstand high column pressures and nearly 90% recovery of the antibody makes EDTPA modified zirconia well suited as an initial capture step . Combining the EDTPA modified zirconia and HCIC columns in series resulted in both purity and final product yield of 72%.

Clin Infect Dis, 2004 Aug 1, 39(3), 357 - 62 Epub 2004 Jul 19.
Signs and symptoms predictive of death in patients with foodborne botulism--Republic of Georgia, 1980-2002; Varma JK et al.; Foodborne botulism is a severe, potentially fatal disease characterized by cranial nerve palsies and descending paralysis . Little is known about signs and symptoms predictive of death from botulism . We studied patients with botulism in the Republic of Georgia, which has the highest reported rate of foodborne botulism in the world . After abstracting medical records of patients with botulism who were hospitalized during 1980-2002, we performed classification-and-regression-tree analysis to identify clinical syndromes predictive of survival and death . We identified records for 706 patients hospitalized for foodborne botulism from 1980-2002 . Trivalent antitoxin was administered to 623 patients (88%) . Fifty-four (8%) died . Patients with shortness of breath and impaired gag reflex and without diarrhea were 23 times more likely to die than were patients without this syndrome . Validating this clinical prediction rule may help reduce mortality from botulism in Georgia . Validation in other settings could help public health preparations for large outbreaks of naturally occurring or bioterrorism-related botulism.

Expert Rev Vaccines, 2004 Aug, 3(4), 477 - 87
Progress toward development of an inhalation vaccine against botulinum toxin; Park JB et al.; The looming threat of bioterrorism has enhanced interest in the development of vaccines against agents such as botulinum toxin . This in turn has stimulated efforts to create vaccines that are effective by the oral and inhalation routes . Recently, considerable progress has been made in creating an inhalation vaccine against botulism . This work stems from the discovery that a polypeptide that represents a third of the toxin molecule retains the ability to be adsorbed from the airway and to evoke an immune response but retains none of the adverse effects of the native toxin . Interestingly, this polypeptide can also serve as a carrier molecule in the creation of inhalation vaccines against other pathogens.

Semin Neurol, 2004 Jun, 24(2), 155 - 63
Botulism: update and review; Cherington M; Botulism is both an old and an emerging disease . Over 100 years ago, the classic food-borne type was found to be caused by ingesting contaminated food containing the toxin produced by a bacteria . In the first half of the 20th century a second form, wound botulism, was discovered . Three additional forms (infant, hidden, and inadvertent) were first described in the last quarter of the 20th century . Our understanding of how botulinum toxin blocks the release of acetylcholine at the neuromuscular junction has been clarified in the past 10 years . In the past 20 years, we have witnessed one of the strangest of all ironies in the history of medicine . The very lethal botulinum toxin is now being used as a treatment in an expanding list of disorders . Research is advancing in several directions . These new avenues include improved methods of preventing and treating botulism and additional novel uses of botulinum toxin as a therapeutic agent . In this article, the five clinical forms of botulism, the actions of botulinum toxins, electrodiagnostic methods, treatments, and possible future directions are discussed .

Crit Rev Neurobiol, 2003, 15(3-4), 175 - 96
Botulinum neurotoxin: the neuromuscular junction revisited; Coffield JA; Botulinum neurotoxin is the neuromuscular poison that is responsible for the fatal disease botulism . This toxin is also a valued therapeutic agent in the treatment of an increasing number of neuromuscular disorders . Unfortunately, in the wrong hands, botulinum neurotoxin is also a deadly biological "weapon . The diverse health consequences of botulinum neurotoxin combined with the increased threat of bioterrorism underscore the profound importance of understanding exactly how this toxin exerts its effects on the clinically relevant mammalian target site, the neuromuscular junction . Despite the fact that a great deal has been learned about the cellular actions of botulinum neurotoxin during the past three decades, questions still remain . For example, what protein or proteins mediate transport of the toxin into the cholinergic nerve terminal? What factors control the duration of toxin action in the nerve terminal? Until recently, scholarly pursuit of such questions was technically challenging in neuromuscular tissues . Recent advancements in biotechnology have now made it feasible to pursue these important issues at the neuromuscular junction and to correlate biochemical studies in nontarget tissues with clinically relevant functional outcomes . This narrative reviews our current understanding of the actions of botulinum neurotoxin at the neuromuscular junction, presents recent findings from our own work in neuromuscular tissues, and encourages future studies regarding botulinum neurotoxin at its target site.

Rev Med Liege, 2004, 59 Suppl 1, 184 - 9
{Electrodiagnostic assessment of neuromuscular junction disorders}; Chauplannaz G et al.; Electrodiagnosis of neuromuscular junction disorders relies on repetitive nerve stimulation tests (RS) and single-fiber EMG (SFEMG) . RS tests are usually performed on proximal and distal nerves (axillary, accessory, radial, facial, ulnar, median, peroneal) . Ischemic test substantially improves ulnar RS sensitivity . More recently RS of masseter and hypoglossal nerves have been proposed to increase RS sensitivity in patients with bulbar symptoms in myasthenia gravis (MG) . RS of phrenic and long thoracic nerves could be used in MG patients with respiratory symptoms . Sensitivities of these tests are widely different but they are complementary . SFEMG is far more sensitive but technical difficulties have limited its use . In generalized MG, RS should be performed first . Clinically involved muscles should be examined first, then other muscles . If RS tests are negative, SFEMG of facial muscles can be used . In ocular MG, SFEMG, if available, is the best option . In Lambert-Eaton myasthenic syndrome, a single shock on ulnar nerve before and after a brief maximum voluntary contraction should be used to demonstrate increment and 3 Hz RS a decrement . If negative, median and radial nerves should be studied . Additionally electrodiagnosis features of congenital myasthenic syndromes and botulism are reviewed.

Dermatol Clin, 2004 Apr, 22(2), 131 - 3, v
Development of botulinum toxin therapy; Scott AB; Justinius Kerner collected data on 230 cases of botulism in the 1820s, suggested the therapeutic use of toxin, and gave a remarkably complete and accurate description of clinical botulism: its symptoms, time course, and the physical findings that the tear fluid disappears, the skin is dry, the eye, gut, and somatic muscles are paralyzed, and mucus and saliva secretion is suppressed . These effects are the clinical targets of botulinum therapy today . Inspired by Drachman's use of toxin to safely paralyze the hind limb in chicks, we worked out the procedures for its safe medical application and licensure from 1972 to 1989, applying it first to correct strabismus, blepharospasm, leg muscle spasm, and torticollis . This list is now extended by others to well over 100 uses . For many years, blepharospasm patients returning for injection around the eyes and upper face would mention as a joke that they were "back to get the wrinkles out." Working in aesthetic dermatology and ophthalmology, Alistair and Jean Carruthers could envision the intentional cosmetic application of botulinum toxin, probably its greatest single use today.

Przegl Epidemiol, 2004, 58(1), 103 - 10
{Botulism in Poland in 2002}; Przybylska A; A total of 85 foodborne botulism were registered in Poland in 2002, with corresponding incidence 0.22 per 100,000 population . In rural areas were registered 67% of cases and in urban areas--33% (adequately--incidence 0.39 and 0.12) . There were 53 outbreaks of one person noted, 11 outbreaks of two people, 2 outbreaks of three, and 1 outbreak of four people . Meat dishes were the main vehicle of botulinum toxin (58 cases; 68.2%) . Out of them, home made conserves (bottling jars) prepared from pork meat (23.5% of cases) and commercial produced sausages (20.0%) prevailed as vehicles . Five deaths (three men and two women) from foodborne botulism were registered in Poland in 2002.

Xi Bao Yu Fen Zi Mian Yi Xue Za Zhi, 2004 Jan, 20(1), 83 - 5
Generation and characterization of monoclonal antibodies against botulinum neurotoxin type A (BoNT/A); Wang JL et al.; AIM: To generate the monoclonal antibodies(mAbs) against botulinum neurotoxin type A (BoNT/A) . METHODS: BALB/c mice were intraperitoneally immunized with purified BoNT/A-Hc, and the splenocytes of immunized mice were fused with myeloma cells Sp2/0 . Hybridoma cells were screened by indirect ELISA and monoclonal hybridoma cells was obtained using limited dilution . RESULTS: Three hybridomas, named 4A8, 2F7 and 4F2, producing the mAbs against BoNT/A, were successfully established, and the titer of ascitic mAbs ranged from 1x10(-4) to 1x10(-6) . Identification of subclass showed that all the produced mAbs belonged to IgG1 . 4A8 and 4F2 were stable in secreting anti-BoNT/A mAbs through three-month continuous culture and showed high specificity to recombinant BoNT/A-Hc and native BoNT/A . CONCLUSION: Anti-BoNT/A mAbs we generated have high specificity, which laid the foundation for the immunological detection of BoNT/A and clinical treatment of botulism in the future.

Acta Pharmacol Sin, 2004 Jun, 25(6), 839 - 48
Cure of experimental botulism and antibotulismic effect of toosendanin; Shi YL et al.; Botulinum neurotoxins (BoNTs), a group of bacterial proteins that comprise a light chain disulfide linked a heavy chain, are the most lethal biotoxins known to mankind . By inhibiting neurotransmitter release, BoNTs cause severe neuroparalytic disease, botulism . A series of important findings in the past 10 years which displayed the molecular targets of BoNTs and hence proposed a four-step action mechanism to explain BoNT intoxication greatly advanced the study of antibotulismic drug . In this article, we reviewed these progresses and anti-botulismic compounds found in recent years . These compounds function due to their facilitation on neurotransmitter release or to their interference on the binding, internalization, translocation, and endopeptidase activity of the toxins . Toosendanin is a triterpenoid derivative extracted from a digestive tract-parasiticide in Chinese traditional medicine . Chinese scientists have found that the compound is a selective prejunctional blocker . In spite of sharing some similar action with BoNT, toosendanin can protect botulism animals that have been administrated with lethal doses of BoNT/A or BoNT/B for several hours from death and make them restore normal activity . The neuromuscular junction preparations isolated from the rats that have been injected with toosendanin tolerate BoNT/A challenge . Toosendanin seems to have no effect on endopeptidase activity of BoNT, but blocks the toxin approach to its enzymatic substrate.

J Med Microbiol, 2004 Jun, 53(Pt 6), 555 - 61
Wound botulism in the UK and Ireland; Brett MM et al.; There are three main, naturally occurring, epidemiological types of botulism: food-borne, intestinal colonization (infant botulism) and wound botulism . The neurological signs and symptoms are the same for all three epidemiological types and may include respiratory paralysis . Wound botulism is caused by growth of cells and release of toxin in vivo, is associated with traumatic wounds and abscesses and has been reported in drug users, such as those injecting heroin or sniffing cocaine . Up to the end of 1999 there were no confirmed cases of wound botulism in the UK . Between the beginning of 2000 and the end of December 2002, there were 33 clinically diagnosed cases of wound botulism in the UK and Ireland . All cases had injected heroin into muscle or by 'skin popping' . The clinical diagnosis was confirmed by laboratory tests in 20 of these cases . Eighteen cases were caused by type A toxin and two by type B toxin.

Curr Opin Investig Drugs, 2004 Feb, 5(2), 135 - 40
Current therapy and the development of therapeutic options for the treatment of diseases due to bacterial agents of potential biowarfare and bioterrorism; Greenfield RA et al.; An important part of biodefense is the optimization of current therapy and the development of new therapeutic options for the treatment of the diseases most likely encountered in the form of biological weapons . Guidelines for the prevention and treatment of anthrax, plague, tularemia and botulinum toxin intoxication are reviewed . The strategies in development for the prevention of anthrax focus primarily on active and passive immunization against protective antigen, because of its central role as a toxin delivery module . Novel vaccine strategies for plague, tularemia and botulism are also reviewed.

Eur J Emerg Med, 2004 Apr, 11(2), 119 - 20
Anticholinergic toxicity associated with lupin seed ingestion: case report; Di Grande A et al.; We describe a case of acute poisoning in a 51-year-old female patient who presented to the Emergency Department with weakness, anxiety, dry mouth, bilateral mydriasis and lid drop . In differential diagnosis, botulism, Guillain-Barre syndrome and myasthenia gravis were considered, as well as cerebral haematoma because of a cranial injury a week before . Symptoms, which resolved within 12 h without any therapy, were instead related to the ingestion of lupin seeds.

Mov Disord, 2004 Mar, 19 Suppl 8, S48 - 52
Roads from vaccines to therapies; Smith LA et al.; Over the past decade, we have demonstrated that various recombinant fragments of botulinum neurotoxin are highly immunogenic, stimulating notable levels of protective antibodies in mice, guinea pigs, and nonhuman primates . One of the fragments evaluated, the fragment C, is a potential next-generation vaccine candidate to replace the current pentavalent botulinum toxoid vaccine . Synthetic genes encoding the carboxyl-terminal regions (approximately 50 kDa) of toxin types A, B, C1, E, and F were expressed in Pichia pastoris, and manufacturing processes were developed for producing highly purified vaccines . These vaccines were shown to be safe, highly efficacious, stable, and amenable to high-level industrial production . Recombinant vaccines are now being produced in accordance with current Good Manufacturing Practices for use in future clinical trials . As our discovery-based program on vaccine development is diminishing, it is concurrently being replaced with a program focused on developing therapeutic interventions to botulism . Synthetic genes encoding the light chains of botulinum toxin have been expressed in Escherichia coli, and purified . These proteolytically active light chains are being used in high-throughput assays to screen for inhibitors of its catalytic activity . Other resources developed as part of the vaccine initiative, likewise, are finding utility in the quest to develop therapies for botulism .

Expert Opin Biol Ther, 2004 Mar, 4(3), 387 - 96
Pathogen-specific recombinant human polyclonal antibodies: biodefence applications; Bregenholt S et al.; The potential use of biological agents such as viruses, bacteria or bacterial toxins as weapons of mass destruction has fuelled significant national and international research and development in novel prophylactic or therapeutic countermeasures . Such measures need to be fast-acting and broadly specific, a hallmark of target-specific polyclonal antibodies (pAbs) . As reviewed here, pathogen-specific antibodies in the form of human or animal serum have long been recognised as effective therapies in a number of infectious diseases . This review focuses in particular on the potential biowarfare agents prioritised by the National Institute of Allergy and Infectious Diseases and the Centers for Disease Control and Prevention (CDC), referred to as the category A organisms . Furthermore, it is propose that the last decade of development in recombinant antibody technologies offers the possibility for developing highly specific human monoclonal or polyclonal pathogen-specific antibodies . In particular, pathogen-specific polyclonal human antibodies offer certain advantages over existing hyperimmune serum products, monoclonal antibodies, small molecule drugs and vaccines . Here, the rationale for designing pAb-based therapeutics against the CDC category A microbial agents causing anthrax, botulism, plague, smallpox, tularaemia and viral haemorrhagic fevers, as well as the overall design of such therapeutics, are discussed.

Headache, 2004 Jan, 44(1), 35 - 42; discussion 42-3
Regulation of calcitonin gene-related peptide secretion from trigeminal nerve cells by botulinum toxin type A: implications for migraine therapy; Durham PL et al.; OBJECTIVES: To determine the effect of botulinum toxin type A on calcitonin gene-related peptide secretion from cultured trigeminal ganglia neurons . BACKGROUND: The ability of botulinum toxins to cause muscle paralysis by blocking acetylcholine release at the neuromuscular junction is well known . Previous studies and clinical observations have failed to demonstrate sensory changes related to botulinum toxins or the disease of botulism . Recent studies, however, have suggested that botulinum toxin type A injected into pericranial muscles may have a prophylactic benefit in migraine . This observation has renewed the debate of a mechanism of sensory inhibition mediated by botulinum toxin type A . METHODS: Primary cultures of rat trigeminal ganglia were utilized to determine whether botulinum toxin type A could directly decrease the release of calcitonin gene-related peptide, a neuropeptide involved in the underlying pathophysiology of migraine . Untreated cultures or cultures stimulated with a depolarizing stimulus (potassium chloride) or capsaicin, an agent known to activate sensory C fibers, were treated for 3, 6, or 24 hours with clinically effective doses of botulinum toxin type A or a control vehicle . The amount of calcitonin gene-related peptide secreted into the culture media following the various treatments was determined using a specific radioimmunoassay . RESULTS: A high percentage (greater than 90%) of the trigeminal ganglia neurons present in 1- to 3-day-old cultures was shown to express calcitonin gene-related peptide . Treatment with depolarizing stimuli (potassium chloride), a mixture of inflammatory agents, or capsaicin caused a marked increase (4- to 5-fold) in calcitonin gene-related peptide released from the trigeminal neurons . Interestingly, overnight treatment of trigeminal ganglia cultures with therapeutic concentrations of botulinum toxin type A (1.6 or 3.1 units) did not affect the amount of calcitonin gene-related peptide released from these neurons . The stimulated release of calcitonin gene-related peptide following chemical depolarization with potassium chloride or activation with capsaicin, however, was greatly repressed by the botulinum toxin, but not by the control vehicle . A similar inhibitory effect of overnight treatment with botulinum toxin type A was observed with 1.6 and 3.1 units . These concentrations of botulinum toxin type A are well within or below the range of tissue concentration easily achieved with a local injection . Incubation of the cultures with toxin for 24, 6, or even 3 hours was very effective at repressing stimulated calcitonin gene-related peptide secretion when compared to control values . CONCLUSIONS: These data provide the first evidence that botulinum toxin type A can directly decrease the amount of calcitonin gene-related peptide released from trigeminal neurons . The results suggest that the effectiveness of botulinum toxin type A in the treatment of migraine may be due, in part, to its ability to repress calcitonin gene-related peptide release from activated sensory neurons.

Protein Expr Purif, 2004 Mar, 34(1), 8 - 16
Cloning, high-level expression, single-step purification, and binding activity of His6-tagged recombinant type B botulinum neurotoxin heavy chain transmembrane and binding domain; Zhou Y et al.; Botulinum neurotoxins (BoNTs) are highly potent toxins that inhibit neurotransmitter release from peripheral cholinergic synapses and associate with infant botulism . BoNT is a approximately 150kDa protein, consisting of a binding/translocating heavy chain (HC; 100kDa) and a toxifying light chain (LC; 50kDa) linked through a disulfide bond . C-terminal half of the heavy chain is binding domain, and N-terminal half of the heavy chain is translocation domain that includes transmembrane domain . A functional botulinum neurotoxin type B heavy chain transmembrane and binding domain (Ile 624-Glu 1291) has been cloned into a bacterial expression vector pET 15b and produced as an N-terminally six-histidine-tagged fusion protein (BoNT/B HC TBD) . (His(6))-BoNT/B HC TBD was highly expressed in Escherichia coli BL21-CodonPlus (DE3)-RIL and isolated from the E . coli inclusion bodies . After solubilizing the purified inclusion bodies with 6M guanidine-HCl in the presence of 10mM beta-mercaptoethanol, the protein was purified and refolded in a single step on Ni(2+) affinity column by removing beta-mercaptoethanol first, followed by the removal of urea . The purified protein was determined to be 98% pure as assessed by SDS-polyacrylamide gel . (His(6))-BoNT/B HC TBD retained binding to synaptotagmin II, the receptor of BoNT/B, which was confirmed by immunological dot blot assay, also to ganglioside, which was investigated using enzyme-linked immunosorbent assay.

J Food Prot, 2004 Jan, 67(1), 203 - 6
Comparison of the mouse bioassay and enzyme-linked immunosorbent assay procedures for the detection of type A botulinal toxin in food; Ferreira JL et al.; Samples of chili linked to a foodborne illness outbreak of type A botulism were examined for preformed type A botulinal toxin using two enzyme-linked immunosorbent assay (ELISA) procedures and the mouse bioassay . One of the samples was positive for type A botulinal toxin and three of the samples were negative for type A, B, E, and F botulinal toxins using the three methods . The mouse bioassay indicated that type A toxin was present at the 10,000 minimal lethal dose per gram (MLD per g) of product . The ELISA tests indicated a toxicity of 7,650 MLD per g with one method and 8,350 MLD per g with the other method . The sample toxicity determined by the ELISA was estimated by comparing samples to a standard curve generated with standard type A neurotoxin in casein buffer . The ELISA methods are more rapid than the mouse bioassay, since the toxin type can be determined in 1 day . The mouse bioassay is more sensitive than the ELISA but usually requires multiple assays to obtain the toxin type and toxicity . Type A culture isolates from the sample were also verified using one ELISA method.

J Protein Chem, 2003 Jul, 22(5), 441 - 8
A capillary electrophoresis technique for evaluating botulinum neurotoxin B light chain activity; Adler M et al.; Botulinum neurotoxin B (BoNT/B) produces muscle paralysis by cleaving synaptobrevin/vesicle-associated membrane protein (VAMP), an 18-kDa membrane-associated protein located on the surface of small synaptic vesicles . A capillary electrophoresis (CE) assay was developed to evaluate inhibitors of the proteolytic activity of BoNT/B with the objective of identifying suitable candidates for treatment of botulism . The assay was based on monitoring the cleavage of a peptide that corresponds to residues 44-94 of human VAMP-2 (V51) following reaction with the catalytic light chain (LC) of BoNT/B . Cleavage of V51 generated peptide fragments of 18 and 33 amino acids by scission of the bond between Q76 and F77 . The fragments and parent peptide were clearly resolved by CE, allowing accurate quantification of the BoNT/B LC-mediated reaction rates . The results indicate that CE is suitable for assessing the enzymatic activity of BoNT/B LC.

Eur J Neurosci, 2005 Jan, 21(1), 151 - 60
Secretion of ATP from Schwann cells in response to uridine triphosphate; Liu GJ et al.; Abstract The mechanisms by which uridine triphosphate (UTP) stimulates ATP release from Schwann cells cultured from the sciatic nerve were investigated using online bioluminescence techniques . UTP, a P2Y(2) and P2Y(4) receptor agonist, stimulated ATP release from Schwann cells in a dose-dependent manner with an ED(50) of 0.24 microm . UTP-stimulated ATP release occurs through P2Y(2) receptors as it was blocked by suramin which inhibits P2Y(2) but not P2Y(4) receptors . Furthermore, positive immunostaining of P2Y(2) receptors on Schwann cells was revealed and GTP, an equipotent agonist with UTP at rat P2Y(4) receptors, did not significantly stimulate ATP release . UTP-stimulated ATP release involved second messenger pathways as it was attenuated by the phospholipase C inhibitor U73122, the protein kinase C inhibitor chelerytherine chloride, the IP(3) formation inhibitor lithium chloride, the cell membrane-permeable Ca(2+) chelator BAPTA-AM and the endoplasmic reticulum Ca(2+)-dependent ATPase inhibitor thapsigargin . Evidence that ATP may be stored in vesicles that must be transported to the cell membrane for exocytosis was found as release was significantly reduced by the Golgi-complex inhibitor brefeldin A, microtubule disruption with nocodazole, F-actin disruption with cytochalasin D and the specific exocytosis inhibitor botulinum toxin A . ATP release from Schwann cells also involves anion transport as it was significantly reduced by cystic fibrosis transmembrane conductance regulator inhibitor glibencamide and anion transporter inhibitor furosemide . We suggest that UTP-stimulated ATP release is mediated by activation of P2Y(2) receptors that initiate an IP(3)-Ca(2+) cascade and protein kinase C which promote exocytosis of ATP from vesicles as well as anion transport of ATP across the cell membrane.

J Biomech, 2005 Mar, 38(3), 609 - 13
Frequency and length-dependent effects of Botulinum toxin-induced muscle weakness; Longino D et al.; While the pathogenesis of Botulinum toxin type A (BTX-A)-induced muscle weakness has been systematically researched, little is known about the effects of motor fibre paralysis on the mechanical properties of skeletal muscle . Here, the long-term effect of BTX-A injection on the force-length and force-frequency properties of rabbit knee extensors is investigated . BTX-A-induced muscle weakness was greater at short compared to long muscle lengths and at low compared to high stimulation frequencies four weeks following intervention . Therefore, we conclude that the paralysing effects of BTX-A are not uniform, and must be considered in biomechanical models of musculoskeletal rehabilitation in which BTX-A is used therapeutically, as for example in patients with cerebral palsy . Although the present results could be explained through a variety of mechanisms, this study does not allow for drawing firm conclusions about the length and frequency-dependent effects of BTX-A.

Eur Neurol . 2005 Jan 12;53(1):3-9 {Epub ahead of print}
Botulinum Toxin: Mechanisms of Action; Dressler D et al.; Botulinum toxin (BT) has been perceived as a lethal threat for many centuries . In the early 1980s, this perception completely changed when BT's therapeutic potential suddenly became apparent . We wish to give an overview over BT's mechanisms of action relevant for understanding its therapeutic use . BT's molecular mode of action includes extracellular binding to glycoprotein structures on cholinergic nerve terminals and intracellular blockade of the acetylcholine secretion . BT affects the spinal stretch reflex by blockade of intrafusal muscle fibres with consecutive reduction of Ia/II afferent signals and muscle tone without affecting muscle strength (reflex inhibition) . This mechanism allows for antidystonic effects not only caused by target muscle paresis . BT also blocks efferent autonomic fibres to smooth muscles and to exocrine glands . Direct central nervous system effects are not observed, since BT does not cross the blood-brain barrier and since it is inactivated during its retrograde axonal transport . Indirect central nervous system effects include reflex inhibition, normalisation of reciprocal inhibition, intracortical inhibition and somatosensory evoked potentials . Reduction of formalin-induced pain suggests direct analgesic BT effects possibly mediated by blockade of substance P, glutamate and calcitonin gene-related peptide . Copyright (c) 2005 S . Karger AG, Basel.

Biochem Soc Symp, 2005, (72), 139 - 50
Lipids, Rafts and Traffic: Chapter 14 - Endocytosis and retrograde axonal traffic in motor neurons; Deinhardt K et al.; Spinal cord motor neurons control voluntary movement by relaying messages that arrive from upper brain centres to the innervated muscles . Despite the importance of motor neurons in human health and disease, the precise control of their membrane dynamics and its effect on motor neuron homoeostasis and survival are poorly understood . In particular, the molecular basis of the co-ordination of specific endocytic events with the axonal retrograde transport pathway is largely unknown . To study these important vesicular trafficking events, we pioneered the use of atoxic fragments of tetanus and botulinum neurotoxins to follow endocytosis and retrograde axonal transport in motor neurons . These neurotoxins bind specifically to pre-synaptic nerve terminals, where they are internalized . Whereas botulinum neurotoxins remain at the neuromuscular junction, tetanus toxin is retrogradely transported along the axon to the cell body, where it is released into the intersynaptic space and is internalized by adjacent inhibitory interneurons . The high neurospecificity and the differential intracellular sorting make tetanus and botulinum neurotoxins ideal tools to study neuronal physiology . In the present review, we discuss recent developments in our understanding of the internalization and trafficking of these molecules in spinal cord motor neurons . Furthermore, we describe the development of a reliable transfection method for motor neurons based on microinjection, which will be extremely useful for dissecting further the molecular basis of membrane dynamics and axonal transport in these cells.

Anal Chem, 2005 Jan 15, 77(2), 549 - 55
Bacillus globigii Bugbeads: A Model Simulant of a Bacterial Spore; Farrell S et al.; Nonpathogenic microorganisms are often used as simulants of biological pathogens during the initial phase of detection method development . While these simulants approximate the size, shape, and cellular organization of the microorganism of interest, they do not resemble its surface protein content, a factor particularly important in methods based on immunorecognition . Here, we develop and detect an artificial bacterial spore-B . globigii (BG) Bugbead-a particle mimicking the antigenic surface of BG spores . Two methods of spore protein extraction were compared both quantitatively (by protein concentration assay) and qualitatively (by SDS-PAGE and Western blot): extraction by mechanical disruption and extraction by chemical decoating . The former method was more efficient in producing more protein and a greater number of antigens . BG Bugbeads were made by conjugating the extracted proteins to 0.8-mum carboxyl-coated polystyrene particles via carbodiimide coupling . BG Bugbeads were successfully detected by a bead-based enzyme-labeled immunoassay with fluorescence detection with a detection limit of 6.9 x 10(3) particles/mL . Formation of the Bugbead-capture bead complex was confirmed by ESEM. , . The concept of a harmless artificial spore can be applied to developing improved simulants for pathogenic spore-forming microorganisms such as B . anthracis, C . botulinum, and B . cereus, which can to be used for method validation, instrument calibration, and troubleshooting.

Protein J, 2004 Nov, 23(8), 539 - 52
Mapping of the synaptosome-binding regions on the heavy chain of botulinum neurotoxin A by synthetic overlapping peptides encompassing the entire chain; Maruta T et al.; The purpose of this work was to map, on the heavy (H) chain of botulinum neurotoxin A (BoNT/A), the regions that bind to mouse brain synaptosomes (snps) . We prepared 60 synthetic overlapping peptides that had uniform size and overlaps and encompassed the entire H chain (residues 499 to 1296) of BoNT/A . The ability of each peptide to inhibit the binding of 125I-labeled BoNT/A to mouse brain snps was studied . The binding of 125I-labeled BoNT/A to mouse brain snps was completely inhibited by free unlabeled BoNT/A, but not by unrelated proteins, indicating that the binding of BoNT/A to mouse brain snps was a specific event . Inhibition studies with the individual peptides showed that, on the H(N) domain, inhibitory activities greater than 10% were exhibited, in decreasing order, by peptides 799-817, 659-677, 729-747, 533-551, 701-719, and 757-775 . Lower inhibitory activities (between 5.6% and 8.7%) were exhibited by five other peptides, 463-481, 505-523, 519-537, 603-621 and 645-663 . The remaining 18 H(N) peptides had little or no inhibitory activity . In the H(C) domain, peptides 1065-1083, 1163-1181 and 1275-1296 had the highest inhibitory activities (between 25% and 29%), followed (10-12% inhibitory activity) by peptides 1107-1125, 1191-1209 and 1233-1251 . Two other peptides, 1079-1097 and 1177-1195, had very low (5.8% and 4.9%) inhibitory activities . The remaining 23 H(C) peptides had no inhibitory activity . Inhibition with mixtures of equimolar quantities of the most active 6 peptides of HN, 5 of H(C) or all 11 of H(N) and H(C) revealed that the peptides contain independent non-competing binding regions . Comparison of the locations of the snp-binding regions on the H-subunit with the regions that bind blocking mouse anti-BoNT/A Abs helped explain the protecting ability of these Abs . In the three-dimensional structure of BoNT/A, the snp-binding regions that completely coincide or significantly overlap with the antigenic regions occupy surface locations and most of them reside in the last half of the H(C) domain . But some of the regions reside in the HN domain and might play a role in the translocation event.

Laryngorhinootologie, 2005 Jan, 84(1), 55 - 62
{The management of Dysphagia - part 2: therapy.}; Schonweiler R et al.; The Management of Dysphagia . In the first part of the article we described diagnostic methods aiming to resolve the individual underlying pathomechanism of chronic swallowing disorders (dysphagia) . From these, we deducted different therapeutic measures that can be applied either alone or in combination . Weakening of the upper esophageal sphincter with botulinum toxin is reserved for patients with structural stenosis or a relative hyperfunction of the sphincter . It can be tried to use the "Passy-Muir Valve" for tracheostomized patients that aspirate . Most cases benefit from a therapy that consists of specific exercises . "Restitution" relies on exercises to practice new movement patterns as well as improvement of muscle strength . "Compensation" is based on exercises to counteract structural and/or functional deficits . Through "adaptation" residual, therapy resistant disease can be alleviated through dietary planning of consistency, temperature, and nutrient content of food . In many cases it is necessary to combine "restitution", "compensation", and "adaptation" . In the first part of the article we described diagnostic methods aiming to resolve the individual underlying pathomechanism of chronic swallowing disorders (dysphagia) . From these, we deducted different therapeutic measures that can be applied either alone or in combination . Weakening of the upper esophageal sphincter with botulinum toxin is reserved for patients with structural stenosis or a relative hypofunction of the sphincter . It can be tried to use the "Passy-Muir Valve" for tracheostomized patients that aspirate . Most cases benefit from a therapy that consists of specific exercises . "Restitution" relies on exercises to practice new movement patterns as well as improvement of muscle strength . "Compensation" is based on exercises to counteract structural and/or functional deficits . Through "adaptation" residual, therapy resistant disease can be alleviated through dietary planning of consistency, temperature and nutrient content of food . In many cases it is necessary to combine "restitution", "compensation" and "adaptation" . Summary . BACKGROUND: In histologic studies, the volumetric status of the intralabyrinthine fluids is judged by the position of the endolymphatic membranes . Bulging of the membranes, commonly known as endolymphatic hydrops, is assumed to be caused by excess of endolymph . The opposite situation, retraction of the membranes is, however, only incidentally described and relatively little attention has been paid to its significance . Almost one hundred years ago Wittmaack described retraction of the endolymphatic membranes, which has since been considered to be preparation artifact - a concept that essentially remains unchallenged . To test the validity of this long held premise, we examined two sets of temporal bones from different centers . MATERIAL AND METHODS: We studied the following collections: 1 . The Wittmaack collection in Hamburg, Germany . The original material of 67 temporal bones (patient ages 0-92 years, average age 35.2 years) on which Wittmaack based his opinions . 2 . For comparison and to exclude age related phenomena, 125 temporal bones from 73 children between the ages newborn to ten years (average age 13.4 months, median 1.5 months) from the temporal bone collection of the Department of Otolaryngology Tufts University School of Medicine . All specimens were studied by light microscopy . Retraction was defined as depression of Reissner's membrane toward the stria vascularis and the Organ of Corti in more than one cochlear turn and was graded into mild, moderate and severe . Additionally the saccule, utricle and semicircular ducts were examined for collapse . RESULTS: The reevaluation of the 67 temporal bones described by Wittmaack, including those of 7 children below the age of 10 years, showed retraction of Reissner's membrane in 81% compared to 33% of the temporal bones from the Tufts collection . In contrast to the high incidence of retraction in the cochlear duct, fewer saccules (12%) and utricles (4%) were collapsed in the Tufts collection . In the Wittmaack collection no significant differences between the underlying diseases were found, however in the Tufts collection the group of children who suffered from extracochlear infections and malignancies had a higher frequency of retraction . CONCLUSION: Mild retraction might be to some extent physiologic or even artifactual . Severe retraction, however, is a definitive finding that is a part of a local or regional otopathologic process . Of material, it is quite possible that Wittmaack's original observations of what he called "hypotonic collapse" was of viral origin (viruses were not known during Wittmaack's time), ototoxicity or even of genetic origin.

J Cutan Med Surg . 2005 Jan 6; {Epub ahead of print}
Novel Opportunities in the Treatment and Prevention of Scarring; Berman B et al.; Numerous treatments have been described for the treatment and prevention of scars, but the optimal management strategy is yet to be defined . In this article we present and evaluate new opportunities for the treatment and prevention of hypertrophic scars, keloids, and atrophic scars . Clinical, animal, and in vitro studies reporting novel techniques for the treatment and prevention of scarring were identified primarily from the MEDLINE/PubMed database . We found that a variety of new treatments exist with potential effectiveness for the treatment of hypertrophic scars and keloids, including interferon, imiquimod 5% cream, tacrolimus, botulinum toxin, 5-fluorouracil, bleomycin, and verapamil . For atrophic scars, different types of lasers represent modern treatment modalities with satisfactory results . Several agents have been reported to be effective in reducing scarring in vitro and in animal studies, representing potential opportunities for scarring management . We conclude that several novel modalities may be potential therapies for scarring.

J Neurosci, 2005 Jan 12, 25(2), 417 - 29
Regulation of gephyrin cluster size and inhibitory synaptic currents on Renshaw cells by motor axon excitatory inputs; Gonzalez-Forero D et al.; Renshaw cells receive a high density of inhibitory synapses characterized by large postsynaptic gephyrin clusters and mixed glycinergic/GABAergic inhibitory currents with large peak amplitudes and long decays . These properties appear adapted to increase inhibitory efficacy over Renshaw cells and mature postnatally by mechanisms that are unknown . We tested the hypothesis that heterosynaptic influences from excitatory motor axon inputs modulate the development of inhibitory synapses on Renshaw cells . Thus, tetanus (TeNT) and botulinum neurotoxin A (BoNT-A) were injected intramuscularly at postnatal day 5 (P5) to, respectively, elevate or reduce motor axon firing activity for approximately 2 weeks . After TeNT injections, the average gephyrin cluster areas on Renshaw cells increased by 18.4% at P15 and 28.4% at P20 and decreased after BoNT-A injections by 17.7% at P15 and 19.9% at P20 . The average size differences resulted from changes in the proportions of small and large gephyrin clusters . Whole-cell recordings in P9-P15 Renshaw cells after P5 TeNT injections showed increases in the peak amplitude of glycinergic miniature postsynaptic currents (mPSCs) and the fast component of mixed (glycinergic/GABAergic) mPSCs compared with controls (60.9% and 78.9%, respectively) . GABAergic mPSCs increased in peak amplitude to a smaller extent (45.8%) . However, because of the comparatively longer decays of synaptic GABAergic currents, total current transfer changes after TeNT were similar for synaptic glycine and GABA(A) receptors (56 vs 48.9% increases, respectively) . We concluded that motor axon excitatory synaptic activity modulates the development of inhibitory synapse properties on Renshaw cells, influencing recruitment of postsynaptic gephyrin and glycine receptors and, to lesser extent, GABA(A) receptors.

Klin Oczna, 2004, 106(4-5), 666 - 9
{Using a botuline toxin diagnostic test in a case of bilateral stilling--TĂźrk--Duane (STD) syndrome found during preparation for cataract surgery}; Broniarczyk-Loba A et al.; PURPOSE: The presentation of complex procedures in preoperative diagnosis, allowing the evaluation of reaction of a patient with bilateral STD syndrome, to a potential change in the long-lasting ocular motility disturbances and corrective head position . MATERIAL AND METHODS: The botuline toxin was injected into the medial rectus muscle of the eye with greater motility disturbance in convergent strabismus . It was discovered during preparation for cataract surgery in a 45 years old female with STD Syndrome I type . Due to reduced visual acuity the diagnosis of binocular vision were performed after bilateral cataract surgery . We were afraid that the fixed sensory status of the patient would change, and therefore we performed botuline injections . Strabismus angle, ocular motility and diplopia were assessed and compared . RESULTS: The reduction of strabismus angle was achieved with no diplopia . The patient no longer needed the corrective head position, with binocular vision present while looking straight ahead . Also, a slight improvement was obtained in the abduction motility of the eye to which botuline toxin was injected. , . CONCLUSION: Preoperative diagnostic botuline toxin injection into the rectus medial muscle of the eye with greater motility disturbance, gives an effect of strabismus reduction . This allows for further decisions of whether, and what type of surgical treatment should be performed.

Klin Oczna, 2004, 106(4-5), 625 - 8
{Botulinum toxin A in the treatment of congenital nystagmus in children}; Oleszczynska-Prost E; PURPOSE: To evaluate the use of, botulinum toxin A in the treatment of congenital nystagmus in children . MATERIAL AND METHODS: 32 children with nystagmus and esotropia (group I), nystagmus and exotropia (group II) and horizontal and vertical nystagmus (group III) . Intramuscular injections of botulinum toxin A was performed in all treated children . RESULTS: In group I the amplitude of nystagmus diminished of 50%, in group II of 42.9% and in group III of 28,6% . Near and distant visual acuity improved in all treated children . CONCLUSIONS: Treatment of congenital nystagmus with botulinum toxin A causes reduction of the amplitude of nystagmus, partial improvement of visual acuity and improvement of anomalous head posture.

Mov Disord . 2005 Jan 11; {Epub ahead of print}
Long-term botulinum toxin efficacy, safety, and immunogenicity; Mejia NI et al.; To determine the long-term efficacy of botulinum toxin (BTX) treatments, we analyzed longitudinal follow-up data on 45 patients (32 women; mean age, 68.8 years) currently followed in the Baylor College of Medicine Movement Disorders Clinic, who have received BTX treatments continuously for at least 12 years (mean 15.8 +/- 1.5 years) . Their mean response rating after the last injection, based one a previously described scale 0-to-4 scale (0 = no effect; 4 = marked improvement) was 3.7 +/- 0.6 and the mean total duration of response was 15.4 +/- 3.4 weeks . Although the latency and total duration of the response to treatment have not changed over time, the peak duration of response (P < 0.005) and dose per visit (P < 0.0001) have increased since the initial visit . Furthermore, global rating (P < 0.02) and peak effect (P < 0.05) have improved . In total, 20 adverse events occurred in 16 of 45 (35.6%) patients after their initial visit and 11 adverse events in 10 of 45 (22.2%) patients at their most recent injection visit . Antibody (Ab) testing was carried out in 22 patients due to nonresponsiveness; blocking Abs were confirmed by the mouse protection assay in 4 of 22 (18%) patients . Of the Ab-negative patients, 16 resumed responsiveness after dose adjustments and2 persisted as nonrespondents . Except for 1 patient, the 4 Ab-positive and the 2 clinical nonresponders are being treated with BTX-B . This longest reported follow-up of BTX injections confirms the long-term efficacy and safety of this treatment . (c) 2005 Movement Disorder Society.

J Urol, 2005 Feb, 173(2), 621 - 4
Inhibitory effect of intravesically applied botulinum toxin a in chronic bladder inflammation; Vemulakonda VM et al.; PURPOSE:: We evaluated a putative inhibitory effect of intravesical botulinum toxin A (BTX-A) on afferent pathways in conditions of chronic bladder inflammation . MATERIALS AND METHODS:: Female Sprague-Dawley rats were divided into 4 groups, namely group 1-saline treated, group 2-BTX-A treated, group 3-cyclophosphamide (CYP) treated and group 4-BTX-A and CYP treated . At the beginning of the treatment period all animals received intravesical protamine sulfate (1%), followed by intravesical BTX-A or saline . Subsequently CYP or saline was injected intraperitoneally every 3 days for 10 days . The rats then underwent cystometrogram evaluation prior to spinal cord harvest . Sections from the L6 and S1 spinal cord segments were examined for the total number of Fos immunoreactive cells . RESULTS:: Comparisons of the L6 and S1 sections showed a significant difference among groups (p <0.05) . CYP treated animals had a significant increase in L6 and S1 (78% and 107%, respectively) c-fos expression compared with saline controls (p <0.001) . Comparison of the CYP and BTX-A/CYP groups showed a significant decrease in L6 and S1 in c-fos expression (50% and 52%, respectively) in the BTX-A/CYP treated group (p <0.001) . No significant difference was present between the saline and BTX-A alone groups . Cystometrogram studies revealed that the nonvoiding intercontractile interval increased by more than 10-fold in BTX-A/CYP treated animals compared with CYP treated rats (p <0.01) . CONCLUSIONS:: In a CYP model of chronic bladder inflammation intravesical BTX-A significantly inhibits the afferent neural response without impairing efferent bladder function.

J Clin Neurosci, 2005 Jan, 12(1), 102 - 4
Primary writing tremor: motor cortex reorganisation and disinhibition; Byrnes ML et al.; BACKGROUND: Primary writing tremor (PWT) is a task-specific tremor of uncertain origin . There has been debate as to whether PWT represents a variant of essential tremor or a tremulous form of focal dystonia related to writer's cramp . In writer's cramp there is evidence of changes in intracortical inhibition (ICI), as well as cortical motor reorganisation . OBJECTIVE: To study corticomotor organisation and short-latency ICI in a patient with typical task-specific PWT . METHODS: Transcranial magnetic stimulation mapping of the corticomotor representation of the hand and studies of ICI using paired-pulse stimulation were performed in a 47-year-old right-handed woman with a pure task-specific writing tremor . RESULTS: The motor maps for the hand were displaced posteriorly on both sides and reverted to a normal position after treatment with botulinum toxin . Short-latency ICI was reduced for the dominant hand . CONCLUSION: The findings indicate reorganisation and disinhibition of the corticomotor projection to the hand and point to the participation of cortical centres in the origin of PWT.

Science, 2005 Jan 7, 307(5706), 124 - 7
Vesicle endocytosis requires dynamin-dependent GTP hydrolysis at a fast CNS synapse; Yamashita T et al.; Molecular dependence of vesicular endocytosis was investigated with capacitance measurements at the calyx of Held terminal in brainstem slices . Intraterminal loading of botulinum toxin E revealed that the rapid capacitance transient implicated as "kiss-and-run" was unrelated to transmitter release . The release-related capacitance change decayed with an endocytotic time constant of 10 to 25 seconds, depending on the magnitude of exocytosis . Presynaptic loading of the nonhydrolyzable guanosine 5'-triphosphate (GTP) analog GTPgS or dynamin-1 proline-rich domain peptide abolished endocytosis . These compounds had no immediate effect on exocytosis, but caused a use-dependent rundown of exocytosis . Thus, the guanosine triphosphatase dynamin-1 is indispensable for vesicle endocytosis at this fast central nervous system (CNS) synapse.

Protein J, 2004 Oct, 23(7), 445 - 51
Factors affecting autocatalysis of botulinum A neurotoxin light chain; Ahmed SA et al.; The light chain of botulinum neurotoxin serotype A undergoes autocatalytic fragmentation into two major peptides during purification and storage (Ahmed S . A . et al . 2001, J . Protein Chem . 20:221-231) by both intermolecular and intramolecular mechanisms (Ahmed S . A . et al . 2003, Biochemistry 42:12539 12549) . In this study, we investigated the effects of buffers and salts on this autocatalytic reaction in the presence and absence of zinc chloride . In the presence of zinc chloride, the fragmentation reaction was enhanced in each of acetate, MES, HEPES and phosphate buffers with maximum occurring in acetate when compared to those in the absence of zinc chloride . Adding sodium chloride in phosphate buffer in the presence of zinc chloride increased the extent of proteolysis . Irrespective of the presence of zinc chloride, adding sodium chloride or potassium chloride in phosphate buffer elicited an additional proteolytic reaction . Higher concentrations of sodium phosphate buffer enhanced the autocatalytic reaction in the absence of zinc chloride . In contrast, in the presence of zinc chloride, higher concentrations of sodium phosphate decreased the autocatalytic reaction . Optimum pH of autocatalysis was not affected significantly by the absence or presence of zinc chloride . Like zinc chloride, other chlorides of divalent metals, such as magnesium, cobalt, iron and calcium also enhanced the autocatalytic reaction . Polyols such as ethylene glycol protected the light chain from fragmentation . Exposure of light chain to UV radiation led to enhanced fragmentation. , . In order to avoid fragmentation, the protein should be stored frozen in a low concentration buffer of neutral or higher pH devoid of any metal . Our results provide a choice of buffers and salts for isolation, purification and storage of intact botulinum neurotoxin serotype A light chain.

J Oral Maxillofac Surg, 2005 Jan, 63(1), 20 - 4
Botulinum toxin type A in the management of masseter muscle hypertrophy; Castro WH et al.; Purpose We sought to evaluate the response of 6 patients with masseter muscle hypertrophy to botulinum toxin type A therapy . Patients and methods Six patients with unilateral or bilateral masseter muscle hypertrophy received intramuscular injection of the botulinum toxin type A . The functional and cosmetic results were evaluated as well as recurrence . Results In all patients, satisfactory regression of the masseter muscle hypertrophy occurred and mild muscular pain was relieved . Recurrence was observed in 2 cases . Conclusions The use of botulinum toxin type A in masseter muscle hypertrophy therapy was shown to be a successful and safe treatment method . This procedure to control parafunctional activities involving the masticatory muscles of patients appears to be useful.

Methods Find Exp Clin Pharmacol, 2004 Nov, 26(9), 723 - 53
Gateways to clinical trials; Bayes M et al.; Gateways to Clinical Trials is a guide to the most recent clinical trials in current literature and congresses . The data in the following tables has been retrieved from the Clinical Trials Knowledge Area of Prous Science Integrity(R), the drug discovery and development portal, This issue focuses on the following selection of drugs: (PE)HRG214, 1E10, 21-Aminoepothilone B; Ad.Egr.TNF.11D, Ad100-B7.1/HLA, adalimumab, adefovir dipivoxil, alefacept, alemtuzumab, AMD-070, anhydrovinblastine, aripiprazole, asimadoline, atrasentan, AVE-5883; Bimatoprost, BNP-7787, bosentan, botulinum toxin type B, BR-1; Canfosfamide hydrochloride, ciclesonide, curcumin, cypher; D0401, darbepoetin alfa, darifenacin hydrobromide, D-D4FC, dendritic cell-based vaccine, desloratadine, dextrin sulfate, dolastatin 10, drospirenone drospirenone/estradiol, DS-992, duloxetine hydrochloride, dutasteride; E-7010, efalizumab, eletriptan, EM-1421, enfuvirtide, entecavir, etoricoxib, everolimus, exenatide, ezetimibe; Favid, fidarestat, fingolimod hydrochloride, FK-352; Gefitinib, gemifloxacin mesilate, gepirone hydrochloride, gimatecan; HE-2000; Imatinib mesylate, indisulam, insulin detemir, irofulven, ISIS-5132; Lapatinib, levocetirizine, liraglutide, lumiracoxib; Metformin/Glyburide, methionine enkephalin, MK-0431, morphine hydrochloride, motexafin gadolinium, mycobacterium cell wall complex; Naturasone, neridronic acid, nesiritide; Oblimersen sodium, olanzapine/fluoxetine hydrochloride, omalizumab, oral insulin; Paclitaxel poliglumex, PC-515, PEG-filgrastim, peginterferon alfa-2a, peginterferon alfa-2b, peginterferon alfa-2b/ ribavirin, pegvisomant, pexelizumab, picoplatin, pramlintide acetate, prasterone, pregabalin; Quercetin; Ramelteon, ranirestat, RG228, rhGAD65, roflumilast, rubitecan; Sitaxsentan sodium, solifenacin succinate; Tadalafil, taxus, tipifarnib, tolevamer sodium, topixantrone hydrochloride; Valganciclovir hydrochloride, vardenafil hydrochloride hydrate, vildagliptin, voriconazole; XTL-001; Zoledronic acid monohydrate .

Indian J Pediatr, 2004 Dec, 71(12), 1087 - 91
Botulinum toxin in children with cerebral palsy; Singhi P et al.; Botulinum toxin is a neurotoxin that blocks the synaptic release of acetylcholine from cholinergic nerve terminals mainly at the neuromuscular junction, resulting in irreversible loss of motor end plates . It is being widely tried as a targeted antispasticity treatment in children with cerebral palsy . A number of studies have shown that it reduces spasticity and increases the range of motion and is particularly useful in cases with dynamic contractures . However improvement in function has not been convincingly demonstrated . It is an expensive mode of therapy and the injections need to be repeated after 3-6 months . Whereas Botulinum toxin can be a valuable adjunct in select cases, it should not be projected as a panacea for children with spastic cerebral palsy.

J Am Acad Dermatol, 2005 Jan, 52(1), 89 - 91
Treatment of facial chromhidrosis with botulinum toxin type A; Matarasso SL; BACKGROUND: Hyperhidrosis is an idiopathic condition of exaggerated sweat production by the eccrine glands that affects approximately 1% of the population . There are many viable therapeutic options and the use of botulinum toxin has become an important treatment option and received FDA approval for this disorder in July 2004 . The other forms of aberrant sweating; bromhidrosis (malodorous) and chromhidrosis (pigmented) are much rarer and more recalcitrant to treatment . METHOD: This is the first case report of dark-colored facial sweat in a young woman that was adequately controlled with botulinum toxin . CONCLUSION: Chromhidrosis is an unusual clinical entity with an ill-defined glandular etiology . The successful response to botulinum toxin supports the eccrine gland as a source of the sweat production and, furthermore, that the administration of this toxin should be considered as a form of therapy.

Curr Opin Urol, 2004 Nov, 14(6), 329 - 34
Botulinum toxin in the management of lower urinary tract dysfunction: contemporary update; Cruz F et al.; PURPOSE OF REVIEW: To review the most recent experience concerning the application of botulinum toxin in the human lower urinary tract . RECENT FINDINGS: Botulinum toxin was initially applied in the bladder of patients with spinal neurogenic detrusor overactivity and urinary incontinence, or in the urethra in cases of detrusor external sphincter dyssynergia . A large multicentric European study fully confirmed the initial expectancy in the former condition . In addition, the application of botulinum toxin was extended to the treatment of other urological disorders including non-neurogenic detrusor overactivity, non-relaxing urethral sphincter and detrusor underactivity . Interesting reports on the injection of botulinum toxin into the prostate of patients with benign prostatic hyperplasia are also reviewed . SUMMARY: Bladder injection of botulinum toxin is not yet an approved treatment for lower urinary tract dysfunction . Nevertheless, available data suggest that in the near future the toxin will become a standard therapeutic option in incontinent patients with neurogenic and non-neurogenic forms of overactive bladder, who do not respond to or do not tolerate anticholinergic medication . In addition, it might be expected that urethral botulinum toxin injections improve bladder emptying in patients with dysfunctional voiding problems besides detrusor external sphincter dyssynergia.

J Rehabil Med, 2004 Sep, 36(5), 238 - 9
Does botulinum toxin A make prosthesis use easier for amputees?
Kern U, Martin C, Scheicher S, Muller H.
Four post-amputation patients (1 with phantom pain, 3 with stump pain) were each treated with 100 IU botulinum toxin A, divided between several trigger points in the distal stump musculature . In 1 female patient (along with a pronounced reduction in phantom pain) hyperhidrosis of the stump ceased completely, probably after diffusion of the drug into the dermal sweat glands, leading to longer and safer use of the prosthesis . Intentional intradermal injection for this issue therefore could be valuable . Another patient was able to use her prosthesis for the whole day again after botulinum toxin A treatment for substantial stump pain, compared with only 4 hours a day before treatment . In 2 male patients, stump pain while wearing the prosthesis subsided to a considerable extent, 1 of the 2 reported an improvement in steadiness of gait . We suggest that stump treatment with botulinum toxin in rehabilitative medicine should be investigated in more detail.

Curr Opin Ophthalmol, 2004 Oct, 15(5), 389 - 400
Thyroid-associated orbitopathy: a clinicopathologic and therapeutic review; Boulos PR et al.; PURPOSE OF REVIEW: To review the literature related to thyroid-associated orbitopathy and to emphasize recent developments in its pathophysiology, diagnosis, and therapy . Current therapeutic trends and controversies are discussed . RECENT FINDINGS: Expression of thyroid stimulating hormone receptor is highest in the fat and connective tissue of patients with thyroid-associated orbitopathy, where fibroblasts have the potential for adipogenesis . Electrophysiology can now detect subclinical optic neuropathy, and somatostatin-receptor scintigraphy can help justify immunomodulation . Other than steroids, radiotherapy can control inflammation, but its use is controversial . Current trends in orbital decompression are to camouflage incisions and to limit strabismus with balanced decompression, deep lateral wall techniques, fat removal, and onlay implants . Proptosis reductions of 0.9 to 12.5mm are possible by the use of various algorithms . Before or after decompression, botulinum toxin can correct strabismus, intraocular pressure elevation, and retraction . The latter is now also treated with full-thickness blepharotomy . SUMMARY: As knowledge of the pathophysiology of thyroid-associated orbitopathy grows, there is a slow movement from nonspecific and invasive measures to more directed treatments causing less morbidity.

Mov Disord . 2004 Dec 29;20(1):121 {Epub ahead of print}
Erratum: Botulinum toxin type a therapy during pregnancy . Mov Disord 2004;19(11):1384-1385; Newman WJ et al.; The original article to which this Erratum refers was published in Movement Disorders (2004) 19(11)1384-1385.

Curr Treat Options Gastroenterol, 2005 Feb, 8(1), 59 - 69
Treatment of Achalasia; Kaufman JA et al.; Achalasia is a primary motility disorder of the esophagus that causes dysphagia . Normal esophageal motility and lower esophageal sphincter (LES) function can not be restored; thus treatment is directed at decreasing the pressure or disrupting the muscle fibers of the LES to allow passage of ingested material . Effective therapy for achalasia can be broadly characterized as surgery based or endoscopy based . Medications (calcium channel blockers and nitrate derivatives) do not provide adequate relief of dysphagia and have substantial side effects, and thus are rarely used as long-term therapy . Botulinum toxin injection, a recently introduced endoscopic therapy, enjoyed much enthusiasm initially but was shown to have only transient effect and is now recommended only for poor operative candidates . The mainstay of therapy remains endoscopic dilation or laparoscopic esophagomyotomy (LEM) combined with an antireflux procedure . We have found that patients who can tolerate a laparoscopic abdominal surgery are best served with an LEM and Toupet (270 degrees ) posterior fundoplication . This provides good or excellent relief of dysphagia in 90% to 95% of patients with very little morbidity.

J Drugs Dermatol, 2004 Nov-Dec, 3(6), 627 - 31
Treatment of axillary hyperhidrosis by chemodenervation of sweat glands using botulinum toxin type A; Glaser DA; Primary axillary hyperhidrosis is a medical condition characterized by excessive underarm sweating that is thought to result from localized hyperstimulation of sweat glands by cholinergic sympathetic nerve fibers . It can be associated with significant professional, physical, and emotional impairment as well as considerable difficulties in social situations and in personal relationships . Available therapies have been limited by short-lived effectiveness and in some cases significant adverse effects that can put patients at risk for potentially serious complications . Chemodenervation of sweat glands using botulinum toxin type A (BTX-A), which has long-lasting therapeutic efficacy with minimal adverse effects, has emerged as a unique therapy for treating primary axillary hyperhidrosis . This article reviews the chemodenervation procedure, including patient preparation, BTX-A administration, and patient assessment and follow-up.

Dis Colon Rectum, 2004 Nov, 47(11), 1947 - 52
Fissurectomy-botulinum toxin: a novel sphincter-sparing procedure for medically resistant chronic anal fissure; Lindsey I et al.; BACKGROUND: Botulinum toxin heals only approximately one-half of glyceryl trinitrate-resistant chronic anal fissures, perhaps because chemical sphincterotomy alone treats internal sphincter spasm but not chronic fissure fibrosis . We aimed to assess whether a novel procedure, fissurectomy-botulinum toxin, improves the healing rate of medically resistant fissures over that achieved with botulinum toxin alone . METHODS: A prospective pilot study of chronic fissure patients failing medical therapy was undertaken . Fissurectomy was performed, with excision of the fibrotic fissure edges, curetting of the fissure base, and excision of the sentinel pile if present . Twenty-five units of botulinum toxin (Botox) were injected into the internal sphincter . The primary end point was fissure healing, and secondary end points were improvement in symptoms, need for lateral internal sphincterotomy, and side effects . RESULTS: Thirty patients underwent fissurectomy-botulinum toxin (57 percent female; median age, 39 years) . Nineteen patients had failed glyceryl trinitrate, whereas 11 had failure of both glyceryl trinitrate and botulinum toxin . At a median of 16.4 weeks follow-up, 28 fissures (93 percent) were healed. , . Two fissures (7 percent) remained unhealed but were symptomatically better and avoided lateral internal sphincterotomy . Two patients (7 percent) experienced transitory flatus incontinence . CONCLUSION: Fissurectomy-botulinum toxin heals over 90 percent of fissures resistant to medical therapy . Fissurectomy-botulinum toxin allows patients with medically resistant fissures to achieve a high rate of healing while avoiding the risk of incontinence associated with lateral internal sphincterotomy.

J Pediatr (Rio J), 2004 Nov-Dec, 80(6), 523 - 6
{Esophageal achalasia of unknown etiology in children}; Fernandez PM et al.; OBJECTIVE: To report a case of a 9-year-old female presented with esophageal achalasia and approached with surgery . The authors discuss the treatment and make a literature review on the topic . DESCRIPTION: Childhood esophageal achalasia is an unusual disease, often with unknown etiology . The main symptoms are esophageal vomits, dysphagia and weight loss . The diagnosis can be made by esophagogram and endoscopy, but the main examination is the esophageal manometry . Even though the surgical approach is a well-established therapy, some alternative treatments have been used, such as the endoscopy balloon dilatation and the use of botulinum toxin . COMMENTS: Esophageal achalasia is a rare disease in childhood, with unknown etiology . The presentation may be confused with gastroeshophageal reflux, sometimes causing a diagnosis delay . The surgical approach, as well as an antireflux procedure, is the treatment of choice.

Plast Reconstr Surg, 2005 Jan, 115(1), 273 - 7
The zygomaticotemporal branch of the trigeminal nerve: an anatomical study; Totonchi A et al.; This study was conducted to determine the site of emergence of the zygomaticotemporal branch of the trigeminal nerve from the temporalis muscle and to identify the number of its accessory branches and their locations . A pilot study, conducted on the same number of patients, concluded that the main zygomaticotemporal branch emerges from the deep temporal fascia at a point on average 17 mm lateral and 6 mm cephalad to the lateral palpebral commissure, commonly referred to as the lateral canthus . These measurements, however, were obtained after dissection of the temporal area, rendering the findings less reliable . The current study included 20 consecutive patients, 19 women and one man, between the ages of 26 and 85 years, with an average age of 47.6 years . Those who had a history of previous trauma or surgery in the temple area were excluded . Before the start of the endoscopic forehead procedure, the likely topographic site of the zygomaticotemporal branch was marked 17 mm lateral and 6 mm cephalad to the lateral orbital commissure on the basis of the information extrapolated from the pilot study . The surface mark was then transferred to the deeper layers using a 25-gauge needle stained with brilliant green . After endoscopic exposure of the marked site, the distance between the main branch of the trigeminal nerve or its accessory branches and the tattoo mark was measured in posterolateral and cephalocaudal directions . In addition, the number and locations of the accessory branches of the trigeminal nerve were recorded . On the left side, the average distance of the emergence site of the main zygomaticotemporal branch of the trigeminal nerve from the palpebral fissure was 16.8 mm (range, 12 to 31 mm) in the posterolateral direction and an average of 6.4 mm (range, 4 to 11 mm) in the cephalad direction . On the right side, the average measurements for the main branch were 17.1 mm (range, 15 to 21 mm) in the lateral direction and 6.65 mm (range, 5 to 11 mm) in the cephalic direction . Three types of accessory branches were found in relation to the main branch: (1) accessory branch cephalad, (2) accessory branch lateral, and (3) accessory branches in the immediate vicinity of the main branch . This anatomical information has proven colossally helpful in injection of botulinum toxin A in the temporalis muscle to eliminate the trigger sites in the parietotemporal region and surgical management of migraine headaches triggered from this zone.

Plast Reconstr Surg, 2005 Jan, 115(1), 1 - 9
Comprehensive surgical treatment of migraine headaches; Guyuron B et al.; The purpose of this study was to investigate the efficacy of surgical deactivation of migraine headache trigger sites . Of 125 patients diagnosed with migraine headaches, 100 were randomly assigned to the treatment group and 25 served as controls, with 4:1 allocation . Patients in the treatment group were injected with botulinum toxin A for identification of trigger sites . Eighty-nine patients who noted improvement in their migraine headaches for 4 weeks underwent surgery . Eighty-two of the 89 patients (92 percent) in the treatment group who completed the study demonstrated at least 50 percent reduction in migraine headache frequency, duration, or intensity compared with the baseline data; 31 (35 percent) reported elimination and 51 (57 percent) experienced improvement over a mean follow-up period of 396 days . In comparison, three of 19 control patients (15.8 percent) recorded reduction in migraine headaches during the 1-year follow-up (p < 0.001), and no patients observed elimination . All variables for the treatment group improved significantly when compared with the baseline data and the control group, including the Migraine-Specific Questionnaire, the Migraine Disability Assessment score, and the Short Form-36 Health Survey . The mean annualized cost of migraine care for the treatment group (925 dollars) was reduced significantly compared with the baseline expense (7612 dollars) and the control group (5530 dollars) (p < 0.001) . The mean monthly number of days lost from work for the treatment group (1.2) was reduced significantly compared with the baseline data (4.41) and the control group (4.4) (p = 0.003) . The common adverse effects related to injection of botulinum toxin A included discomfort at the injection site in 27 patients after 227 injections (12 percent), temple hollowing in 19 of 82 patients (23 percent), neck weakness in 15 of 55 patients (27 percent), and eyelid ptosis in nine patients (10 percent) . The common complications of surgical treatment were temporary dryness of the nose in 12 of 62 patients who underwent septum and turbinate surgery (19.4 percent), rhinorrhea in 11 (17.7 percent), intense scalp itching in seven of 80 patients who underwent forehead surgery (8.8 percent), and minor hair loss in five (6.3 percent) . Surgical deactivation of migraine trigger sites can eliminate or significantly reduce migraine symptoms . Additional studies are necessary to clarify the mechanism of action and to determine the long-term results.

Z Orthop Ihre Grenzgeb, 2004 Nov-Dec, 142(6), 701 - 5
{Therapy for chronic radial epicondylitis with botulinum toxin A}; Placzek R et al.; AIM: Chronic radial epicondylitis (tennis elbow) is not a serious disease but patients may suffer greatly . If standard conservative and possibly operative treatment modalities have not been effective, patients need further therapy . First trials with injection of Botulinum toxin A (Btx A) have shown promising results . The purpose of the study was to clarify if a single injection of Btx A could be an efficient therapy for chronic radial epicondylitis . METHODS: In this study 16 patients received injections into the forearm extensors . The site of injection was determined by local tenderness and pain provocation on finger and wrist extension . RESULTS: A significant clinical improvement was already seen at 2 weeks following injection . The effect was noted up to the last follow-up at 2 years . Continuous and maximal pain during the last 48 h, as self-assessed on a visual analogue scale, was also significantly reduced . In a few cases a significant decrease of muscle strength was seen for the third finger two weeks after injection . It slowly returned thereafter . CONCLUSION: A single injection of Btx A was effective as therapy for chronic tennis elbow . It can be carried out in an out-patient setting, and allows the patient to continue working.

Laryngorhinootologie, 2004 Dec, 83(12), 862 - 70; quiz 871-4
{The management of Dysphagia . Part 1: diagnostics}; Schonweiler R; Patients with chronic dysphagia are often in need of artificial nutrition; though being well balanced in terms of energy and vitamins, patients are at a high risk for the loss of resistance and body weight . Dysphagia also causes a severe drawback of the overall quality of life . This paper gives an overview of the present management of dysphagia from the point of view of otolaryngologists, head-neck-surgeons, phoniatricians, and medical speech-language-voice-pathologists . The physiology of swallowing and typical symptoms of dysphagia are first explained . Then the current most important diagnostic procedures as orofacial and laryngeal function analysis, video-endoscopy, and quantitative assessments, are discussed (part 1) . This also includes considerations on bolus viscosity variation, postures, swallowing maneuvers, and sensory enhancement procedures, while actual options like botulinum toxin, passy-muir speaking valve, electromyographic biofeedback, and electrostimulation are also mentioned (part 2).

Arch Otolaryngol Head Neck Surg, 2004 Dec, 130(12), 1393 - 9
Perceptual analyses of spasmodic dysphonia before and after treatment; Cannito MP et al.; OBJECTIVE: To evaluate expert listeners' perceptions of voice and fluency in persons with adductor spasmodic dysphonia (ADSD) before and after treatment with botulinum toxin type A (Botox), as a function of initial severity of the disorder (while controlling for patients' age at injection) . DESIGN: Simple before-and-after trial with blinded randomized listener judgments . SETTING: Ambulatory care clinic at a single medical center . PARTICIPANTS: Forty-two consecutive patients with ADSD who underwent examination, with a 3- to 6-week follow-up, after initial botulinum toxin type A injection . There were also 42 age- and sex-matched healthy control subjects . INTERVENTIONS: Injections of botulinum toxin type A into the thyroarytenoid muscle(s) . MAIN OUTCOME MEASURES: Computer-implemented visual analog scaling judgments of voice quality and speech fluency made by expert listeners under psychoacoustically controlled conditions . RESULTS: Response to botulinum toxin type A varied markedly as a function of pretreatment severity of ADSD . More severe initial symptoms exhibited greater magnitudes of improvement . Patients with mild dysphonia did not exhibit pretreatment to posttreatment change . Following treatment, voice and fluency remained significantly (P<.05) poorer in ADSD than in healthy speakers . Older patients exhibited less improvement than younger patients when the effect of initial severity was statistically controlled. , . CONCLUSIONS: Voice quality and fluency improved for most patients following treatment, but older patients and those with milder dysphonia exhibited the least optimal responses to the procedure . Patients who were profoundly impaired demonstrated the greatest amount of improvement . Computer-implemented visual analog scaling provided a reliable clinical tool for determining treatment-related changes in those with ADSD.

Arch Med Res, 2004 Sep-Oct, 35(5), 378 - 84
Characterization of two long vesicle-associated membrane proteins or longins genes from Entamoeba histolytica; Tamayo EM et al.; BACKGROUND: This study characterizes two long vesicle-associated membrane protein (VAMP) genes (SYBL-1 and SYBL-2) obtained from DNA of Entamoeba histolytica by PCR amplification . (Nucleotide sequences of the Entamoeba histolytica SYBL-1 and SYBL-2 genes appear in the GeneBank under accession numbers AY256852 and AY309014.) METHODS: The two cDNA products include one of 663 bp with sequence of 220 deduced amino acids, and a second of 693 bp with 230 deduced amino acid residues . Both products possess corresponding sequences for longin domain at N-terminus, a soluble N-ethylmaleimide-sensitive factor {NSF} attachment protein receptor (SNARE) coiled-coil region, a transmembrane domain (TM), and an intravesicular tail C-terminal, characteristics of all long VAMPs or longins . The current study identified presence of deduced peptide bonds in SYBL-1 and -2, which indicates that these two long VAMPs from E . histolytica could be appropriate substrates for zinc endopeptidases from tetanus and botulinum neurotoxins with specific activity toward neuronal synaptobrevins . RESULTS: Alignment by Basic Local Alignment Search Tool (BLAST) of deduced amino-acid sequence of long VAMPs genes SYBL-1 and -2 showed identity of between 20 and 40% with Caenorhabditis elegans, Dictyostelium discoideum, Drosophila melanogaster, Arabidopsis thaliana, Mus musculus, Homo sapiens, and Plasmodium falciparum . CONCLUSIONS: It is possible that these two putative transport proteins are involved in endocytosis/exocytosis during a biological membrane fusion process, which may make them suitable candidates as targets for new drugs . According to published data, this is the first time that two such genes have been isolated from E . histolytica.

Dermatol Surg, 2004 Dec, 30(12 Pt 2), 1518 - 20
Cutis laxa: Improvement of facial aesthetics by using botulinum toxin; Tamura BM et al.; BACKGROUND: Cutis laxa is characterized by the total loss of skin elasticity, which is also called generalized elastosis that leads to the appearance of early aging . OBJECTIVE: The authors report a patient with cutis laxa in which botulinum toxin was used for the improvement of facial aesthetics . This is a case report with a literature review . Botulinum toxin was injected into the classical sites usually used for the treatment of dynamic wrinkles . RESULTS: The patient showed improvement of the aging appearance . CONCLUSION: The use of botulinum toxin may represent an additional, less invasive resource to improve facial defects in these patients.

Dermatol Surg, 2004 Dec, 30(12 Pt 2), 1515 - 7
Dry eyes and superficial punctate keratitis: a complication of treatment of glabelar dynamic rhytides with botulinum exotoxin A; Northington ME et al.; BACKGROUND: Dry eyes and superficial punctate keratitis are potential complications of periocular botulinum exotoxin A treatment . OBJECTIVE: To report a patient who had these side effects after being treated with botulinum exotoxin A for glabelar rhytides and discuss possible causes including excessive paralysis of the orbicularis oculi leading to lagophthalmos and direct paralysis of the lacrimal gland . METHODS: A case report and brief literature review is presented . CONCLUSION: Paralytic lagophthalmos caused dry eyes and superficial punctate keratitis in our patient . To avoid this complication, if an injection is to be done in the lateral brow area, it should be done 1 cm above the orbital rim.

Dermatol Surg, 2004 Dec, 30(12 Pt 2), 1510 - 4
Plantar hyperhidrosis and pitted keratolysis treated with botulinum toxin injection; Tamura BM et al.; BACKGROUND: Sulcate plantare keratolysis or pitted keratolysis (plantar keratolysis sulcatum) is a disease that is commonly found in tropical countries . Patients have also reported plantar hyperhidrosis . OBJECTIVE: Two patients with pitted keratolysis resistant to topical and systemic treatments are described . METHODS: Both patients were injected with botulinum toxin distributed evenly through the plantar extension . RESULTS: The response to the treatment was excellent despite using a low dose of botulinum toxin with the plantar keratolysis healing completely . CONCLUSION: Hyperhidrosis may be considered the major etiologic factor for pitted keratolysis that does not respond to treatment.

Br J Dermatol, 2004 Dec, 151(6), 1115 - 22
The place of botulinum toxin type A in the treatment of focal hyperhidrosis; Lowe N et al.; BACKGROUND: Hyperhidrosis (primary or secondary) is excessive sweating beyond that required to return body temperature to normal . It can be localized or generalized, commonly affecting the axillae, palms, soles or face, and can have a substantial negative effect on a patient's quality of life . IMPACT OF DISEASE: Objective evaluation comprising quantitative assessment (gravimetric and Minor's iodine starch test) and subjective evaluation (Dermatology Quality of Life Index and Hyperhidrosis Impact Questionnaire) allow accurate assessment of the impact of hyperhidrosis on patients . BOTULINUM TOXIN TYPE A: Botulinum toxin type A acts by inhibiting the release of acetylcholine at the presynaptic membrane of cholinergic neurones . It has proved useful in treating a number of diseases relating to muscular dystonia and is now proving beneficial in treating hyperhidrosis . Clinical trials investigating botulinum toxin type A use in axillary and palmar hyperhidrosis show significant benefits with few side-effects reported, with a favourable impact also being seen on patient quality of life . Botulinum toxin type A injections are generally well-tolerated with beneficial results lasting from 4 to 16 months . CONCLUSIONS: Botulinum toxin type A injections are an effective and well-tolerated treatment for hyperhidrosis . This paper proposes a positioning of this treatment along with current established treatments, and highlights the role of botulinum toxin type A as a valuable therapy for the treatment of hyperhidrosis.

Methods Find Exp Clin Pharmacol, 2004 Oct, 26(8), 639 - 63
Gateways to clinical trials; Bayes M et al.; Gateways to Clinical Trials is a guide to the most recent clinical trials in current literature and congresses . The data in the following tables has been retrieved from the Clinical Trials Knowledge Area of Prous Science Integrity, the drug discovery and development portal, This issue focuses on the following selection of drugs: Abiraterone acetate, Ad5CMV-p53, adefovir dipivoxil, AE-941, ambrisentan, aripiprazole, atomoxetine hydrochloride, atrasentan; BCH-10618, bimatoprost, BMS-184476, BMS-275183, BMS-387032, botulinum toxin type B, BR-1, BR96-Doxorubicin; Capravirine, caspofungin acetate, cinacalcet hydrochloride; Darbepoetin alfa, desloratadine, dextrin sulfate, DJ-927, duloxetine hydrochloride; Elacridar, emtricitabine, eplerenone, ertapenem sodium, escitalopram oxalate, ESP-24217, etoricoxib, exenatide, ezetimibe; Ferumoxtran-10, fondaparinux sodium, fosamprenavir calcium; GS-7904L, GW-5634; HMN-214, human insulin; IC-14, imatinib mesylate, indiplon, insulin glargine, insulinotropin, iseganan hydrochloride; Lanthanum carbonate, L-Arginine hydrochloride, LEA29Y, lenalidomide, LE-SN38, lestaurtinib, L-MDAM, lometrexol, lopinavir, lopinavir/ritonavir; Magnesium sulfate, maraviroc, mepolizumab, metreleptin, milataxel, MNA-715, morphine hydrochloride; Nesiritide, neutrophil-inhibitory factor, NK-911; Olanzapine/fluoxetine hydrochloride, olmesartan medoxomil, omalizumab, ortataxel, oxycodone hydrochloride/ibuprofen; Panitumumab, patupilone, PC-515, PD-MAGE-3 Vaccine, peginterferon alfa-2a, peginterferon alfa-2b, peginterferon alfa-2b/ ribavirin, pemetrexed disodium, pimecrolimus, prasugrel, pregabalin, PRO-2000; Rosuvastatin calcium, RPR-113090; sabarubicin hydrochloride, safinamide mesilate, SB-715992, sitaxsentan sodium, soblidotin, synthadotin; Tadalafil, taltobulin, temsirolimus, tenofovir disoproxil fumarate, tenofovir disoproxil fumarate/emtricitabine, testosterone gel, tigecycline, tipranavir, tirapazamine, trabectedin, travoprost; UCN-01; Vardenafil hydrochloride hydrate; XB-947; Yttrium 90 (90Y) ibritumomab tiuxetan . (c) 2004 Prous Science

Harefuah, 2004 Nov, 143(11), 775 - 8, 840
{Primary esophageal achalasia in octogenarians: does it really exist?}; Kagansky N et al.; Recent case reports described primary esophageal achalasia (PEA) at an older age, even in the very elderly . However, very few cases over the age of eighty were published and there is no data on the clinical presentation and the appropriate treatment at this age . A retrospective record review at a six-hundred bed university-affiliated hospital revealed the diagnosis of PEA in eleven patients over the age of eighty (age range 81-90 years), during a 5-year period . Seven patients complained of cough and dyspnea, most of them also suffered from dysphagia . One patient complained of chest pain . The diagnosis was made in most patients by using a barium meal or gastroscopy, without manometry . Exceedingly few patients had a prolonged response to nitrates or to calcium channel blockers . However, a prolonged one year response was achieved after botulinum toxin injection or pneumatic dilatation . IN CONCLUSION: In contrast to younger patients, the elderly patient with PEA usually does not complain of chest pain but rather of cough and dyspnea. , , , . The therapeutic approach should include surgery only in the very fit elderly due to a possible high complication rate . Botulinum toxin injection or pneumatic dilatation are the preferred treatment options.

Ann Plast Surg, 2004 Dec, 53(6), 543 - 6
Evaluating the effects of ice application on the pain felt during botulinum toxin type-a injections: a prospective, randomized, single-blind controlled trial; Sarifakioglu N et al.; The pain felt during botulinum toxin type-A injections and the troubled and distressed treatment it induces is common and well known for the patient and the doctor applying the treatment . This problem is further intensified on the patients who have needle phobia . The effect of ice application on the treatment zone before botulinum toxin type-A treatment on the pain felt during injections is investigated . Totally, 24 patients who underwent botulinum toxin type-A treatment in upper face region for esthetic purposes are included in the study . Ice was applied 5 minutes before the injections on the right lateral orbital zones (crow's feet area) of the patients, whereas on their left sides, toxin was injected without applying any ice . All the drugs were diluted by normal saline; 5 U of active botulinum toxin type-A was used in each diziem (0.1 mL) . Total injection number was determined both in right and left areas as 8 . Visual analog scale (VAS) was used for pain intensity and evaluation . On the side where ice was applied, the treatment was completed in 1 session and lasted shorter when compared with that of the control side . However, the average VAS values defining the pain that the patients felt in their right and left sides were found as 1.1 and 5.9, respectively . The clinical findings obtained indicated that pain is significantly reduced on the side where ice is applied . The statistical significance of the test results were evaluated by Student's t test, and the difference between VAS values was found statistically significant (P = 0.000).

Clin Neuropharmacol, 2004 Sep-Oct, 27(5), 234 - 44
Evidence-based review of patient-reported outcomes with botulinum toxin type A; Jankovic J et al.; This review systematically examines the effects of botulinum toxin type A (BTX-A) on patient-reported outcomes across disorders using evidence-based criteria . The evidence provided by these studies ranged from randomized, controlled trials to case series . The effects of BTX-A on quality of life or global treatment outcomes were assessed in 48 studies across 16 different conditions . All but 7 of these reported benefits of BTX-A over baseline or the comparator condition (placebo or other treatment) . The effects of BTX-A on impairment, activities, or participation were assessed in 46 studies across 17 different conditions . All but 4 reported benefits of BTX-A over baseline or the comparison group . The effects of BTX-A on satisfaction or preference were assessed in 14 studies across 11 different conditions, all of which reported high rates of satisfaction with BTX-A or preference over the comparator . These studies provide evidence that BTX-A exerts meaningful benefits on the quality of life of patients treated with this biologic agent.

Altern Lab Anim, 2003 Sep, 31(4), 381 - 91
Growing old disgracefully: the cosmetic use of botulinum toxin; Bottrill K; The explosive growth in the use of botulinum toxin for cosmetic purposes has undoubtedly had an impact on the number of animals used in the potency testing of this product . The test used is a classical LD50, a severe procedure during which animals experience increasing paralysis until the occurrence of death . The enthusiastic adoption by the general public of the use of botulinum toxin as an anti-wrinkle treatment has, at least in Europe, paradoxically taken place against a background of moves to stop animal testing of cosmetics and cosmetic ingredients . There appears to be a dearth of information aimed at the public concerning botulinum toxin testing . Botulinum toxin does have important medical applications; however, the question arises whether a blanket licence for the testing can be justified, when a large proportion of the product is being used cosmetically . A further question is why death continues to be the endpoint of the potency test, when a more-humane endpoint has been proposed . In addition, a number of alternative methods have been developed, which could have the potential to replace the lethal potency test altogether . These methods are discussed in this paper, and the importance of establishing a strategy for their validation is emphasised, a need that has become even more urgent in the light of the recently published draft monograph on botulinum toxin by the European Pharmacopoeia Commission.

Bioorg Med Chem, 2005 Jan 17, 13(2), 333 - 41
Conformational sampling of the botulinum neurotoxin serotype a light chain: implications for inhibitor binding; Burnett JC et al.; Botulinum neurotoxins (BoNTs) are the most potent of the known biological toxins, and consequently are listed as category A biowarfare agents . Currently, the only treatments against BoNTs include preventative antitoxins and long-term supportive care . Consequently, there is an urgent need for therapeutics to counter these enzymes--post exposure . In a previous study, we identified a number of small, nonpeptidic lead inhibitors of BoNT serotype A light chain (BoNT/A LC) metalloprotease activity, and we identified a common pharmacophore for these molecules . In this study, we have focused on how the dynamic movement of amino acid residues in and surrounding the substrate binding cleft of the BoNT/A LC might affect inhibitor binding modes . The X-ray crystal structures of two BoNT/A LCs (PDB refcodes=3BTA and 1E1H) were examined . Results from these analyses indicate that the core structural features of the examined BoNT/A LCs, including alpha-helices and beta-sheets, remained relatively unchanged during 1ns dynamics trajectories . However, conformational flexibility was observed in surface loops bordering the substrate binding clefts in both examined structures . Our analyses indicate that these loops may possess the ability to decrease the solvent accessibility of the substrate binding cleft, while at the same time creating new residue contacts for the inhibitors . Loop movements and conformational/positional analyses of residues within the substrate binding cleft are discussed with respect to BoNT/A LC inhibitor binding and our common pharmacophore for inhibition . The results from these studies may aid in the future identification/development of more potent small molecule inhibitors that take advantage of new binding contacts in the BoNT/A LC.

Addiction, 2005 Jan, 100(1), 46 - 50
Heroin and diplopia; Firth AY; ABSTRACT Aims To describe the eye misalignments that occur during heroin use and heroin detoxification and to give an overview of the management of persisting diplopia (double vision) which results from eye misalignment . Methods A literature review using Medline and the search terms strabismus, heroin and substance withdrawal syndrome is presented . General management of cases presenting to the ophthalmologist and orthoptist with acute acquired concomitant esotropia is described . Findings A tendency towards a divergence of the visual axes appears to be present in heroin users, although when present it may not always lead to diplopia . Following detoxification intermittent esotropia or constant esotropia (convergence of the visual axes) can occur; if intermittent the angle tends to be small and diplopia present when viewing distance objects . Occlusion of one eye to eliminate the second image could encourage the development of a constant deviation . The deviation is not caused by a cranial nerve palsy . Constant deviations of this type are classified as 'acute acquired concomitant esotropia' . Relief from the diplopia may be gained by prismatic correction, and the deviation may then resolve spontaneously . Botulinum toxin or surgical intervention may be necessary in cases that do not resolve . Conclusions Heroin use may lead to intermittent or constant exotropia and withdrawal may result in intermittent or constant esotropia . Awareness of the mechanism causing this may avoid referral to other specialties (e.g . neurology) and awareness of treatment modalities could encourage patients to seek appropriate help for relief of symptoms.

Am J Health Syst Pharm, 2004 Nov 15, 61(22 Suppl 6), S24 - 6
Proper dose, preparation, and storage of botulinum neurotoxin serotype A; Anderson ER Jr; PURPOSE: The proper dose, preparation, and storage of the formulation of botulinum neurotoxin serotype A (botulinum toxin type A) that is available in the United States (Botox) are described . SUMMARY: The recommended dose of botulinum toxin type A varies widely from 1.25 Units to 100 Units, depending on the site . Small initial doses are used for patients without previous treatment with botulinum toxin . Repeat injections often are required, and subsequent doses should be individualized based on response . Larger repeat doses often are used when the response to initial doses is insufficient . An antitoxin is availabl