International consensus recommendations on the aesthetic usage of botulinum toxin type A (Speywood Unit)--Part II: Wrinkles on the middle and lower face, neck and chest.

BACKGROUND: Azzalure® (Galderma SA), a newly approved European botulinum neurotoxin type A (BoNT-A), is derived from Dysport™ (Ipsen Ltd.), which has a 20-year history of product consistency and has been widely used for various aesthetic and therapeutic applications. Azzalure® and Dysport™ are collectively referred to as BoNT-A (Speywood Unit) after the unit of their activity, and are distinct from other commercial BoNT-A preparations. Consensus has been developed for the treatment of upper facial wrinkles with BoNT-A (Speywood Unit). OBJECTIVE: To provide consensus recommendations on the treatment with BoNT-A (Speywood Unit) for wrinkles on the middle and lower face, neck and chest region. METHODS: The members of the International Board on Botulinum toxin Azzalure (IBBA) convened to develop consensus based on their extensive experience. RESULTS: The recommended final concentration of BoNT-A (Speywood Unit) is 200 Speywood Units/ml after reconstitution. The consensus recommendations were provided for nine indications, including lower eyelid wrinkles, bunny lines, drooping nasal tip, perioral wrinkles, masseter hypertrophy, drooping mouth corners, dimpled chin, platysmal bands and décolleté wrinkles. For each indication, anatomy of the region to be treated was discussed, as were potential side-effects. The consensus recommendations included the number and location of the injection points, dose range of each point and the total injection, as well as specific injection technique. CONCLUSION: These recommendations provide a guideline for physicians who wish to perform safe and efficacious treatment with BoNT-A (Speywood Unit) on the less commonly treated middle and lower face, neck and chest region.

The cumulative effect of small dietary changes may significantly improve nutritional intakes in free-living children and adults.

BACKGROUND/OBJECTIVES: The ELPAS (Etude Longitudinale Prospective Alimentation et Santé) study was an 8-month randomized controlled dietary modification trial designed to test the hypothesis that family dietary coaching would improve nutritional intakes and weight control in 2026 free-living children and parents. It resulted in significant nutritional changes, with beneficial effects on body mass index in adults. In these ancillary analyses, we investigated dietary changes throughout the intervention. SUBJECTS/METHODS: Before the study, modeling analyses were carried out on the French Association Sucre Produits Sucrés Consommation et Communication (ASPCC) food-consumption database to identify the most efficient dietary intervention strategy. During the study, all participants performed monthly three nonconsecutive 24-h dietary recalls: this allowed for measuring changes in the number of servings per day and serving size for each targeted food category throughout the intervention. RESULTS: Modeling analyses showed that targeting only the 10 main foods contributing to fat and carbohydrate intakes did not allow for reaching the ELPAS nutritional goals. As a result, it was decided to target more foods and to propose several types of dietary advice (such as change in serving size, change in cooking method, food substitution). This strategy led to many appropriate dietary changes during the intervention, but only a few of them reached significance. The mean number of servings per day was indeed significantly modified for only 7% of the targeted food categories in children and 17% in parents. The mean serving size was modified for only 12% of targeted food categories in children and 9% in parents. CONCLUSIONS: The cumulative effect of small dietary changes may induce significant nutritional improvements, with limited burden for populations.

International consensus recommendations on the aesthetic usage of botulinum toxin type A (Speywood Unit)--Part I: Upper facial wrinkles.

BACKGROUND: Azzalure (Galderma SA) is a newly approved European botulinum neurotoxin type A (BoNT-A). It is derived from Dysport (Ipsen Pharma), which has a long history of usages in various applications. Azzalure and Dysport are collectively referred to as BoNT-A (Speywood Unit) and are different from other BoNT-A preparations. OBJECTIVE: To provide consensus recommendations on the treatment of upper face wrinkles with BoNT-A (Speywood Unit). METHODS: The members of the International Board on Botulinum toxin Azzalure (IBBA) convened to develop consensus on the treatment of upper facial wrinkles based on their own extensive experience. RESULTS: The consensus recommendations address the general issues regarding treatment and provide specific guidelines on the anatomy, injection points, dose, injection technique and safety precautions concerning each common upper face indication. The recommended final concentration of BoNT-A (Speywood Unit) is 200 s.U/mL (10 s.U/0.05 mL) after reconstitution. For glabellar lines, the members recommend a total of five injection points with 10 s.U/point. For forehead wrinkles, the members recommend four to six injections into the frontalis with 5-10 s.U/point. For crow's feet, the members recommend three injections per side with 5-10 s.U/point at the lateral part of the orbicularis oculi. For lateral eyebrow lift, the members recommend one point at each eyebrow tail and an additional one in each side of the frontalis with 5-10 s.U/point. CONCLUSION: This guideline provides a framework for physicians who wish to perform safe and efficacious injection of BoNT-A (Speywood Unit).

DNA markers and crossbreeding scheme as means to select sires for heterosis in egg production of chickens.

Genotypes for 24 microsatellite markers, dispersed across the chicken genome, were used to predict progeny performance and heterosis for egg production (number and mass) in 'layers' (egg-type chickens). These markers were used to evaluate genetic distance between each of 39 sires sampled from two-layer male-lines; Rhode Island Red (RIR) and White egg Leghorn (Leghorn), and a DNA pool of 30 randomly sampled females from a Brown-egg female line (Silver). Each sire was analysed for egg production across months in the laying period and cumulatively in each of three subperiods; onset (2 month), mid (9 month) and late (1 month). The average Reynolds' genetic distance between Leghorn sires and the Silver female line (theta;=0.6) was significantly higher than that between RIR sires and the Silver female line (theta;=0.5). Neither performance nor heterosis values in the RIR sire's daughters were associated with genetic distance values between sires and the Silver female line. On the other hand, performance as well as heterosis values of Leghorn's daughters were positively associated with genetic distance. This association was particularly evident in the mid-subperiod. If 25% of the most genetically distant Leghorn sires from the Silver female line had been selected in a single generation on the basis of DNA markers information only, average egg production of the crossbred daughters would have been improved by about nine eggs (3%). In principle, further improvement is possible if selection to increase genetic distance between the parental lines is carried on.

Treatment of facial telangiectasias with a diode-pumped Nd:YAG laser at 532 nm.

OBJECTIVE: Facial telangiectasias are a common cause of cosmetic concern. Current treatment modalities present various untoward effects and limits. The pulsed dye laser has been considered the gold standard in efficacy and safety; unfortunately it causes postoperative intracutaneous hematomata, discouraging many patients from undergoing this treatment. Several other vascular lasers (argon, tunable dye, copper, krypton, etc.) are disadvantaged by the risk of hypopigmented and atrophic scars. MATERIALS AND METHODS: We assessed a recent powerful version of the potassium titanyl phosphate (KTP) 532 nm laser, which delivers sufficient energy in single pulse lasting 10-50 msec (DioLite 532; IRIDEX, Mountain View, CA, USA). Collateral damage is reduced while the heating of the vessel is slow enough to avoid explosive photothermolysis with its associated purpura. Sixty six patients with facial telangiectasias were treated. RESULTS: In 62/66 patients (93.9%) we achieved a 75-100% clearance of the lesions, while two treatments were needed to reach an acceptable clearance in the remaining 4/66 patients (6.1%). The eventual need for more sessions was well tolerated because the acceptable postoperative appearance allowed patients to continue normal business and social activities between treatments. No permanent complications or undesired effects were noted. CONCLUSION: We conclude that this diode-pumped frequency-doubled Nd:YAG laser is an effective device for the treatment of facial telangiectasias, with a low profile of undesired effects that can be well tolerated by patients.

Cardiorespiratory consequences of sleep apnoea syndrome in patients with massive obesity.

Assessment of cardiorespiratory consequences of sleep apnoea syndrome (SAS) is difficult owing to confounding factors, especially obesity, that are strongly associated with SAS. This study was designed to assess the cardiorespiratory consequences of SAS by comparing the results of a comprehensive cardiorespiratory evaluation in apnoeic and nonapnoeic patients with massive obesity. In a retrospective chart-review study, we studied 60 patients with massive obesity defined by a body mass index (BMI) >40 kg.m(-2), presenting no chronic respiratory disease, who underwent an extensive assessment of cardiorespiratory consequences of obesity, including overnight polysomnography, lung function tests, arterial blood gas analysis, evaluation of vascular risk factors, myocardial scintigraphy with dipyridamole stress-test, isotopic ventriculography, Doppler echocardiography and Holter electrocardiogram recording. SAS defined by an apnoea + hypopnoea index (AHI) > or = 10 was diagnosed in 42% of patients (25 out of 60). Mean+/-SD AHI of SAS-positive (SAS+) patients was 38+/-24. Age, BMI, ventilatory function parameters, prevalence of smoking history and diabetes mellitus did not differ significantly in SAS+ versus SAS-negative (SAS-) groups. The following complications were observed more frequently in SAS+ than in SAS- patients: daytime hypoxaemia (35 vs 9%, p<0.02), pulmonary arterial hypertension (36 vs 7%, p<0.05) and increased interventricular septal thickness (50 vs 15%, p<0.03). No association was found between SAS on the one hand and systemic arterial hypertension, coronary artery disease, left ventricular dysfunction and nocturnal cardiac arrhythmias on the other. Nocturnal apnoeas in massive obesity may thus be associated with moderate daytime hypoxaemia, mild pulmonary arterial hypertension and moderate left ventricular hypertrophy, but not with severe cardiorespiratory complications.

A mutation in the human leptin receptor gene causes obesity and pituitary dysfunction.

The adipocyte-specific hormone leptin, the product of the obese (ob) gene, regulates adipose-tissue mass through hypothalamic effects on satiety and energy expenditure. Leptin acts through the leptin receptor, a single-transmembrane-domain receptor of the cytokine-receptor family. In rodents, homozygous mutations in genes encoding leptin or the leptin receptor cause early-onset morbid obesity, hyperphagia and reduced energy expenditure. These rodents also show hypercortisolaemia, alterations in glucose homeostasis, dyslipidaemia, and infertility due to hypogonadotropic hypogonadisms. In humans, leptin deficiency due to a mutation in the leptin gene is associated with early-onset obesity. Here we describe a homozygous mutation in the human leptin receptor gene that results in a truncated leptin receptor lacking both the transmembrane and the intracellular domains. In addition to their early-onset morbid obesity, patients homozygous for this mutation have no pubertal development and their secretion of growth hormone and thyrotropin is reduced. These results indicate that leptin is an important physiological regulator of several endocrine functions in humans.

[Mechanisms of diurnal hypercapnia in sleep apnea syndromes associated with morbid obesity]. / Mécanismes de l'hypercapnie diurne dans le syndrome d'apnées du sommeil associé à une obésité massive.

OBJECTIVES: The prevalence and mechanisms of diurnal hypercapnia in subjects with sleep apnea syndrome are not well known, particularly in the morbidly obese. METHODS: We studied a group of 24 subjects with sleep apnea syndrome and morbid obesity defined as a body mass index greater than 40 kg/m2 and free of chronic respiratory disease. RESULTS: Hypercapnia (PaCO2 > 42 mmHg) was found in 50% of the subjects. Age, body mass index, waist/hip ratio, apnea index, ratio of maximum forced expiratory volume in one second (FEV1) to vital capacity and expiratory reserve volume were not significantly different between hypercapnic and normocapnic subjects. Total pulmonary capacity, vital capacity and FEV1 were significantly lower in hypercapnic subjects than in normocapnic subjects. CONCLUSION: These findings suggest that ventilatory restriction plays an important role in the development of diurnal alveolar hypoventilation in subjects with sleep apnea syndrome and morbid obesity.

[Medical kits in Army physicians' vehicles].

Physicians' medical kits (PMK) were distributed to 50 physicians, graduates of an advanced trauma life support course. The kits were always to be present in the physicians' designated vehicles, enabling them to provide advanced life support at the earliest possible stage (the "golden hour"). The kits have equipment for advanced airway intervention and management, chest trauma management (chest tube insertion, etc.) and fluid administration. To help assess the impact of the PMK and its cost effectiveness, questionnaires were sent to the physicians involved, of whom 35/50 responded. The questions included 2 subjects: the presence of the kit in the car and details of its use for injuries. The kit was present at all times in the cars of all except 1 of 31 physicians. 7 (22.5%) of them used the kit in 50 incidents which involved 74 injured persons. The injuries were caused by road accidents in 54 cases, in 17 by terrorist activity, and 3 cases involved heart attacks and cardiac resuscitation. Distribution of the PMK among army physicians appears to be valuable in the field, and before hospitalization.

Microalbuminuria and body fat distribution in obese subjects.

The aim of this work was to evaluate the prevalence of microalbuminuria in an obese population and to study the relation between albumin excretion rate (AER), various clinical (body mass index, adipose tissue distribution) nutritional (macronutrient intake) and metabolic parameters. A cross-sectional study was carried out, and AER was evaluated in 182 obese subjects (BMI > 27) with no medication, no intercurrent disease, no cardiac, pulmonary or endocrinological disorders (including diabetes and hypertension) and also in 31 control subjects at the outpatient clinic of the department of Nutrition, Hôtel Dieu, Paris, France. The following were measured: BMI, waist/hip ratio (WHR), urinary AER, blood glucose, insulin and C peptide levels, cholesterol (CT), triglycerides, HDL cholesterol (HDL-CT), apoprotein A1 and B. In the obese population, 18 subjects (9.9%) were found to have an increased AER: 13 subjects (7.1%) with microalbuminuria (AER between 30 to 300 mg/24 h) and five with AER over 300 mg/24 h. AER was normal in all control subjects but one, who was found to have microalbuminuria. Log AER was positively correlated to WHR (P < 0.001), blood pressure (P < 0.05), cholesterol (P < 0.05), Apo B levels (P < 0.01) and with fasting Insulin levels and protein intake (P < 0.001). Positive association between log AER and protein intake, insulin levels, Apo B and blood pressure were found independently of BMI and WHR. It is suggested that abdominal obesity may be associated with incipient nephropathy in some obese subjects without diabetes and hypertension. Microalbuminuria may be included among metabolic abnormalities connected with abdominal-type excess weight distribution.(ABSTRACT TRUNCATED AT 250 WORDS)

[Treatments of massive obesity]. / Traitements des obésités massives.

Treatment of massive obesity aims at somatic, psychological and social targets and therefore requires a multidisciplinary team co-ordinated by a physician. Treatment usually begins by taking care of the most worrying somatic and metabolic problems (cardio-respiratory and metabolic disorders) and by correcting the diet. It is then enhanced by a psychological assistance provided by the treating team and, in certain cases, by a psychotherapist. Massive obesity is a chronic, recurrent and severe disease. Its treatment is prolonged and implies numerous constraints (diet, drugs, treatment of a possible sleep apnoea syndrome) which are difficult to tolerate in the long term. This type of management resembles that of other chronic diseases, such as complicated diabetes. From dietetics to the most technical medicine, from the doctor-patient relationship to psychotherapy, the therapeutic methods are numerous, and the burden of using them in a coherent manner falls on the physician.

Results of long-term continuous subcutaneous octreotide administration in 14 patients with medullary thyroid carcinoma.

OBJECTIVE: Treatment by octreotide has been suggested in medullary thyroid carcinoma patients with post-surgery metastases. The purpose of this study was to evaluate if the tumoral regression could be improved by a high dose and by prolonged octreotide treatment. DESIGN: Fourteen thyroidectomized patients were studied. All patients had persistently elevated plasma calcitonin levels with normal or elevated carcino-embryonic antigen levels. Five hundred micrograms/day of octreotide were administered by continuous subcutaneous infusion for 90 days. MEASUREMENTS: Plasma calcitonin and carcino-embryonic antigen levels were determined at days -30, -20, -2, -1, 0, +30, +60, +90, +120; morphological extension was evaluated every month. RESULTS: Continuous infusion of octreotide did not induce any significant decrease of calcitonin levels, or any morphological improvement, and had no major undesirable effect. However, in 4/14 patients calcitonin levels fell during treatment (-43, -50, -15, -20%), and in 9 patients calcitonin increased (+22 to +130%) after cessation of therapy. CONCLUSION: Biological or morphological parameters of medullary thyroid carcinoma are not significantly improved in a large series of patients treated by octreotide.

[Respiratory complications of massive obesity]. / Les complications respiratoires des obésités massives.

Massive obesity may lead to serious, and sometimes fatal, respiratory complications. Alterations of ventilatory mechanics and function are well known; they include a decrease in respiratory compliance, an increase in ventilatory work and a restrictive pulmonary disease. Hypoxemia is rather due to an impaired ventilation/perfusion ratio than to alveolar hypoventilation. Sleep Apnea Syndrome (SAS) is very frequent in excessively obese patients. These subjects with daytime hypersomnolence should be systematically screened for SAS before the occurrence of life-threatening complications. Continuous positive airway pressure ventilation through a nasal mask is the treatment of choice of SAS especially since the results of body weight reduction and ENT surgery are inconstant and variable in these patients.