Botulinum Research Articles

Impact of intralesional botulinum toxin type A therapy on the keloid-related quality of life

BackgroundWe aimed to validate the translated Arabic version of the head and neck keloid quality-of-life (QOL) questionnaire. We also aimed to evaluate the impact of intralesional botulinum toxin type A (BTA) therapy on the keloid-related quality of life.MethodsThis prospective study included 140 patients with a keloid in the head and neck regions. They were divided into two groups. In Group A, the patient filled out the questionnaire four times: 1 week before the start of the treatment, the first injection (day using intralesional BTA, the second injection day, and 6 months after the first injection. In group B, the patients completed the questionnaires once before any keloid therapy (control group).ResultsCronbach’s alpha between all questions was 0.921. The intra-class correlation coefficient between the first and second visits was above 0.8. In Group A, the total score in the first visit was 84.12 ± 5.86, while it was 34.87 ± 3.73 in the fourth fulfilment, with a statistically significant difference between them as the P-value was < 0.0001. The results of Group A differed significantly from the control group.ConclusionsThe translated Arabic version of the head and neck QOL questionnaire was reliable and reproducible. It has strong internal consistency, responsiveness, and validity. According to this study, intralesional BTA injection effectively improved the QOL of patients with keloids.

Robot-assisted ileocystoplasty for the treatment of adult neurogenic bladder: A video demonstration and outcomes

Abstract Ileocystoplasty is one of the treatment options in the armamentarium for the management of adults with neurogenic bladder dysfunction, after failure of less invasive treatment alternatives, such as intravesical onabotulinum toxin A injection therapy and sacral neuromodulation. It has traditionally been performed as open surgery and can be associated with significant morbidity, especially in the early postoperative period.[1] Complications associated with open ileocystoplasty include prolonged postoperative ileus, wound infections, and pain. Performing robot-assisted ileocystoplasty can reduce the morbidity associated with open surgery[2] and has been shown to be safe and feasible in experienced hands,[3] although it may be associated with increased operative duration because of its learning curve. Our technique of robot-assisted ileocystoplasty and early postoperative outcomes is demonstrated in this video (Supplemental Digital Content, http://links.lww.com/CURRUROL/A47). Robotic console time was 180 minutes, with minimal blood loss. Eight-hourly catheter aspiration and flushes were performed to manage the mucus in the urine. There were no metabolic acidosis or electrolyte derangements postoperatively. The patient was discharged on postoperative day 5. Postoperative cystogram at week 2 showed no leak and the patient is doing well at 1 year postoperatively. Robotic ileocystoplasty is safe and feasible and can reduce the morbidity associated with open surgery with good outcomes.

Botulinum toxin type A outcomes in infants with refractory congenital muscular torticollis.

The aim of this study was to determine the effectiveness of botulinum toxin type A (BoNT-A) injections in infants with congenital muscular torticollis (CMT) who were refractory to conservative management. This was a retrospective study in which all subjects included were seen between 2004 and 2013 and were deemed appropriate for BoNT-A injections. A total of 291 patients were reviewed for inclusion in the study, and 134 patients met the inclusion criteria. Each child was injected with 15-30 units of BoNT-A into each of the following muscles: ipsilateral sternocleidomastoid, upper trapezius, and scalene muscles. The key outcome and variable measurements analyzed included age at time of diagnosis, age at time of initiation of physical therapy, age at time of injection, total number of injection series utilized, muscles injected, and degrees of active and passive cervical rotation and lateral flexion pre- and post-injection. A successful outcome was documented if a child could achieve 45° of active lateral flexion and 80° of active cervical rotation post-injection. Secondary variables including sex, age at time of injection, number of injection series utilized, surgery required, adverse effects of botulinum toxin, presence of plagiocephaly, side of torticollis, orthosis used, presence of hip dysplasia, skeletal anomalies, complications during pregnancy or birth, and any other pertinent information regarding the delivery were also measured. Based on this criteria, 82 children (61%) had successful outcomes. However, only four of the 134 patients required surgical correction. BoNT-A may be an effective and safe method for treatment in refractory cases of congenital muscular torticollis.

Combined Prophylaxis of Chronic Migraine with OnabotulinumtoxinA and Anti-CGRP Antibodies

Objective: To evaluate the efficacy of adding large molecule anti-calcitonin gene-related peptide monoclonal antibodies (mAbs) to onabotulinumtoxinA (OBT-A) for chronic migraine prevention. Background: Chronic migraine (CM) is a highly prevalent, debilitating disorder that leads to personal, social, and economic burdens. Both OBT-A and mAbs are proven safe and effective in chronic migraine prevention. The use of combination therapy has not been formally studied but may prove more effective than either monotherapy alone in select patients. Methods: This is a retrospective chart review of patients with chronic migraine, treated with OBT-A, who received additional mAb preventative therapy. The primary endpoint was migraine headache days per month (MHD) after 3 months of combined therapy. Secondary endpoints included total headache days per month, headache intensity, disability level, and use of abortive medications. Results: Of 1503 patients reviewed, 133 met inclusion criteria. At 3 months of combined therapy, mean reduction of MHD from baseline was 6.2 (95% CI 4.91 to 7.49, p &lt; 0.0001). Nearly 2/3rd of patients (60.9%) experienced ≥ 50% MHD reduction. Fewer patients reported high disability level (14.6% [17/126], compared to 29.4%) and high headache intensity (13.0% [16/119], compared to 51.3%) at 3 months (all p &lt; 0.0001). A reduction in abortive medication doses needed and discontinuation of concomitant oral preventative medications was also noted in 15.8% and 6.8% of patients, respectively. Conclusions: Combined therapy with OBT-A and mAbs is well-tolerated, effective in further reducing migraine frequency, and may improve quality of life for patients with CM refractory to monotherapy.

Switching from onabotulinum toxin A to abobotulinum toxin A for treating detrusor overactivity in spinal cord injured patient, does it really work?

To assess the efficacy of switching to Abobotulinumtoxin A (ATA) intradetrusor injections (IDI) after failure of Onabotulinumtoxin A (OTA) IDI for the treatment of neurogenic detrusor overactivity in patients with spinal cord injury (SCI). A single-centre retrospective chart review study. All SCI patients who started OTA IDI after 2011 and had an ATA IDI switch were included. The primary outcome was the clinical and urodynamic efficacy of the switch to ATA IIDs at the last follow-up. Secondary outcomes were initial efficacy, duration of ATA treatment, and patient outcome including the occurrence of augmentation enterocystoplasty at last follow-up. Sixty-two patients were included. Eighteen patients (28.9%) were initially responders to ATA IDI. Nine patients (14.5%) remained responders at last follow-up after a median of 17months (AE 8.8-29). Thirty-two patients (51.6%) had had or were awaiting augmentation enterocystoplasty with a follow-up time of 18.5months (IQR 8-27). Eleven patients (17.7%) were on ATA IDI with low efficacy. Seven patients (11.3%) were switched back to OTA and 3patients (4.8%) changed their voiding pattern. Switching from OTA to ATA toxin for IDI in the treatment of detrusor overactivity after spinal cord injury have long-term efficacy for a limited number of patients but may delay the need for surgery.

Botulinum toxin type A for spasticity in cerebral palsy patients: Which impact on popliteal angle to hamstring length? A proof-of-concept study.

Cerebral palsy (CP) is the most common physical disability in childhood. It is a heterogeneous condition in terms of etiology, motor type and severity of impairments. Clinical impairments, such as increased muscle tone (spasticity), muscle weakness and joint stiffness contribute to the abnormal development of functional activities, including gait. The objective of this study was to investigate the popliteal angle to hamstring length after ultrasound guided Incobotulinum toxin A injections for spasticity in CP patients. In this proof-of-concept study, we included outpatients with CP and crouch gait correlated to hamstrings spasticity referred to the Pediatric Rehabilitation outpatient clinic of Umberto I University Hospital, Sapienza University of Rome, in the period between February and October 2018. Modified Ashworth Scale (MAS) of hamstring muscles, Popliteal Angle and Modified Popliteal Angle, Passive Knee Extension and 10 Meter Walk Test (10MWT) were assessed at baseline (T0) and three weeks after ultrasound guided injection (T1) of Incobotulinum Toxin A (dose weight and site dependent). Thirteen patients (5 male and 8 female), mean aged 9.91 ± 3.59, were included. The clinical evaluation at T0 showed hamstring muscles spasticity, with MAS of 2.4 ± 0.6, popliteal angle -51.7∘± 11.0∘, modified popliteal angle of -39.5∘± 11.0∘, passive knee extension of -14.0∘± 8.7∘ and 10MWT of 14.3 ± 4.6 seconds. At T1, hamstring muscles MAS mean value was 1.7 ± 0.6 (p< 0.01), popliteal angle 41.3∘± 7.0∘ (p< 0.001), modified popliteal angle -32.9∘± 10.4∘ (p< 0.001), passive knee extension -4.0∘± 4.2∘ (p< 0.05) and 10MWT 12.6 ± 4.8 seconds (p< 0.05). None of the treated patients reported any adverse event related to Incobotulinum Toxin A injection. Incobotulinum toxin A treatment has been proven to be safe and effective for hamstring muscles spasticity management in CP patients. Further studies with larger samples and longer follow-up are warranted to assess the efficacy of this treatment on the popliteal angle.

Experience of treatment of chronic migraine with botulinum toxin type A among aesthetic medicine professionals in Poland.

This study aimed to evaluate the knowledge and standard of treatment of chronic migraine with botulinum toxin by Polish aesthetic medicine professionals. Onabotulinum toxin A injections are used as a preventive treatment for chronic migraine. Besides neurologists, healthcare professionals of multiple specialisms can offer this treatment. Aesthetic medicine professionals commonly use the treatment to extend the scope of their practice. This may bring about a situation wherein physicians with different levels of experience and training are providing botulinum toxin injections for chronic migraine. An online survey asking about patient qualification procedures, the level of adherence to the PREEMPT paradigm, product-, technique-, dosing-, and treatment intervals-related aspects of the treatment, efficacy evaluation practices and concerns about the use of botulinum toxin in chronic migraine was sent to 110 Polish physicians practicing aesthetic medicine. The response rate was 73.6%. The results of the survey revealed multiple deviations from the current paradigm of treatment of chronic migraine with botulinum toxin, from improper patient qualification through treatment procedure to the evaluation of the efficacy. Only around one-third of professionals evaluated the observed effectiveness of therapy as very good. Most respondents wanted to expand their knowledge and skills in chronic migraine treatment. There is a considerable willingness among aesthetic medicine specialists to treat patients with chronic migraine with botulinum toxin. The current levels of knowledge and skills in this treatment are limited, and multiple physicians declared deviations from the diagnostic criteria and the therapeutic protocol. Transferring aesthetic medicine practices to neurology treatment is common and may result in a lack of effectiveness of treatment or even intensification of symptoms. An appropriate educational programme should be implemented for all physicians authorised to administer BoNT-A in Poland.

The Effect of Botulinum Toxin Type A Injection in the Rectus Femoris in Stroke Patients Walking With a Stiff Knee Gait: A Randomized Controlled Trial

Background Over activity of the rectus femoris is often cited as a main cause for stiff knee gait (SKG). Botulinum toxin (BoNT) can be used to reduce this over activity. Inconsistent results for the effect of BoNT injections were found in literature which can possibly be explained by the study design as these were uncontrolled or non-randomized studies. Objective To conduct a randomized controlled trial (RCT) to investigate the effect of botulinum toxin type A (BoNT-A) injections in the rectus femoris on gait kinematics and functional outcome in adult stroke patients. Methods Twenty-six participants were included in this triple-blind cross-over RCT. The intervention consisted of an injection with BoNT-A. Placebo is an injection with saline. Besides knee and hip kinematics, functional outcomes were measured. Results Comparison of the effect of BoNT-A injection to placebo injection showed a significant increase in peak knee flexion and knee range of motion of 6.7° and 4.8° respectively. There was no difference in hip kinematics. In functional outcomes, only the 6 Minute Walking Test showed a significant increase of 18.3 m. Conclusions BoNT-A injections in the rectus femoris is a valuable treatment option for stroke patients walking with a SKG to improve knee kinematics. To study the effect on functional outcome more research is necessary with different functional outcome measures that can capture the effect in kinematics. It is important to use kinematic measurements to demonstrate effects in quality of movement that are not captured by commonly used functional outcome measurements post stroke. Clinical Trial Registration: https://trialsearch.who.int/Trial2.aspx?TrialID=NTR2169

A prospective assessment of the validity of the CUA neurogenic bladder guideline.

The Canadian Urological Association (CUA) neurogenic bladder guideline surveillance strategy for neurogenic lower urinary tract dysfunction (NLUTD) has not been formally evaluated. Our objective was to evaluate the validity of the risk stratification suggested in these guidelines. This was a prospective, observational cohort study of adult NLUTD patients with spinal cord injury, multiple sclerosis, or spina bifida who required urodynamics. Patients with a requirement for immediate bladder surgery (not suitable for surveillance) were excluded. Patients completed standardized medical history/questionnaires, baseline urodynamics, renal imaging, and creatinine tests. The primary outcome was the need for different types of urological management between the high-risk and moderate-risk groups. We enrolled 68 patients; most commonly, these were spinal cord injury patients, and most people were using intermittent catheters. At baseline, 62% (40/68) were classified as high-risk. In this group, there was a numerically greater proportion who received a recommendation for a new urological medication (48% vs. 25%, p=0.06) or a change to their bladder management (45% vs. 36%, p=0.44). A total of 26 high-risk and 23 medium-risk NLUTD patients had a one- year followup visit. A larger proportion of the high-risk patients had a recommendation for a new bladder medication (15.4% vs. 8.7% p=0.47), intravesical onabotulinum toxin (34.6% vs. 13% p=0.08), or an alternate method of bladder management (15.4% vs. 4.3%, p=0.2). Mean creatinine change was slightly greater in the high-risk group (+6.1 vs. +0.4 umol/L, p=0.05). Approximately 1/3 of both high-risk and moderate-risk patients didn't accept the recommended interventions. A higher proportion of high-risk NLUTD patients had urology-relevant interventions recommended, both at baseline and at their one-year followup visit. This supports the general concept of risk stratification and the variables used to define high-risk in the CUA's neurogenic bladder guideline.

Laryngeal dystonia: Phenomenology, genetics, and management

Laryngeal dystonia is a task-specific movement disorder causing abnormal movement of the adductor or abductor muscles of the vocal folds. In 1984, Blitzer pioneered the first use of onabotulinum toxin A to treat this disorder. Over 1400 patients were diagnosed with laryngeal dystonia in the last thirty years. In this paper, we summarize their clinical and endoscopic findings as well as treatment results. We also summarize the underlying genetics of the disorder.82% of patients were diagnosed with adductor type laryngeal dystonia and 17% of patients manifested an abductor laryngeal dystonia. Patients with adductor dystonia were treated with toxin to the thyroarytenoid muscles and those with abductor dystonia were treated with toxin to the posterior cricoarytenoid muscle. All patient achieved greater than 70% improvement in percent normal function. Laryngeal dystonia is a rare movement disorder of the larynx with an incidence of approximately 35.1 per 100,000 individuals (Simonyan et al., 2021). Presently, there is no cure for laryngeal dystonia, but botulinum toxin has shown significant success in treating the symptoms of the disorder.

Histomorphometric Changes of the Masseter Muscle of Rats After a Single Injection of Botulinum Toxin Type A.

It has been reported that botulinum toxin type A (BoNT-A) produces structural changes in masticatory muscles. However, not all histomorphometric parameters affected by BoNT-A parameters have been assessed. This study investigated the histomorphometric changes in the masseter muscle of rats after a single injection of BoNT-A. Forty-four adult animals were randomly divided into control group (n = 22) and BoNT-A group (n = 22). Controls received a single dose of 0.14mL/kg of saline in masseter muscles, and the BoNT-A group received a 7U/Kg of BoNT-A. The groups received the same volume of injected substances. Animals were sacrificed on 7th (n = 5), 14th (n = 5), 21st (n = 5), 28th (n = 4) and 90th (n = 3) days post-treatment. Histological masseter tissue slides were obtained from hematoxylin-eosin treatment and analyzed in optical microscopy regarding muscle cross-sectional area, amount of connective tissue and quantity and diameter of myocytes. For statistical analysis, generalized linear models were used to compare the data (ANOVA). In all test, the significance level of 5% was set. BoNT-A values of cross-sectional area of the masseter muscle were significantly lower than controls (p < 0.01) throughout the study. Regarding myocytes quantity, BoNT-A subgroups presented higher values than controls (p < 0.0001) since the 14th day until the end of the study; however, the diameter of myocytes was smaller in all BoNT-A subgroups (p < 0.0001) in all assessment points. The amount of connective tissue was higher in BoNT-A subgroups (p < 0.0001) throughout the study. A single injection of BoNT-A altered the structure of masseter muscle of rats, regarding its histomorphometric parameters. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Botulinum toxin use in patients with post-stroke spasticity: a nationwide retrospective study from France.

Current guidelines recommend intramuscular botulinum toxin type A (BoNT-A) injection as first-line treatment for spasticity, a frequent and impairing feature of various central nervous system (CNS) lesions such as stroke. Patients with spasticity commonly require BoNT-A injections once every 3 to 4 months. We conducted a nationwide, population-based, retrospective cohort study, using the French National Hospital Discharge Database (PMSI), to describe BoNT-A use for spasticity in clinical practice in France between 2014 and 2020. The PMSI database covers the whole French population, corresponding to over 66 million persons. We first searched the PMSI database for healthcare facility discharge of patients who received BoNT-A injections between 2014 and 2020, corresponding to the first set. For each BoNT-A-treated patient, we identified the medical condition for which BoNT-A may have been indicated. Another search of the PMSI database focused on patients admitted for acute stroke between 2014 and 2016 and their spasticity-related care pathway (second set). Overall, two subpopulations were analysed: 138,481 patients who received BoNT-A injections between 2014 and 2020, and 318,025 patients who survived a stroke event between 2014 and 2016 and were followed up until 2020. Among the 138,481 BoNT-A-treated patients, 53.5% received only one or two BoNT-A injections. Most of these patients (N = 85,900; 62.0%) received BoNT-A because they had CNS lesions. The number of patients with CNS lesions who received ≥1 BoNT-A injection increased by a mean of 7.5% per year from 2014 to 2019, but decreased by 0.2% between 2019 and 2020, corresponding to the COVID-19 outbreak. In stroke survivors (N = 318,025), 10.7% were coded with post-stroke spasticity, 2.3% received ≥1 BoNT-A injection between 2014 and 2020, and only 0.8% received ≥3 injections within the 12 months following BoNT-A treatment initiation, i.e., once every 3 to 4 months. Our analysis of the exhaustive PMSI database showed a suboptimal implementation of BoNT-A treatment recommendations in France. BoNT-A treatment initiation and re-administration are low, particularly in patients with post-stroke spasticity. Further investigations may help explain this observation, and may target specific actions to improve spasticity-related care pathway.

Treating rosacea with botulism toxin: Protocol for a systematic review and meta-analysis.

Rosacea is a chronic inflammatory disease usually associated with persistent erythema and periodic flushing. This disease is difficult to treat, and the outcomes are often unsatisfactory and prone to recurrence. In recent years, botulinum toxin has been used as a new treatment for rosacea; however, its efficacy and safety remain under discussion. Although a systematic review of the effectiveness and safety of botulinum toxin has been previously conducted by other researchers, our systematic review and meta-analysis evaluate the efficacy of botulinum toxin from a more comprehensive and detailed perspective to provide evidence for clinicians. Any study using botulinum toxin for the treatment of rosacea was considered for the analysis. A total of 22 studies were included, 9 of which were randomized controlled trials involving 720 subjects. After treatment, all studies showed varying degrees of improvement in patient signs and symptoms along with reduced Clinician's Erythema Assessment (CEA) scores. The improvement was maintained for several months, and the adverse effects were mild and self-limiting. Botulinum toxin may be an effective treatment for patients with rosacea; however, further clinical evidence is needed to confirm its long-term efficacy and side effects. The study was preregistered with Prospero (CRD42022358911).

Current state of headache training within Canadian Neurology Residency program: a national survey

BackgroundHeadache disorders are the most common neurological disorders worldwide. Despite their widespread prevalence and importance, the topic of headache is inconsistently taught at both the undergraduate and postgraduate levels. The goal of this study is to establish a better picture of the current state of Headache Medicine (HM) training in Neurology postgraduate programs in Canada and describe the impact of the current pandemic on training in this domain.MethodsOnline surveys were sent to senior residents of adult Neurology programs in Canada. We also conducted telephone interviews with Neurology Program Directors. Descriptive statistics were analyzed, and thematic analysis was used to review free text.ResultsA total of 36 residents, and 3 Program Directors participated in the study. Most of the teaching in HM is done by headache specialists and general neurology faculty. Formal teaching is mainly given during academic half day. Most of the programs expose their residents to Onabotulinum toxin A injections and peripheral nerve blocks, but they don’t offer much formal teaching regarding these procedures. Residents consider HM teaching important and they would like to have more. They don’t feel comfortable performing interventional headache treatments, despite feeling this should be part of the skillset of a general neurologist.ConclusionOur study is the first to establish the current state of headache teaching in post-graduate neurology programs as perceived by trainees and program directors in Canada. The current educational offerings leave residents feeling poorly prepared to manage headaches, including procedural interventions. There is a need to diversify the source of teaching, so the educational burden doesn’t lie mostly upon Headache specialists who are already in short supply. Neurology Residency programs need to adapt their curriculum to face the current need in HM.

Task-specific oromandibular dystonia secondary to chewing Khat (Catha edulis)- A series of 35 cases

BackgroundThe leaves of “Khat” (Catha edulis), an indigenous shrub of Yemen and Arabian Peninsula are habitually chewed by the inhabitants for psychostimulant properties. ObjectiveTo describe a unique task specific Oro-mandibular dystonia (OMD) in Yemenese men, with a temporal association with chewing “Khat”. MethodsMulticentric, retrospective analysis (2009–2020) of patients with OMD associated with “Khat” chewing, evaluating clinical features and response to Onabotulinum toxin A. Results35 Yemenese men with a negative family history, normal neuroimaging mean age of 44.31(±3.21) years and prolonged (20.31 ± 3.27 years) history of chewing Khat, around 5.16(±0.80) hours/day presented with OMD-20 jaw opening, 13 jaw closing and 2 mixed affecting chewing (n = 6), speech (n = 3), or both (n = 26). Additional lingual dystonia was seen in five. ConclusionsChewing of khat is a repetitive task involving the jaw musculature and may be one of the causative factors of this task specific OMD. Recognition can prevent disability in these regions.

Volumetry after botulinum toxin A: the impact on abdominal wall compliance and endotracheal pressure.

Botulinum toxin type A (BTA) is an adjuvant tool used in the preoperative optimization of complex hernias before abdominal wall reconstruction (AWR). This study aims to investigate changes in the abdominal cavity and hernia sac dimensions after BTA application. A prospective study with 27 patients with a hernia defect of ≥ 10cm and loss of domain (LOD) ≥ 20% underwent AWR. Computed tomography (CT) measurements and volumetry before and after the application of BTA were performed. Intraoperative and postoperative outcomes were evaluated. Imaging post-BTA revealed hernia width reduction of 1.9cm (p = 0.002), lateral abdominal wall muscle elongation of 3.1cm (p < 0.001), hernia volume reduction (HV) from 2.9 ± 0.9L to 2.4 ± 0.8L (p < 0.001), increase in abdominal cavity volume (ACV) from 9.7 ± 2.5L to 10.3L ± 2.4L (p = 0.003), and a reduction in the HV/ACV ratio from 30.2 ± 5% to 23.4 ± 6% (p < 0.001). Fascial closure was achieved in 92.6% of cases and component separation was required in 78%. The average variation in pulmonary plateau pressure was 3.53 cmH2O, and there were no postoperative respiratory failure recorded. At the 90-day follow-up, the wound morbidity rate was 25%, unplanned readmissions were 11%, and hernia recurrence 7.4%. BTA produces measurable volumetric changes in abdominal wall and appears to facilitate fascial closure. Further studies are required to determine the role of BTA in the surgical armamentarium for complex hernia repair.

Intramuscular versus intradermal botulinum toxin for forehead wrinkles: a review of side effects and efficacy.

Botulinum toxin type A (BTA) is a neurotoxin used for both cosmetic and non-cosmetic purposes. BTA is commonly administered as an intramuscular injection to treat wrinkles. However, when it comes to treating forehead wrinkles, intramuscular injection is associated with a greater rate of ptosis. Intradermal injection is currently thought to be a better alternative. We searched PubMed and Google Scholar for research articles published between 1989 and 2023 using the following keywords: "intradermal," "intramuscular," "botulinum toxin," and "forehead wrinkle." The search yielded three randomized controlled trials and a double-blind, split-face case report on 58 patients. We found that although intradermal and intramuscular injections have symmetrical anti-wrinkle effects, the former results in a lower rate of ptosis and a greater degree of pain.

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

To compare the long-term efficiency of botulinum toxin type A (BTXA) injection and surgery on acute acquired comitant esotropia (AACE). This retrospective study enrolled patients with AACE from January 2020 to August 2022. The horizontal angle of deviation pre- and post-treatment was measured. Deviations in BTXA and surgical treatment were compared. The BTXA group was divided into adequate treatment (AT) and inadequate treatment (inAT) subgroup based on the deviation of no more than 4 prism diopters (at near and distance) or temporary exotropia at the 2 week follow-up. The two subgroups were compared to determine the long-term efficacy of BTXA treatment. Ninety-two patients with AACE were included. Follow-up was 6 months. The deviations of the surgery and BTXA group were significantly smaller at the 6 month follow-up than at pre-treatment (p < 0.001). The deviation before treatment in the surgery group was larger than in the BTXA groups (p < 0.001) but smaller at the 6 month follow-up (p < 0.001). The deviation was similar in the AT-BTXA and inAT-BTXA subgroups before treatment (p = 0.322 for distance and p = 0.051 for near) but smaller in the AT-BTXA subgroup at 6 month follow-up (p < 0.001 for near and distance). Surgery and BTXA successfully treat AACE. Surgery has a more precise and lasting therapeutic effect than BTXA. AACE patients adequately treated with BTXA and with deviations of no more than 4 prism diopters at 2 weeks follow-up had better outcomes.

The Effect of Botulinum Toxin A on the NADPH Oxidase System and Ischemia-Reperfusion Injury.

Despite the increasing popularity of various materials for ischemia-reperfusion (I/R) injury mitigation, research on botulinum toxin type A (BoNTA) remains limited. This study assesses BoNTA's efficacy in protecting flaps from I/R injury by inhibiting the nicotinamide adenine dinucleotide phosphate (NADPH) oxidase system and reducing reactive oxygen species (ROS) production. Seventy-six Sprague-Dawley rats were studied. We examined the effects of BoNTA on superoxide production in four rats using a lucigenin-enhanced chemiluminescence assay (LECL). Another group of 60 rats had their superficial inferior epigastric artery (SIEA) flaps treated with either BoNTA or saline and clamped for 0, 1, and 4 hours before reperfusion. Flap survival and histological outcomes were assessed five days post-operation. ROS production in SIEA flaps and femoral vessels was analyzed in 12 additional rats, post-I/R injury. The LECL results showed that the BoNTA group had significantly lower superoxide production compared to controls, with notable reductions at 4 hours. While no significant differences were noted at the 0 and 1-hour marks, the 4-hour mark showed significant protective effects in BoNTA-treated groups. The survival rate was 90% for BoNTA-treated rats versus 60% for controls ( P = 0.028). Significant reductions in ROS were also observed in the 4-hour I/R group. BoNTA effectively protects against I/R injury by inhibiting the NADPH oxidase system and reducing ROS levels. These results support further investigation into the specific mechanisms of NADPH oxidase inhibition by BoNTA and its potential clinical applications, given its safety profile. The findings from the present study are expected to provide a basis for clinical studies regarding this use of BoNTA.

Therapeutic Effectiveness of Needle Injection Versus Needle-Free Jet Injector System for Botulinum Toxin Type a in Palmar Hyperhidrosis.

The most important problem with local injections of botulinum toxin type A (BTX-A) in palmar hyperhidrosis is pain during the injections. We evaluated therapeutic effectiveness and pain of local injections of BTX-A using needle-free direct administration system. We performed BTX-A local injection therapy using a conventional injection needle in the left hand and a needle-free direct administration system in the right hand. A reduction in the quantity of perspiration was observed 4 weeks after administration of both Needle and Needle-free BTX-A, and reduction was maintained throughout 28 weeks observation period. Both hyperhidrosis Disease Severity Scale scores and Dermatology Life Quality Index for hands treated with Needle BTX-A and hands treated with Needle-free BTX-A had decreased significantly by 4 weeks after treatment. Pain visual analog scale scores and the degree of pain were significantly lower in hands treated with Needle-free BTX-A than in hands treated with Needle BTX-A. When the trigger of the pressurized needle-free injector device is activated, the gas powered driving pressure propels BTX-A through an orifice (0.13 mm) about four times narrower than a 30 G needle at very high speed. As most pain occurs during the needle prick itself, the advantage of a small orifice coupled with high-speed penetration of BTX-A through the pressurized device results in reduced pain during administration. The needle-free direct administration system administers the injectate under the skin without a visible needle.