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Botulinum toxin type A (BONT-A) has shown promise in improving the mood-related symptoms of psychiatric disorders by targeting muscles linked to the expression of negative emotions. We conducted a systematic review of past and ongoing efficacy trials of BONT-A therapy for psychiatric disorders to identify relevant trends in the field and discuss the refinement of therapeutic techniques. A comprehensive search for published clinical trials using BONT-A injections for psychiatric disorders was performed on 4 May 2023 through OVID databases (MEDLINE, Embase, APA PsycINFO). Unpublished clinical trials were searched through the ClinicalTrials.gov and International Clinical Trial Registry Platform public registries. The risk of bias was assessed using the JBI Critical Appraisal tools for use in systematic reviews. We identified 21 studies (17 published, 4 unpublished clinical trials) involving 471 patients. The studies focused on evaluating the efficacy of BONT-A for major depressive, borderline personality, social anxiety, and bipolar disorders. BONT-A was most commonly injected into the glabellar area, with an average dose ranging between 37.75 U and 44.5 U in published studies and between 32.7 U and 41.3 U in unpublished trials. The results indicated significant symptom reductions across all the studied psychiatric conditions, with mild adverse effects. Thus, BONT-A appears to be safe and well-tolerated for psychiatric disorders of negative affectivity. However, despite the clinical focus, there was a noted shortage of biomarker-related assessments. Future studies should focus on pursuing mechanistic explorations of BONT-A effects at the neurobiological level. [ABSTRACT FROM AUTHOR]

Anaphylactic reaction during general anaesthesia represents a rare event in clinical practice with a possible fatal outcome. We present a case of a female patient with no prior history of allergic reactions to rocuronium. Shortly after rocuronium administration, she developed the following signs: tachycardia, low blood pressure and bronchospasm. Skin rash and peripheral signs were absent, probably due to previous premedication. Events like this could be potentially fatal if not recognized and treated in time. [ABSTRACT FROM AUTHOR]

Anxiety disorders represent one of the most prevalent categories of psychiatric illnesses, affecting individuals regardless of gender, age, or social standing. They result in substantial personal and societal costs. The pursuit of novel pharmacological approaches for treating these disorders is driven by the increasing medical necessity to enhance the effectiveness and safety profiles of anxiolytic medications. Due to the fact that benzodiazepines and their derivatives have anti-anxiety, hypnotic-sedative, antidepressant, anticonvulsant, and muscle relaxant properties, they occupy a leading place in the treatment of anxiety disorders. An essential aspect of investigating the pharmacological activity of new triazolobenziazepine derivatives is assessing their impact on rodent muscle tone and coordination of movements. The aim of the work is to find out the influence of new 1,2,3-triazolo-1,4-benzodiazepine derivatives on the muscle tone of rodents in the “vertical grid” test and coordination of movements using the rotarod test. Materials and methods. The objects of the study were 5 new derivatives of 1,2,3-triazolo-1,4-benzodiazepines. Before conducting in vivo experiments, these derivatives were mixed with lactose at a ratio of 1:1000. The “vertical grid” test and rotarod test (rotating rod test) were used to reproduce the model of motor behavior of rodents. Results. The presence of a tendency to the manifestation of a myorelaxant effect in the “vertical grid” test was established. The indicator of the total duration of detention at the facilities was similar and did not differ significantly in the control and experimental groups at doses of 0.50 mg/kg and 0.75 mg/kg. Derivatives MA-252, MA-253 and MA-254 at a dose of 1 mg/kg reduced the total duration of retention on the vertical grid, which indicates their mild muscle relaxant effect. In the rotating rod test, MA-253 derivative at a dose of 1 mg/kg increased the retention time on the rotarod, which demonstrates greater physical endurance of the animals of these experimental groups. Conclusions. The study’s findings indicated that the 1,2,3-triazolo-1,4-benzodiazepine derivatives did not exhibit an adverse impact on movement coordination. Some of these derivatives demonstrated a mild muscle relaxant effect. These results support the need for further research into their influence on spontaneous motor activity. Additionally, there’s a necessity to determine the dosage regimen, establish an effective dose, and adapt it for human use.

BackgroundSpasticity is common in cerebral palsy and can result in pain and diminished health-related quality of life.ObjectiveTo evaluate the safety and efficacy of onabotulinumtoxinA for lower limb spasticity treatment in children with cerebral palsy.MethodsIn this registrational phase 3, multinational, randomized, double-blind, placebo-controlled trial (NCT01603628), children (2-

ObjectiveTo examine the safety and efficacy of abobotulinumtoxinA in patients previously treated with botulinum toxin type A (BoNT-A) products other than abobotulinumtoxinA.DesignSecondary analysis from a phase 3, double-blind, single-cycle, randomized, placebo-controlled study.SettingFifty-two centers (11 countries).PatientsAdults with spastic hemiparesis were randomized (1:1:1) to receive abobotulinumtoxinA 1000 U, 1500 U, or placebo in their affected lower limb.Main outcome measurementsMuscle tone (6-point Modified Ashworth Scale [MAS], 0-5) for the gastrocnemius-soleus complex (GSC); proportion of MAS responders (≥1-point improvement); angle of catch (XV3 ) and spasticity grade (Y) for the GSC and soleus. Assessments were at weeks 1, 4, and 12 post-injection. Only descriptive statistics are presented.ResultsOf 388 patients, 84 received previous BoNT-A treatment (abobotulinumtoxinA 1000 U: N = 30; abobotulinumtoxinA 1500 U: N = 28; placebo: N = 26). At week 4, mean (SD) changes in MAS score in the GSC were - 0.8 (1.1), -0.9 (1.0), and - 0.4 (0.7) for abobotulinumtoxinA 1000 U, 1500 U, and placebo, respectively. Greater MAS responder rates were observed for abobotulinumtoxinA versus placebo at all time points. Mean (SD) changes (week 4) for abobotulinumtoxinA 1000 U, 1500 U, and placebo for XV3 were: GSC, 8° (21), 6° (10) and 1° (7); soleus, 11° (21), 5° (9) and 0° (8), respectively; for Y: GSC, -0.4 (0.7), -0.6 (0.8) and - 0.0 (0.9); soleus, -0.5 (0.7), -0.5 (0.7) and - 0.1 (0.6), respectively. Safety data and adverse events were consistent with the overall known profile of abobotulinumtoxinA.ConclusionsPatients previously treated with other BoNT-As showed improved muscle tone and spasticity at week 4 following abobotulinumtoxinA injection versus placebo. These findings suggest that abobotulinumtoxinA, at the recommended doses, has a good safety and efficacy profile in adults with lower limb spasticity who were previously treated with other BoNT-A products.

INTRODUCTION:3,4-diaminopyridine has been used to treat Lambert-Eaton myasthenia (LEM) for 30 years despite the lack of conclusive evidence of efficacy. METHODS:We conducted a randomized double-blind placebo-controlled withdrawal study in patients with LEM who had been on stable regimens of 3,4-diaminopyridine base (3,4-DAP) for ≥ 3 months. The primary efficacy endpoint was >30% deterioration in triple timed up-and-go (3TUG) times during tapered drug withdrawal. The secondary endpoint was self-assessment of LEM-related weakness (W-SAS). RESULTS:Thirty-two participants were randomized to continuous 3,4-DAP or placebo groups. None of the 14 participants who received continuous 3,4-DAP had > 30% deterioration in 3TUG time versus 72% of the 18 who tapered to placebo (P

A total of 27 children with esotropia (mean age, 3.9 years; range, 9 months to 13.8 years) were enrolled in a 9-month observational study following botulinum toxin A (BTX-A) injection of one (n = 7) or both (n = 20) medial rectus muscles. BTX-A dosage ranged from 3.0 to 6.0 units per muscle. Three participants developed tonic pupil, noted at the first follow-up visit, occurring 12-19 days after injection. All 3 cases occurred in the left eye of participants who underwent bilateral BTX-A injection by the same surgeon. Anisocoria diminished from a maximum of 4 mm at the 2-week visit to 1-2 mm in all patients over the 9-month postinjection data collection period. No adverse visual outcomes were noted. Tonic pupil is an infrequently reported complication of BTX-A injection for strabismus. The experience of our investigator group suggests the need for careful injection technique and thorough preinjection counseling.

Background: Recovery from neuromuscular blockade is commonly assessed by clinical signs. There exists wide disparity in what is recommended to monitor neuromuscular blockade and routine clinical practice by anesthesiologists. The objective signs of train-of-four (TOF) ratio of >0.9 and double burst stimulation (DBS) ratio of 1.0 indicate adequate neuromuscular function. This study was planned at a tertiary care hospital to evaluate the ongoing practice of assessing neuromuscular recovery employing clinical signs and comparing with simultaneous TOF and DBS values. Design: A cross-sectional analytical study. Methodology: A total of 100 consecutive patients undergoing surgical procedures lasting more than 1-h duration under general anesthesia with intermediate acting muscle relaxant were enrolled and data of 60 patients analyzed. After extubation, an independent observer recorded simultaneous TOF and DBS ratio using acceleromyography as the clinical signs of neuromuscular recovery (eye opening, tongue protrusion, head lift, sustained bite, hand grip strength, and ability to cough) were attained. Statistical Analysis: Statistical analysis was done utilizing SPSS version 20 (SPSS Inc., Chicago IL, USA) software. Continuous variables are expressed as mean (standard deviation) and Pearson's correlation coefficient was applied to study the correlation between the clinical parameters and quantitative measures of neuromuscular recovery. Results: There was a significant association between ability to retain tongue depressor (sustained bite), absent double vision and ability to cough effectively and TOF and DBS ratios (P < 0.05). None of the clinical signs correlated with TOF ratio >0.9 or DBS ratio of 1.0. Conclusion: Clinical signs of recovery fail to reliably predict postoperative residual paralysis compared to objective neuromuscular monitoring.

BackgroundMyofascial pain syndrome is a regional condition of muscle pain and stiffness and is classically characterized by the presence of trigger points in affected musculature. Botulinum toxin type A (BoNT-A) has been shown to have antinociceptive properties and elicit sustained muscle relaxation, thereby possibly affording even greater relief than traditional strategies. Our goal was to determine whether direct injection of BoNT-A into painful muscle groups is effective for cervical and shoulder girdle myofascial pain.MethodsAn enriched protocol design was used, wherein 114 patients with cervical and shoulder girdle myofascial pain underwent injection of BoNT-A to determine their response to the drug. Fifty-four responders were then enrolled in a 12-week, randomized, double-blind, placebo-controlled trial. Pain scales and quality of life measures were assessed at baseline and at routine follow-up visits until completion of the study after 26 weeks.ResultsInjection of BoNT-A into painful muscle groups improved average visual numerical pain scores in subjects who received a second dose of BoNT-A compared to placebo (P = 0.019 [0.26, 2.78]). Subjects who received a second dose of BoNT-A had a reduced number of headaches per week (P = 0.04 [0.07, 4.55]). Brief Pain Inventory interference scores for general activity and sleep were improved (P = 0.046 [0.038, 3.700] and 0.02 [0.37, 4.33], respectively) in those who received a second dose of BoNT-A.ConclusionBoNT-A injected directly into painful muscle groups improves average pain scores and certain aspects of quality of life in patients experiencing severe cervical and shoulder girdle myofascial pain.

Neurologic rehabilitation aims to reduce impairments and disabilities so that persons with serious stroke can return to participation in usual self-care and daily activities as independently as feasible. New strategies to enhance recovery draw from a growing understanding of how types of training, progressive task-related practice of skills, exercise for strengthening and fitness, neurostimulation, and drug and biological manipulations can induce adaptations at multiple levels of the nervous system. Recent clinical trials provide evidence for a range of new interventions to manage walking, reach and grasp, aphasia, visual field loss, and hemi-inattention.

Purpose: Intradetrusor onabotulinum toxin A (BTX-A) has been demonstrated to be an effective treatment option for overactive bladder (OAB). However, concerns about frailty and frequent injections may deter its use in the elderly. This study aims to assess the safety, efficacy, and treatment duration of BTX-A in managing OAB in elderly women., Methods: We retrospectively reviewed female patients aged 70 and above who were diagnosed with OAB with predominant urge urinary incontinence and underwent intravesical BTX-A treatment. We collected demographic and clinical data, with repeat BTX-A injections re-administered upon patient-reported symptom recurrence., Results: Twenty-one female patients, median age 77 (range 71-92), were included. The median time between the first and second injection was 185 (84-448) days, 186 (105-959) days between the second and third injection, and increased to 206.5 (84-256) days between the third and fourth injection. However, the median interval trended downward after the fourth injection (Fig. 1). Patients with four or more injections had a shorter median interval between injections, 154 days, compared to those with fewer injections, 210 days. Two patients (6.9%) experienced urinary retention after the initial treatment, with 1 (2.2%) among a total of 46 subsequent treatments (Table 3). There were ten (13.3%) episodes of UTIs within 2 weeks of treatment. Patients reported improvement in symptoms following 93.3% of the injections., Conclusion: This real-world study demonstrates that BTX-A effectively controls OAB symptoms in elderly women, with just two injections annually. BTX-A appears safe and efficacious for treating OAB in elderly females., (© 2023. The Author(s), under exclusive licence to Springer Nature B.V.)

Objective: To evaluate urinary outcomes following cystoscopic external urinary sphincter onabotulinumtoxinA (BTX) injections in patients with cerebral palsy (CP). Adults with CP can suffer from bladder outlet obstruction and urinary retention due to a spastic external urethral sphincter ("pseudodysynergia"). We have used BTX injections into the sphincter to relieve the obstruction and allow patients to maintain spontaneous voiding rather than intermittent catheterization., Methods: Patients were included in this retrospective cohort study if they had a diagnosis of CP, were at least 18 years of age, and underwent a urethral external sphincter BTX injection between 2016-2023. The procedure included 100 u or 200 u of BTX mixed in 4cc of saline. Primary outcomes were subjective, patient or caregiver reported changes in retention, lower urinary tract symptoms (LUTS), frequency of recurrent urinary tract infections (UTIs), and hydronephrosis or bladder stones/debris on ultrasound., Results: Fifty patients were included; the majority were male (60%), lived at home with assistance (58%), and had a Gross Motor Function Classification System level of V (50%; ie, severe CP). The most common indications for BTX were retention (96%), LUTS (48%), hydronephrosis (18%), and recurrent UTIs (22%). Post-BTX improvement was seen in 67% of those with LUTS, 65% with retention, 67% with hydronephrosis, and 73% with recurrent UTIs. Most patients underwent repeat injections (60%). There were no significant complications associated with injections., Conclusion: External urethral sphincter BTX is a safe, effective option for treating pseudodysynergia in adults with CP., Competing Interests: Declaration of Competing Interest The authors have no conflict of interest to declare., (Copyright © 2024. Published by Elsevier Inc.)

Background: Botulinum toxin injections are widely sought after in the field of medical aesthetics, offering consumers a variety of brand choices. Two commonly available botulinum toxin products, onabotulinumtoxinA and neubotulinumtoxinA, are featured in numerous clinics, leading many to question whether there are discernible differences in results, given their varying price ranges., Objective: To evaluate the efficacy and safety of neubotulinumtoxinA for the treatment of forehead horizontal lines., Methods: A 12-week prospective, single-centre, interventional split-face study was conducted, including 30 subjects. These enrolled subjects received a single treatment session, with neubotulinumtoxinA applied to the left side of the forehead and onabotulinumtoxinA to the right side. A superficial injection was performed in all individuals, where the product was injected subdermally in the frontalis muscle. Evaluation was conducted at baseline, 7 days, 14, days and 4, 8, and 12 weeks after treatment, both when the eyebrows were at maximum lift and in a resting position. Treatment efficacy was assessed by two physicians and self-assessed by the patients, using the Fitzpatrick Wrinkle Classification system. Adverse events were documented to evaluate safety., Results: The study found no statistically significant difference in the efficacy of neubotulinum and onabotulinum for treating forehead wrinkles, as indicated by p-values above 0.05 for both static and dynamic conditions. No safety and adverse events were observed in both formulations., Conclusion: This study has demonstrated that neither formulation is inferior to each other in the treatment of forehead horizontal lines., (© 2024 The Authors. Skin Research and Technology published by John Wiley & Sons Ltd.)

Background: Botulinum toxin has been widely and mainly used for the treatment of conditions affecting the upper and middle face; however, recent efforts have expanded the indications of botulinum toxin injection to the lower face and neck areas for cosmetic and medical purposes., Aims: We have reviewed the latest updates on using botulinum toxin in the lower face and neck focusing on cosmetic purposes and have discussed the existing concerns as well as the adverse sequelae of these newer indications., Patients/methods: A comprehensive literature search was performed using the following keywords [[botulinum] AND [[Toxin] OR [Neurotoxin]]] AND [[Lower AND Face] AND/OR [Neck]] within the main databases including Web of Science, PubMed, Embase and gray literature on and before February 2023. The data were screened using titles and abstracts and those relevant to the topic were included in the paper., Results: Botulinum toxin injection has considerable cosmetic and therapeutic effect on facial contouring, masseteric hypertrophy, lower face and neck scars, gummy smile, drooping lip corner and even skin rejuvenation., Conclusion: BNT injection has been widely used for the treatment of different medical and cosmetic purposes. Low rates of side effects, which were self-limited in most cases, have been reported in the literature, making BNT a safe therapeutic medication in most cases. However, regulatory status needs to be updated and more accurately revised in many countries and more comprehensive research is required to address the existing gaps in this area including the site, dosage, and method of injection in each case., (© 2023 The Authors. Journal of Cosmetic Dermatology published by Wiley Periodicals LLC.)

Background: Treatment for medial lower eyelid wrinkles is in great demand now. However, conventional injection of botulinum toxin A (BTX-A) often leads to serious complications., Aims: We aim to evaluate the safety and efficacy of BTX-A injection with microneedle to treat medial lower eyelid wrinkles., Methods: We collected clinical data of 16 patients to treat dynamic wrinkles on the medial aspect of the lower eyelid. Adverse effects at each stage of the treatment were recorded. We used VISIA to compare the static and dynamic wrinkles of the medial lower eyelid before and after treatment. Furthermore, patients and physicians evaluated the wrinkles with Kappa scores., Results: All 16 patients completed the study. The objective evaluation indicator (the Ra variable given by VISIA) progressively and significantly decreased at 1 month and 3 months after treatment. The kappa scores given by patients and by surgeons were both significantly reduced after treatment. No adverse reactions, such as pouch prolapse, diplopia, and canthal tendon laxity, occurred at 1 week, 1 month, or 3 months after the treatment., Conclusion: BTX-A treatment of medial lower eyelid wrinkles with microneedle injection allows better control of the injection depth and reduces both the amount of BTX-A needed and the incidence of complications while maintaining the natural dynamic expression., (© 2023 The Authors. Journal of Cosmetic Dermatology published by Wiley Periodicals LLC.)

Background: The variable relationship between the orbicularis supercilii and frontalis muscles may cause side effects with botulin toxin; steadily frowning is the usual recommendation. Eliminating the need to frown until all injections are over might enhance efficacy and lessen the neurotoxicity risks related to muscle exhaustion., Objectives: The goal of this study was to investigate whether the digital caliper-assessed distances between the medial and lateral corrugator injection sites and the midline differed significantly in patients persistently frowning from patients resting., Methods: Seventy-six individuals with glabellar wrinkles treated with botulinum toxin in the authors' private practices for glabellar lines voluntarily contributed their retrospective data about the positions of injection sites. The investigators had freely chosen to inject the medial and lateral sections of the corrugator supercilii during persistent maximum frown or at rest., Results: The mean differences in distances between the medial and lateral injection points and the estimated midline were clinically trivial (1.0 ± 1.28 and 1.5 ± 2.53 mm, respectively), although the distances between the relaxed and contracted medial and lateral injection sites exceeded 1.8 and 2.5 mm in 33.9% and 46.4% of patients, respectively. Distance differences, not significant before 40 years old, were statistically significant only for the lateral injections in older patients (on average, 1.9 ± 3.01 mm)., Conclusions: The average distances from the medial and lateral injection points and the midline appear minimally different in patients who frown until all injections are over and, conversely, patients who rest. Persistently frowning might be advisable only in patients older than 40. Facial asymmetries may be a confounding factor., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Blepharospasm is rarely due to an identifiable etiology. In the majority of cases, imaging fails to reveal any structural lesion. Here we describe an otherwise healthy patient with blepharospasm who was found to have pontine capillary telangiectasia. We propose a potential association between blepharospasm and pontine capillary telangiectasia.

Background: OnabotulinumtoxinA (BTX) has become a mainstream treatment for chronic migraine (CM). Patients often have varied expectations for treatment success but little is known about how these initial impressions influence continuation of therapy. Objective: To record expectations of benefit and procedural discomfort (PD) from initial BTX treatment and to investigate their association with treatment success, defined as continuation of treatment for >3 sessions within a 2‐year period. Methods: A retrospective chart review of CM patients receiving initial treatment with BTX was performed. Patients were questioned about their expectations of benefit and PD as rated on a 0‐10 scale. Responses were then compared with continuation of therapy beyond 3 sessions to identify the presence of significant association. Results: Responses from patients (N = 297) were analyzed. About 173 subjects continued with BTX therapy for more than 3 sessions (173/297, 58.3%). Unadjusted odds ratios (OR) for expectation of benefit (EOB) (OR 1.11, 95% CI 0.99‐1.24, P =.087) and PD (OR 1.02, 95% CI 0.90‐1.16, P =.780) were not significantly predictive of continuing treatment. After considering sex, age, year of treatment, and previous headache preventative trials, only female sex (OR 2.02, 95% CI 1.09‐3.74, P =.025) was found to be significantly associated with treatment continuation. Conclusions: In the usual care setting, PD and EOB are not significantly associated with therapy continuation in patients receiving initial treatment with BTX for the prevention of CM. However, after considering sex, age, year of treatment, and number of previous headache preventives attempted, we found that female patients had twice the likelihood of continuing with BTX therapy compared to male patients with CM. [ABSTRACT FROM AUTHOR]

Background: Recovery from neuromuscular blockade is commonly assessed by clinical signs. There exists wide disparity in what is recommended to monitor neuromuscular blockade and routine clinical practice by anesthesiologists. The objective signs of train-of-four (TOF) ratio of >0.9 and double burst stimulation (DBS) ratio of 1.0 indicate adequate neuromuscular function. This study was planned at a tertiary care hospital to evaluate the ongoing practice of assessing neuromuscular recovery employing clinical signs and comparing with simultaneous TOF and DBS values. Design: A cross-sectional analytical study. Methodology: A total of 100 consecutive patients undergoing surgical procedures lasting more than 1-h duration under general anesthesia with intermediate acting muscle relaxant were enrolled and data of 60 patients analyzed. After extubation, an independent observer recorded simultaneous TOF and DBS ratio using acceleromyography as the clinical signs of neuromuscular recovery (eye opening, tongue protrusion, head lift, sustained bite, hand grip strength, and ability to cough) were attained. Statistical Analysis: Statistical analysis was done utilizing SPSS version 20 (SPSS Inc., Chicago IL, USA) software. Continuous variables are expressed as mean (standard deviation) and Pearson's correlation coefficient was applied to study the correlation between the clinical parameters and quantitative measures of neuromuscular recovery. Results: There was a significant association between ability to retain tongue depressor (sustained bite), absent double vision and ability to cough effectively and TOF and DBS ratios (P < 0.05). None of the clinical signs correlated with TOF ratio >0.9 or DBS ratio of 1.0. Conclusion: Clinical signs of recovery fail to reliably predict postoperative residual paralysis compared to objective neuromuscular monitoring. [ABSTRACT FROM AUTHOR]

The obliquus capitis inferioris (OCI) muscle is a significant driver of cervical dystonia with torticaput movements and a no-no head tremor. Limited data are available on the efficacy of OCI injections on patient outcomes. Our study aims to determine whether the botulinum toxin injection into OCI improves subjective patient quality of life in those with dystonic head tremors. A retrospective chart review was performed for 25 patients receiving injections into the OCI for a dystonic head tremor at the London Movement Disorders Clinic between January 2020 and January 2022. Toronto Western Spasmodic Torticollis Scale-2 (TWSTRS-2) subscale scores for disability and pain, TWSTRS-PSYCH scores, and the global impression of severity were extracted. The average TWSTRS-2 disability subscale change was -2.8 points ( p < 0.003). The average TWSTRS-2 pain subscale change was -4.6 points ( p < 0.003). The average TWSTRS-PSYCH score prior to injection was 5.6. After injection, the average score was 3.7 ( p < 0.004). The patient self-reported average global impression of severity before injection was 7.0; after this, it was 4.2 ( p < 0.0003). The OCI injection showed significant improvement in retrospective patient self-reported outcomes; it should be considered early in the treatment plan for cervical dystonia with a no-no head tremor.

Background: Spastic movement disorder (SMD) develops in up to 43% of cases as a sequela of stroke. In the event of a functionally relevant or daily life impairing SMD or to avoid an impending complication, the medicinal treatment of a focal, multifocal and segmental increase in muscle tone with botulinum neurotoxin A (BoNT-A) is recommended; however, treatment data reveal a lack of guideline-conform treatment with BoNT‑A in Germany., Objective: The aim of the reported expert meeting was to discuss solutions to the incorrect treatment and undertreatment of patients with SMD and to formulate consensus recommendations to improve the care situation., Methods: At a consensus meeting held in April 2022, eight experts from the fields of neurology, physical medicine and rehabilitation discussed the causes for the incorrect treatment and undertreatment and formulated consensus solution approaches., Results: Possible reasons for the current incorrect treatment and undertreatment in SMD management in Germany include insufficient awareness of SMD among physicians, a lack of treatment capacities, a lack of information transfer in discharge management as well as staff shortages in the specialized inpatient and outpatient SMD treatment centers. The committee therefore recommended a patient pathway in which affected patients with SMD are provided with correctly implemented BoNT‑A treatment in combination with physical measures., Conclusion: The recommended treatment pathway for use in stroke patients is intended to close gaps in care and thus ensure guideline-conform treatment of post-stroke SMD., (© 2023. The Author(s).)

Background: Botulinum neurotoxin type A (BTX-A) to the masseter muscle is a useful tool for the aesthetic narrowing of the width of the lower face. The administration of BTX-A to visible parotid glands is also effective to reduce lower facial width. However, no studies have quantitatively analyzed the effect of BTX-A on the parotid glands., Methods: The purpose of this study was to confirm the impact of BTX-A injection on the parotid gland and to suggest the effective dosage of BTX-A in facial slimming. This study was conducted by selecting patients who desired facial slimming from among patients who required surgery for a facial bone fracture. Patients undergoing BTX-A injection were randomized to high-dose, low-dose, and placebo groups, and different doses of BTX-A for each group were injected into both parotid glands during facial bone surgery., Results: A total of 30 patients were enrolled in this study. Ten patients in the high-dose group, eight in the low-dose group, and nine in the control group completed the clinical trial. There were significant changes in both the high- and low-dose groups compared with the control group ( P < 0.001, P < 0.001), and in interaction of time and group ( P < 0.001). Volume recovery after 3 months was found in 7.6% in the high-dose group and in 4.8% in the low-dose group., Conclusion: BTX-A injection into parotid glands can be an effective treatment option in managing salivary gland enlargement for lower face contouring., Clinical Question/level of Evidence: Therapeutic, II., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Summary: The frontalis muscle is situated across the forehead and is a representative target muscle for botulinum neurotoxin (BoNT) injections aimed at treating horizontal wrinkles in this region. However, a lack of anatomical information regarding the shape and thickness of the frontalis may lead to unexpected adverse effects, such as ptosis and samurai eyebrows, caused by the lack of detail on anatomical variation. Achieving the maximum effect using the minimal amount of BoNT requires a precise injection into the frontalis muscle. The anatomical factors associated with BoNT injection into the frontalis muscle have been reviewed in the current study. Up-to-date understanding of the localization of the BoNT injection point according to an updated understanding of the anatomy leads to more accurate localization of the injection point into the frontalis muscle. Optimal injection sites have been provided for the frontalis muscle, and the injection method has been recommended. The authors suggest optimal injection sites according to the external anatomical landmarks of the forehead. Furthermore, these proposals could aid in a more precise procedure that avoids the deleterious effects of BoNT., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Alluzience (abobotulinumtoxinA RTU; Ipsen, Paris, France and Galderma SA, Lausanne, Switzerland) is the first ready-to-use (RTU) botulinum toxin type A liquid solution approved for the treatment of glabellar lines in Europe. In this article, the authors provide consensus recommendations on the aesthetic usage of abobotulinumtoxinA RTU. Members of the International Board on Alluzience convened to develop consensus on the treatment of glabellar lines as well as other facial wrinkles based on their own extensive experience. Consensus recommendations were developed to provide practical guidelines for injection of abobotulinumtoxinA RTU. General guidance on proper assessment, treatment planning, and patient education is provided, as well as specific injection guidelines per indication. Indications covered include glabellar lines, crow's feet, horizontal forehead lines, lateral eyebrow lift, lower eyelid wrinkles, bunny lines, drooping nasal tip, perioral wrinkles, drooping mouth corners, masseter hypertrophy, hollow cheek lines, dimpled chin, and platysmal bands. These guidelines provide a practical framework to support routine injection of facial muscles with Alluzience., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Aesthetic Society.)

Background:  The application of botulinum toxin (BoNT) in the treatment of blepharospasm and hemifacial spasm (HS) is a well-established practice. However, neurology residency programs often rely on real patients for training, which has limitations in terms of patient availability and skill acquisition., Objective:  Assess the efficacy of a new facial phantom model for acquiring motor skills in BoNT application., Methods:  An anthropomorphic facial phantom model was developed in collaboration with a medical training simulator start-up. A group of seven neurologists and one ophthalmologist with expertise in BoNT application evaluated the model using an adapted learning object review instrument (LORI). The instrument assessed aspects such as: content quality, alignment of learning objectives, feedback and adaptation, motivation, presentation design, and accessibility., Results:  The facial phantom model received high scores in the LORI evaluation, with the highest ratings given to alignment with learning objectives and motivation. The model also scored well in terms of accessibility, content quality, and presentation design. However, feedback and adaptation received a lower score due to the static nature of the model., Conclusion:  The facial phantom model shows promise as a valuable tool for teaching and developing competence in BoNT application for HS and blepharospasm. The model reduces the reliance on real patients for training, providing a broader and safer learning experience for neurology residents. It also provides a realistic learning experience and offers portability, cost-effectiveness, and ease of manufacturing for use in various medical training scenarios. It is an effective and accessible tool for teaching BoNT application., Competing Interests: RAS, PF: Have no conflict of interest to declare. COGJ: Serves as deputy editor of Arquivos de Neuro-Psiquiatria journal., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution 4.0 International License, permitting copying and reproduction so long as the original work is given appropriate credit (https://creativecommons.org/licenses/by/4.0/).)

Objective: Operating room (OR) injection of botulinum toxin (BTX) injection is effective in the management of retrograde cricopharyngeal dysfunction (RCPD). This study aims to analyze the efficacy and safety of in-office (IO) 30 Unit BTX injection into the cricopharyngeus via lateral transcervical approach., Methods: A retrospective chart review of patients who underwent BTX injection either in the OR or IO for RCPD was performed. Postoperative success, defined by patient-reported complete or near complete resolution of symptoms, side effects, and complication rates of each group was determined and compared. To determine the learning curve of IO injections, success rates of the injections performed in the early and late 6 months were compared. Chi-square test was used for determining the statistical significance., Results: Overall, 78 injections (37 IO and 41 OR) for RCPD were performed by the senior author. The success rate of OR injections (90.2%) is significantly higher than IO injections (64.9%) at the first-month follow-up (p = 0.022). No significant difference was found in the side effect rates. Success and side effect rates were also similar in early and late injections (p > 0.05)., Conclusions: IO lateral transcervical BTX injection for RCPD is a safe method that does not require general or topical anesthesia. While the side effects are similar and IO injections have many advantages, the success rates are lower than OR injections., Level of Evidence: 3 Laryngoscope, 134:283-286, 2024., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Owing to its safety and convenience, botulinum toxin type A (BoNtA) has become a first-choice treatment for contouring calf muscle asymmetries or deformities. Different injection methods and dosages have been discussed in the literature, but a standardized BoNtA treatment remains unclear., Aims: This study aimed to classify gastrocnemius muscle hypertrophy (GMH) through multiple measurements to provide a personalized BoNtA treatment protocol., Methods: The measurements combining of gastrocnemius muscle (GM) contour, max leg circumference and GM thickness was applied to classify different type of GMH in a normal population. Based on these findings, a personalized BoNtA treatment protocol was determined and evaluated regarding max leg circumference, GM thickness, the position of max leg circumference, patient and doctor satisfaction rate, and complications., Results: A total of 100 GMH were classified into two bulging types (bilateral-bulging type and unilateral-bulging type) and two categories (moderate GMH and severe GMH). 40 cases were treated with personalized BoNtA injection methods ("Even" or "Intense"method) and dosages (300 or 400 units). Follow-up examinations at 1, 3, and 6 months after treatment. Max leg circumference and GM thickness decreased significantly and the position of max leg circumference rose prominently during treatment (2.56 ± 1.93; p < 0.05). The overall patient satisfaction rate was 70%-100%. No serious complications occurred., Conclusions: We identify four groups of GMH through several measurements and outline a personalized BoNtA treatment for each type. This recommended protocol may improve the therapeutic outcomes and patient satisfaction after treatment., (© 2023 The Authors. Journal of Cosmetic Dermatology published by Wiley Periodicals LLC.)

The purpose of this technique is to offer patients wishing a labial restoration without morphological changes a simple, fast, discreet, comfortable, adaptable and reversible method by combining the two compounds most used in aesthetic medicine, botulinum toxin and hyaluronic acid. The originality of this combination is based on their mixing in the same syringe and their injection with cannula through a paracommissural approach which makes it possible to treat the entire upper lip in a very homogeneous manner. Botulinum toxin diffuses directly into the underlying muscle layer; hyaluronic acid allows to unfold the damaged cutaneous fan. The useful reciprocal dose of the two products remains intuitive; for starting barcodes the dose of botulinum toxin will be 8-10 Speywood units (4 Allergan units), for those already marked at rest 10-20 Speywood units (4-8 Allergan units); the hyaluronic acid will be chosen according to the depth of the wrinkles. We present a series of 63 patients with an average age of 67 years with a result deemed positive in 79% of cases. The incidents reported are generally due to excessive doses of botulinum toxin which can lead to the classic incidents of fluid leaks in this location (6%). The expected efficacy of the treatment depends on that of the components used (four to six months) but prolonged results have been regularly observed (up to 18 months). All complementary resurfacing treatments have been discarded here since the aim pursued is that of a natural labial restoration allowing an immediate return to socio-professional activities., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Neuromodulator treatment of the upper face has been extensively studied and serves as an excellent tool to enhance facial appearance, non-verbal communication, and social functioning. Optimal outcomes are best achieved when health care providers take an individualized approach, based on knowledge of structural and functional anatomy, thorough facial assessment, and customized injection techniques and patterns., Competing Interests: Disclosure None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Botulinum toxin type A (BoNT/A) injections are the first-line treatment for primary hemifacial spasms (HFS), but require frequent painful injections. Although micro-hypodermic needles are commonly used for aesthetic BoNT/A injections to lessen pain and bruising, their benefits in HFS remain unclear., Objective: To compare side effects of BoNT/A injection, specifically pain and bruising, between primary HFS patients who received injections using micro-hypodermic needles (34-G) and those using standard needles (30-G)., Methods: This cross-over, double-blind, randomised controlled trial involved HFS patients who received BoNT/A injections using either a 34-G or 30-G needle at two visits 12 weeks apart. Primary outcomes, pain and bruising were assessed immediately after injection using the Visual Analogue Scale (VAS) and Short-form McGill Pain Questionnaire (Thai version, SF-MPQ). Bruise assessment was also conducted one week after each injection. Secondary outcomes involved comparing efficacy of BoNT/A between the two types of needles and assessing other complications beyond pain and bruising., Results: 65 HFS patients (47 women and 18 men; mean age 59.46 ± 11.48 years; mean disease duration 5.86 ± 4.16 years) were included in the study. Patients who received 34-G needle injections reported significantly reduced pain, as indicated by VAS, total SF-MPQ scores, and bruise scores, compared to those who received 30-G needle injections (p < 0.001, each). There were no differences in efficacy or occurrence of other complications associated with BoNT/A between the two needle types., Conclusion: In HFS patients, BoNT/A injections using micro-hypodermic needles resulted in reduced pain and bruising, compared to standard needles, while maintaining similar BoNT/A benefits., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

To provide a historic snapshot as regards the evolution of headache treatment throughout the human history, i.e. starting from trepanation to perisutural botulinum toxin (BoNT) injections. Ancient surgeons had aimed to reach the cranium with trepanation (a surgical operation) for headache. As BoNT inhibits the release of nociceptive and pro-inflammatory neuropeptides, it has been recently suggested as an effective alternative in the prophylactic treatment of chronic migraine headache. Chronic migraine is a complex neurological disorder for which the underlying pathophysiology is yet not totally explained. According to the generally accepted hypotheses, peripheral neurogenic activation and central trigeminal sensitization are the two main mechanisms through which its pain develops. Since the headache most commonly occurs around the perisutural areas, and as the primary pathogenesis stem from the meningeal nerve fibers; collateral sensorial branches of the meningeal nerves can be optimal paths to transport BoNT inside the cranium. Concerning the therapeutic efficacy, we anticipate that perisutural injections would be technically challenging with blind techniques and actually possible only if performed under an imaging guidance, e.g. very conveniently with high frequency ultrasound.

Competing Interests: Conflicts of interest Disclosures including pharmaceutical and device product(s): Murad Alam has no financial interests to declare in relation to the content of this article, and has not received payment or stock from Bonti, AbbVie, or any related organization. Domenico Vitarella, at the time of study conduct, was an employee of Bonti Inc and held Bonti stock prior to its acquisition by Allergan, an AbbVie Company. Wajdie Ahmad, at the time of study conduct, was a cofounder and chief operating officer of Bonti Inc and held Bonti stock prior to its acquisition by Allergan, an AbbVie Company. Susan Abushakra, at the time of study conduct, was a cofounder and chief medical officer of Bonti Inc, was co-inventor on several BoNT/E (EB-001) patents, and held Bonti stock prior to its acquisition by Allergan, an AbbVie Company. Cheri Mao is a former employee of AbbVie. Mitchell F. Brin is an employee of, and owns stock/stock options in, AbbVie. This product (BoNT/E; EB-001) is not labeled for the use under discussion.