Botulinum toxin assessment, intervention and after-care for lower limb spasticity in children with cerebral palsy: international consensus statement.

Botulinum neurotoxin type-A (BoNT-A) has been used in association with other interventions in the management of spasticity in children with cerebral palsy (CP) for almost two decades. This consensus statement is based on an extensive review of the literature by an invited international committee. The use of BoNT-A in the lower limbs of children with spasticity caused by CP is reported using the American Academy of Neurology Classification of Evidence for therapeutic intervention. Randomized clinical trials have been grouped into five areas of management, and the outcomes are presented as treatment recommendations. The assessment of children with CP and evaluation of outcomes following injection of BoNT-A are complex, and therefore, a range of measures and the involvement of a multidisciplinary team is recommended. The committee concludes that injection of BoNT-A in children with CP is generally safe although systemic adverse events may occur, especially in children with more physical limitations (GMFCS V). The recommended dose levels are intermediate between previous consensus statements. The committee further concludes that injection of BoNT-A is effective in the management of lower limb spasticity in children with CP, and when combined with physiotherapy and the use of orthoses, these interventions may improve gait and goal attainment.

The effect of botulinum toxin type A on the functional ability of the child with spastic hemiplegia a randomized controlled trial.

It has been demonstrated that botulinum toxin type A (BTX-A) injections reduce spasticity and improve muscle growth in children with spasticity. It has been postulated that BTX-A allows the learning of more normal movement patterns. The aim of this study was to measure the effect of this treatment on functional ability, as measured by the Gross Motor Function Measure (GMFM), in children with spastic hemiplegic cerebral palsy. Children of 3--13 years and meeting the selection criteria were randomly allocated to the control or injection group using a matched pair design. A match constituted a child within 6 months of age with the same Modified Ashworth Score (MAS) for the gastroc-soleus and within 10% of the same goal scores on the Gross Motor Function Measure. Twelve matched pairs were enrolled. Outcomes were measured on enrolment and at 1, 3 and 6 months post injection. The time course of the response to BTX-A was assessed with measurements of the MAS, dynamic range of motion (R1) and static muscle length (R2). Motor function was assessed using the 88-item GMFM and parental satisfaction with a 10-point visual analogue scale. Within pair comparisons of the GMFM using the Wilcoxon signed rank test indicated that the treatment group made significantly greater gains than controls at 3 months (P=0.02) with even greater differences seen at 6 months (P=0.004). Using parametric statistics, the intrapair difference in proportional change of GMFM increased from 35% (4 to 65) at 3 months to 52% (17--87) at 6 months. Response to injection was confirmed by a decrease in MAS in the treatment group and very little change in controls. This difference was significant (P=0.002) at 3 months and was attenuated but still significant (P=0.016) at 6 months; the difference in proportional change decreased from 44% at 3 months to 22% at 6 months. Changes in R1 reflected those of MAS in the treatment group and deteriorated significantly over the study period in controls. Parents of children in the treatment group were more satisfied than controls, but satisfaction scores did not correlate with changes in function or technical outcomes suggesting that this may be a placebo effect. The changes in GMFM correlated with changes in technical outcomes at 3 months, suggesting a causal relationship. The intrapair differences in GMFM continued to increase even after the local response to injection had started to wane.

Proportional change: an additional method of reporting technical and functional outcomes following clinical interventions.

One of the major challenges in disability management research is to express results in a manner that can be generalized to subjects with varying degrees of disability. Absolute measurements of change are often dependent on initial characteristics, in which case they can only be generalized to subjects with the same characteristics. We define proportional change as the ratio of change to the maximum possible or targeted change. It can be assessed in any situation where a maximum possible or targeted change is definable. Its estimated value will be sensitive to the choice of denominator. Subjective assessments, such as those measured with Likert scales, are naturally expressed as proportional change with the denominator being set by the subject. Denominators may also be determined objectively by physical limitations or, less desirably, by the measurement tool. Where there is no readily or objectively determinable denominator, they should be chosen for each subject in advance of the intervention according to carefully specified criteria. Proportional change is proposed, as an adjunct to the reporting of absolute measures of change following therapeutic interventions, as a means of expressing change in a manner that is both individualized and generalizable.

Principles for the use of macrocyclic lactones to minimise selection for resistance.

OBJECTIVE: To provide principles for the appropriate use of avermectin/milbemycin or macrocyclic lactone (ML) anthelmintics in sheep, to ensure effective worm control and to minimise selection for ML resistance. STRATEGY: The principles were based on an assessment of the information currently available. The MLs were categorised into three groups (ivermectin [IVM], abamectin [ABA] and moxidectin [MOX]) based on structural differences, persistence and efficacy against ML resistant strains. The reported order of activity or efficacy against ML resistant worm strains was IVM

Enteritis associated with Yersinia pseudotuberculosis infection in a buffalo.

A week after transport a 4 month old buffalo calf developed diarrhoea. Its condition gradually deteriorated and it died. Necropsy revealed acute haemorrhagic enteritis and enlarged mesenteric lymph nodes. Haemorrhages and numerous microabscesses were detected in the lamina propria of the small intestine associated with colonies of Gram negative bacteria. Yersinia pseudotuberculosis was isolated from the small intestine and from mesenteric lymph node. Enteritis caused by Y pseudotuberculosis does not appear to have been reported previously in buffalo in Australia.

Development of a method for the identification, using the polymerase chain reaction, of Aspergillus fumigatus isolated from ostriches.

OBJECTIVE: To develop a method for identifying DNA of Aspergillus fumigatus from ostriches, using the polymerase chain reaction (PCR). A fumigatus is the principal causative agent of avian aspergillosis. DESIGN: A biochemical trial. SAMPLE POPULATION: Twelve Aspergillus fumigatus isolates and three other Aspergillus species. PROCEDURE: PCR primers that were based on the sequence of the alkaline protease gene from human isolates of A fumigatus were used. RESULTS: We successfully tested the method on ostrich isolates from five states and showed that the test is specific for A fumigatus. CONCLUSIONS: In most cases the DNA sequence of A fumigatus isolates from ostriches is similar to that of human isolates. DNA sequences vary significantly among A fumigatus isolates, including those from affected ostriches in the same flock. The genetic variation may be used to trace aspergillus infections in ostrich flocks and determine if the disease is transmitted by contact with infected birds.

Verminous bronchitis and bronchiolitis in potoroid marsupials associated with a new Capillaria sp.

We describe verminous bronchitis and bronchiolitis in potoroid marsupials associated with a new species of Capillaria resident in the epithelial lining of bronchi and bronchioles. The parasites was associated with alveolar oedema and emphysema, and a mixed inflammatory cell exudate within and surrounding the airways.

Anasarca and myopathy in ostrich chicks.

Twenty ostrich chicks that died at, or within, 1 week after hatching were examined from 7 farms with poor (43 to 75%) hatchability. All chicks had anasarca and 15 had mild, generalised, acute degenerative changes in the complexus and pelvic limb muscles. One had fibrinoid degeneration of arterioles. Biochemical examinations produced no evidence of deficiencies of selenium, vitamin A or vitamin E. The syndrome was related to high relative humidity during incubation. Malpositioning also was a cause of embryo mortality.