BOTOX: a review.

The history of medicine has many amazing stories of odd anecdotes for the treatment of a variety of ailments. Who would have thought that common mold would revolutionize the treatment of infection, or slimy leaches could assist in the resolution of venous congestion? When retching from the effects of food poisoning, or even worse, developing severe paralysis acquired from food contaminated with the anaerobic bacterium Clostridium Botulinum (Botulism), who could have guessed that toxins produced by this bacteria could be used as an effective cosmetic treatment for frown lines and wrinkles? Such is the story of medicine: always inventive and surprising, and sometimes downright odd.     

Other noncosmetic uses of BOTOX

Botulinum toxin A has a wide variety of clinical applications, which are related by blockade of acetylcholine and often are related to abnormal muscle contractures. These applications include ocular disorders, disorders of the upper aerodigestive tract, dystonia and hemifacial spasm, cosmetic, gastrointestinal disorders, genitourinary disorders, management of pain, and use in autonomic nervous system disorders. Many of these diseases will be discussed with regard to their treatment with botulinum toxin compared to conventional treatments. Advantages and disadvantages of botulinum toxin use are delineated. General guidelines for adult and pediatric dosing will also be discussed.     

Methylphenidate: a review.

Methylphenidate is a useful, proven method for the effective treatment of minimal brain dysfunction (MBD). Dosage should be titrated individually for each patient, and it is best to start with small doses given at least 15 to 30 minutes before meals. Toxicity, side effects, and drug abuse are not major problems. Unfortunately it is not yet possible to determine in advance who will and will not benefit from drug therapy; not all patients do. Treatment of MBD requires a multidisciplinary approach, for no one discipline alone can satisfactorily solve the problems involved. We believe, however, that medicine is the primary therapy in most instances.     

Tetanus: a review.

Tetanus is caused by the organism Clostridium tetani, which produces tetanospasmin, a neurotoxin responsible for the clinical manifestations of muscle rigidity and reflex spasms. The majority of cases follow an anaerobic wound infection associated with trauma. Incubation period is usually 3 days to 3 weeks. 75% of patients present with trismus. Reflex spasms are seen in 70% of patients and characterize the severity of the disease. Treatment involves removal of the offending organism, neutralization of free neurotoxin, controlling rigidity and reflex spasm, and minimizing complications. Diazepam may be used alone in mild cases. Severe cases require the addition of nondepolarizing neuromuscular blocking agents and mechanical ventilation. Respiratory complications occur early and require aggressive airway management. A serious, late complication is the syndrome of sympathetic nervous system overactivity that is treated with alpha and beta blockade. High mortality rates seen in the United States may be due to delays in diagnosis and lack of familiarity with treatment. The disease is preventable with adequate immunization.     

Hepatitis-B: a review.

The recent literature on various aspects of hepatitis-B is reviewed with emphasis on the interrelationships of viral structure, antigenic components, and host immune response in acute, chronic, and asymptomatic carrier states of the infection. The mode of replication and mechanisms of transmission are discussed. Special attention is paid to potential non-parenteral routes of spread. The role of hepatitis-B in associated immune complex diseases and in hepatoma is outlined. A guide to the interpretation of serologic tests for hepatitis-B associated antigen and antibody patterns is presented in relation to the clinical stage and prognosis of the infection. Therapy, except in conceptual terms, is not covered but a summary of the current status of active and passive immunization is given. The unresolved question of the infectivity of carrier medical staff for their patient contacts, and the reverse, is discussed.     

Botulinum toxin type A as a migraine preventive treatment. For the BOTOX Migraine Clinical Research Group

OBJECTIVE: To assess the safety and efficacy of botulinum toxin type A (BOTOX; Allergan, Inc) in the prevention of migraine. BACKGROUND: Current migraine preventive therapies are often unsatisfactory because of their limited efficacy, adverse effects, and drug interactions. Botulinum toxin type A injections often reduce the pain associated with conditions such as cervical dystonia, achalasia, rectal fissures, and myofascial pain syndrome. An open-label, noncontrolled study of botulinum toxin type A suggested benefits for patients with migraine. DESIGN AND METHODS: This was a double-blind, vehicle-controlled study of 123 subjects with a history of two to eight moderate-to-severe migraine attacks per month, with or without aura. Participants were randomized to receive single administrations of vehicle or botulinum toxin type A, 25 U or 75 U, injected into multiple sites of pericranial muscles at the same visit. During a 1-month baseline period and for 3 months following injection, subjects kept daily diaries in which they recorded migraine frequency, migraine severity, and the occurrence of migraine-associated symptoms. RESULTS: Compared with vehicle treatment, subjects in the 25-U botulinum toxin type A treatment group showed significantly fewer migraine attacks per month, a reduced maximum severity of migraines, a reduced number of days using acute migraine medications, and reduced incidence of migraine-associated vomiting. Both the 25-U and 75-U botulinum toxin type A groups were significantly better than the vehicle group on subject global assessment. Botulinum toxin A treatment was well tolerated, with only the 75-U treatment group exhibiting a significantly higher rate of treatment-related adverse events than vehicle. CONCLUSIONS: Pericranial injection of botulinum toxin type A, 25 U, was found to be a safe treatment that significantly reduced migraine frequency, migraine severity, acute medication usage, and associated vomiting.     

Salmonella empyema: a review.

A 35-year-old man developed salmonella pleural empyema during a three-month illness. Cultures of the empyema fluid yielded S enteritidis, serotype typhimurium. Cure was achieved by decortication and obliteration of the pleural empyema space, in combination with chloramphenicol therapy given parenterally. Review of the published reports revealed eight similar instances of salmonella empyema. Manifestations and treatment of this group are reviewed.     

Third-generation cephalosporins: a review.

Third-generation cephalosporins play a pivotal role in the management of infections because of their potent and broad-spectrum antimicrobial activity, proven clinical efficacy in a wide variety of infections, safety, and potential for cost savings. Selection of third-generation cephalosporins poses a dilemma, however, particularly for clinicians who view the six antibiotics within this class as interchangeable. Choice of drug should be based on antimicrobial spectrum and other factors such as lack of resistance development and cost considerations. This review focuses on the distinguishing features of the parenteral third-generation cephalosporins. Such differences suggest the need for retiring the convenient "generation" classification system for cephalosporins in favor of a system that encourages recognition of clinically important features of each agent in this diverse group of cephalosporin antibiotics.     

Pheochromocytoma: a clinical review.

Few disorders of endocrine function are so sudden and dramatic in their presentation as those caused by a pheochromocytoma. This chromaffin cell tumor arises within the adrenal medulla or within the sympathetic nervous system and causes wide fluctuations in blood pressure, tachydysrhythmias, and manifestations of intense anxiety. The patient experiences explosive paroxysms of catecholamine overload. The diagnoses of accelerated hypertension or panic disorder often are prematurely adopted. The condition kills, with deaths primarily attributed to irreversible cardiovascular and end-organ damage caused by profound hypertension. For those with a pheochromocytoma, the disorder caused by the tumor is a terrifying constellation of symptoms. Although pheochromocytoma is rare, it must be considered in the treatment of any patient with sudden, extreme hypertension and accompanying hypermetabolism. A cure is possible, but only with early diagnosis and treatment.     

Enzyme immunoassay: a review.

In the last few years, the use of enzyme labels in immunoassays has been investigated. The aim of this review is to evaluate critically the role of such labels in clinical biochemistry. Special attention has been given to the problems involved in preparing enzyme labels and the ways in which such labels can be used in a variety of heterogeneous and homogeneous assay systems.     

Yohimbine: a clinical review.

Although yohimbine (YOH) has been available for the treatment of male erectile dysfunction (ED) for longer than Viagra, there is a perception that little is known about the clinical performance of the drug. This review attempts, by comprehensive analysis of the literature, to cover the clinical, pharmacological, and therapeutic profiles of YOH, relevant to its potential utility in the management of patients with ED. Relatively few well-designed studies have been completed. From these, however, it can be concluded that YOH as monotherapy possesses only modest efficacy in ED patients. In acute and chronic (long-term) studies, YOH has been found to be relatively free of side effects over the dose range predicted to be effective in ED. At much higher doses, the most frequently observed effects, consistent with the primary pharmacological action of the drug, are elevation of blood pressure, a slight anxiogenic action, and increased frequency of urination. These side effects are all easily reversible on termination of YOH therapy. There is increasing evidence that the erectogenic action of YOH can be augmented by concomitant administration of agents that augment the release and/or action of nitric oxide in the corpus cavernosum. YOH has yet to be studied in female sexual dysfunction. Overall, the benefit risk profile of YOH would indicate that it has potential, more probably as part of a combination strategy, e.g., with a drug that enhances the nitric oxide pathway, in the treatment of ED.     

Heterotopic ossification: a review.

Heterotopic ossification is defined as the presence of lamellar bone at locations where bone normally does not exist. The condition must be distinguished from metastatic calcifications, which mainly occur in hypercalcaemia, and dystrophic calcifications in tumours. It is a frequent complication following central nervous system disorders (brain injuries, tumours, encephalitis, spinal cord lesions), multiple injuries, hip surgery and burns. In addition to this acquired form, hereditary causes also exist, such as fibrodysplasia ossificans progressiva, progressive osseous heteroplasia and Albright's hereditary osteodystrophy. Although these conditions are extremely rare, they can provide useful information on the physiopathology of heterotopic ossification, and thus lead to novel and causal treatment modalities. Heterotopic ossification is no trivial complication. A limitation of the range of joint motion may have serious consequences for the daily functioning of people who are already severely incapacitated because of their original lesion. Increased contractures and spasticity, pressure ulcers and increasing pain further compromise the patient's capabilities. Consequently, we feel that attention should be paid to the pathogenesis and particularly the prevention and treatment of this disorder.     

Meperidine: a critical review.

Meperidine was initially synthesized as an anticholinergic agent but was soon discovered to have analgesic properties. Although meperidine's anticholinergic effects were demonstrated in vivo, the anticholinergic effects on the biliary and renal tracts have not been demonstrated in vivo. Studies have clearly demonstrated that meperidine is no more efficacious in treating biliary or renal tract spasm than comparative mu opioids. The initial studies demonstrating the analgesic efficacy of meperidine were mostly case reports and not double-blind, randomized, controlled trials in specific populations. Subsequent comparative studies failed to demonstrate any advantages of meperidine over comparable doses of other analgesics. Meperidine was portrayed in practice and teaching as having unique clinical advantages. The analgesic effects of meperidine are not pronounced, and, in addition, meperidine use is complicated by unique side effects including serotonergic crisis and normeperidine toxicity. Meperidine's poor efficacy, toxicity, and multiple drug interactions have resulted in a movement to replace meperidine with more efficacious and less toxic opioid analgesics.     

Low-intensity laser therapy: a review.

Low-intensity laser radiation is characterized by its ability to induce athermic, nondestructive photobiological processes. Although it has been in use for more than 30 years, this phototherapy is still not an established therapeutic modality. We have summarized the main arguments being brought up against the use of this therapy and have reviewed the literature addressing both its in vitro and in vivo effects. We conclude that low-intensity laser irradiations might be of benefit in selected indications if the existing preliminary data can be confirmed by more prospective and well-controlled studies.