Injection site number and outcomes of intradetrusor onabotulinumtoxinA for refractory overactive bladder syndrome: a randomized clinical trial.

INTRODUCTION AND HYPOTHESIS: The optimal number of onabotulinumtoxinA injections for the treatment of refractory overactive bladder syndrome is unknown. Our primary objective was to determine whether 10-injections sites with 100 units of onabotulinumtoxinA each were associated with less pain than 20-injections sites. METHODS: In a single-blinded randomized trial, 100 units of onabotulinumtoxinA was administered, either as 10 × 1 ml or as 20 × 0.5 ml injections following the instillation of 30 ml of bupivacaine and 5 ml of NaHCO3 solution for 15 min. The primary outcome was procedural pain, as measured on an 11-point Numerical Pain Rating Scale (NPRS) immediately following the procedure. A power calculation estimated that 16 subjects in each arm were needed to detect a mean difference of 1 with a standard deviation of 1, on the NPRS score between the two treatment groups, with α 0.05 and power 80%. To adjust for an estimated 20% dropout rate, the final sample size was planned for 20 patients per group. RESULTS: From October 2020 to November 2022, a total of 56 patients were approached and 40 were enrolled and randomized to two groups (21 in the 10-injections group and 19 in 20-injections group). The difference in the median pain score between the group was not statistically significant (4 [1.5-5] for 10 injections vs 3 [1-4] for 20 injections, p=0.823). CONCLUSION: Patients' perception of pain, efficacy, and adverse events did not significantly differ between patients receiving 10 and those receiving 20 injections of 100 units of onabotulinumtoxinA.

The Response of the Urinary Microbiome to Botox.

INTRODUCTION AND HYPOTHESIS: Our objective was to evaluate if botox alters the urinary microbiome of patients with overactive bladder and whether this alteration is predictive of treatment response. METHODS: This multicenter prospective cohort study included 18-89-year-old patients undergoing treatment for overactive bladder with 100 units of botox. Urine samples were collected by straight catheterization on the day of the procedure (S1) and again 4 weeks later (S2). Participants completed the Patient Global Impression of Improvement form at their second visit for dichotomization into responders and nonresponders. The microbiome was sequenced using 16s rRNA sequencing. Wilcoxon signed rank and Wilcoxon rank sum were used to compare the microbiome, whereas chi-square, Wilcoxon rank sum, and the independent t-test were utilized for clinical data. RESULTS: Sixty-eight participants were included in the analysis. The mean relative abundance and prevalence of Beauveria bassiana, Xerocomus chrysenteron, Crinipellis zonata, and Micrococcus luteus were all found to increase between S1 and S2 in responders; whereas in nonresponders the mean relative abundance and prevalence of Pseudomonas fragi were found to decrease. The MRA and prevalence of Weissella cibaria, Acinetobacter johnsonii, and Acinetobacter schindleri were found to be greater in responders than nonresponders at the time of S1. Significant UM differences in the S1 of patients who did (n = 5) and did not go on to develop a post-treatment UTI were noted. CONCLUSIONS: Longitudinal urobiome differences may exist between patients who do and do not respond to botox.

Antibiotic prophylaxis for onabotulinum toxin A injections: systematic review and meta-analysis.

INTRODUCTION AND HYPOTHESIS: To our knowledge, there are no evidence-based recommendations regarding the optimal prophylactic antibiotic regimen for intradetrusor onabotulinum toxin type A (BTX) injections. This systematic review and meta-analysis was aimed at investigating the optimal prophylactic antibiotic regimen to decrease urinary tract infection (UTI) in patients undergoing BTX for overactive bladder syndrome (OAB). METHODS: A systematic search of MEDLINE, Embase, CINAHL, and Web of Science was conducted from inception through 30 June 2022. All randomized controlled trials and prospective trials with > 20 subjects undergoing BTX injections for OAB in adults that described prophylactic antibiotic regimens were included. Meta-analysis performed to assess UTI rates in patients with idiopathic OAB using the inverse variance method for pooling. RESULTS: A total of 27 studies (9 randomized controlled trials, 18 prospective) were included, representing 2,100 patients (69% women) with 19 studies of idiopathic OAB patients only, 6 of neurogenic only, and 2 including both. No studies directly compared antibiotic regimens for the prevention of UTI. Included studies favor the use of antibiotics in patients with idiopathic OAB and favor continuing antibiotics for 2-3 days after the procedure for prevention of UTI. Given the heterogeneity of the data, direct comparisons of antibiotic type or duration could not be performed. Meta-analysis found a 10% UTI rate at 4 weeks and 15% at 12 weeks post-injection. CONCLUSIONS: Although there are insufficient data to support the use of a specific antibiotic regimen, available studies favor the use of prophylactic antibiotics for 2-3 days in idiopathic OAB patients undergoing BTX injection. Future trials are needed to determine the optimal regimens to prevent UTI in patients undergoing BTX for OAB.

Management of androgenic alopecia: a systematic review of the literature.

We aimed to determine the efficacy of the various available oral, topical, and procedural treatment options for hair loss in individuals with androgenic alopecia. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review of the National Library of Medicine was performed. Overall, 141 unique studies met our inclusion criteria. We demonstrate that many over the counter (e.g. topical minoxidil, supplements, low-level light treatment), prescription (e.g. oral minoxidil, finasteride, dutasteride), and procedural (e.g. platelet-rich plasma, fractionated lasers, hair transplantation) treatments successfully promote hair growth, highlighting the superiority of a multifaceted and individualized approach to management.

Use of botox for sialorrhea and dysphagia in the neonatal population.

INTRODUCTION: Botox is frequently used for sialorrhea in patients with compromised airways and those with etiologies causing difficulty with secretion management (i.e. strokes, neurologic disorders, etc.). There are no published studies regarding the use of botulinum toxin (BoNT) in the neonate population. We aim to discuss our experience and safety of BoNT use in the neonate population in regards to alleviating secretion management and airway protection. METHODS: Retrospective review of neonates admitted to the neonatal intensive care unit (NICU) ≤12 months of age who received BoNT injection to submandibular (SMG) and parotid (PG) glands for sialorrhea/dysphagia. BoNT was administered under ultrasound (u/s) guidance by interventional radiology. RESULTS: 6 children were examined. 2 (33 %) were male. Avg NICU stay was 87.5 ± 33.1 days. 2 underwent surgical airway intervention prior to injection. Mean age at initial BoNT was 1.5 ± 0.7 months. Avg weight at injection was 4 ± 1.1 kg. Each PG and SMG were injected in 5/6 cases. Bilateral SMG were unidentified on u/s in 1 case and thus not injected. Dose range injected per gland was 5-15u. 100 % required tube feeds, 50 % with tubes distal to stomach (NJT/NDT). 83 % were completely NPO prior to injection and there was no noted clinical improvement in oral skills post injection. All had noted desats/apneas prior to injection and 83 % had reported decreased events post injection. 50 % had reported decrease O2 requirements and frequent suctioning 2wks after injection, however 2 (33 %) required surgical airway intervention after injection (trach, SGP/MDO). 4/6 (67 %) trialed medical therapy, anticholinergics being the most common. 50 % underwent 2nd injection (age = 6.5 ± 0.3 months) avg. 4.7 ± 0.7mo after 1st injection, and the same 3pts underwent 3rd injection (age = 12.5 ± 2.4 months) avg. 6.1 ± 2.5mo after 2nd injection. 1 pt. had a total 6 injections. There were no injection related complications. CONCLUSION: BoNT injection is a safe, non-invasive alterative for management of sialorrhea in neonates. Further extensive study needs to be performed to identify the optimal dose per gland in this population.

Evaluation of the Effect of Botulinum Toxin A on the Lymphatic Endothelial Cells.

INTRODUCTION: Botulinum toxin A (BoTA) is a neurotoxin formed by Clostridium botulinum, with a broad medical application spectrum. While the primary effect of BoTA is on the muscles, the effects of BoTA in other systems including the blood vasculature have already been examined, revealing unexpected actions. However, no studies exist to the best of our knowledge regarding the potential effects of BoTA on the lymphatic vascular system, possessing a critical role in health and disease. Isolated human lymphatic endothelial cells (LECs) were cultured in dedicated in vitro culture systems. The analysis including imaging and cell culture approaches as well as molecular biology techniques is performed to examine the LEC alterations occurring upon exposure to different concentrations of BoTA. MATERIALS AND METHODS: Human LECs were cultured and expanded on collagen-coated petri dishes using endothelial basal medium and the commercial product Botox from Allergan as used for all our experiments. Harvested cells were used in various in vitro functional tests to assess the morphologic and functional properties of the BoTA-treated LECs. Gene expression analysis was performed to assess the most important lymphatic system-related genes and pathways. RESULTS: Concentrations of 1, 5 or 10 U of BoTA did not demonstrate a significant effect regarding the proliferation and migration capacity of the LECs versus untreated controls. Interestingly, even the smallest BoTA dose was found to significantly decrease the cord-like-structure formation capacity of the seeded LECs. Gene expression analysis was used to underpin possible molecular alterations, suggesting no significant effect of BoTA in the modification of gene expression versus the starvation medium control. CONCLUSION: LECs appear largely unaffected to BoTA treatment, with an isolated effect on the cord-like-structure formation capacity. Further work needs to assess the effect of BoTA on the smooth-muscle-cell-covered collecting lymphatic vessels and the possible aesthetic implications of such an effect, due to edema formation. LEVEL OF EVIDENCE V: 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 .

Onabotulinum toxin A block of the sphenopalatine ganglion in patients with persistent idiopathic facial pain: a randomized, triple-blind, placebo-controlled, exploratory, cross-over study.

OBJECTIVE: To investigate the efficacy and safety of injecting onabotulinum toxin A (BTA) towards the sphenopalatine ganglion (SPG) using the MultiGuide® in patients with persistent idiopathic facial pain (PIFP). METHODS: This cross-over, exploratory study compared the injection of 25 units BTA versus placebo in patients who met modified ICDH-3 criteria for PIFP. Daily pain diaries were registered for a 4-week baseline, a 12-week follow-up after each injection, and an 8-week conceptual washout period in between. The primary efficacy endpoint was the change from baseline to weeks 5-8 in average pain intensity using a numeric rating scale. Adverse events were recorded. RESULTS: Of 30 patients who were randomized to treatment, 29 were evaluable. In weeks 5-8, there was no statistically significant difference in average pain intensity between BTA versus placebo (0.00; 95% CI = -0.57 to 0.57) (P = 0.996). Following both BTA and placebo injections, five participants reported at least a 30% reduction in average pain during weeks 5-8 (P = 1.000). No serious adverse events were reported. Post-hoc analyses indicated a possible carry-over effect. CONCLUSIONS: Injection of BTA toward the SPG with the MultiGuide® did not appear to provide a reduction in pain reduction at 5-8 weeks, although this finding may be influenced by a carry-over effect. The injection appears to otherwise be safe and well-tolerated in patients with PIFP.Trial Registration: The study protocol is registered in ClinicalTrial.gov (NCT03462290) and EUDRACT (number: 2017-002518-30).

Design, implementation and assessment of a novel, introductory curriculum into female, neurological and urodynamic urology: a 7-year experience of urology simulation bootcamp course.

PURPOSE: To present the seven-year experience of a multi-component and interactive module on female, neurological and urodynamic urology (FNUU) training at the UK National Urology Simulation Bootcamp Course (USBC) and demonstrate trainee satisfaction and competency progression. METHODS: During the week-long USBC, a four-hour module on FNUU was designed which consisted of short interactive presentations with an emphasis on practical stations in urodynamics, intravesical botulinum toxin injection, urethral bulking injection, female pelvic examination and, initially, mid-urethral tapes (subsequently replaced with percutaneous sacral nerve evaluation). The trainee's level of knowledge, operative experience and confidence were assessed pre- and post-course. The practical assessment consisted of preparation and intravesical administration of botulinum toxin, female pelvic examination, urodynamic trace interpretation or mid-urethral tape simulation. Trainee feedback was also collected. RESULTS: Two-hundred sixty-one newly appointed urology trainees participated in the USBC during this period. A high level of satisfaction was constantly reported. The highest rated session was urethral bulking with 72% being very satisfied, followed by Botox and urodynamics. The final assessment showed 70% had achieved level 4 competency in cystoscopy and Botox. Qualitative feedback was also obtained. CONCLUSION: To our knowledge, this is the first module of its kind, and it shows that it is feasible to develop, implement and evaluate an introductory curriculum into FNUU that is reproducible over a 7-year period with very positive feedback.

Unusual herpetic reactivation in a young female following botox injection: a case report study.

BACKGROUND: Botox injections are commonly used for cosmetic and therapeutic purposes because they temporarily paralyze muscles, reduce wrinkles, and alleviate certain medical conditions. Although generally considered safe and effective, Botox injections may cause potential complications. While herpes reactivation is more commonly associated with immunosuppressive therapies, such as chemotherapy or corticosteroid use, its association with Botox injection is poorly documented. CASE PRESENTATION: A 33-year-old woman presented with progressive painful rashes and vesicles on her forehead, scalp, and right upper eyelid, accompanied by fever and malaise following a Botox injection to treat wrinkles. A positive Tzanck smear test result confirmed the diagnosis of herpes infection. The patient was treated with antiviral medication, and her symptoms gradually regressed over several days. CONCLUSIONS: Although herpes reactivation is more commonly associated with immunosuppressive therapies, few cases of herpes zoster and herpes simplex following Botox injection have been reported. The pathogenesis of herpes reactivation following Botox injection is unclear; however, it has been hypothesized that the Botox protein is a potent antigen that may activate the cellular immune system, making it easier for the virus to reactivate. Healthcare providers should be aware of this potential complication and consider it when evaluating patients who present with painful rashes following Botox injections. In addition, individuals who want to receive Botox injections should be informed of this complication. The diagnosis of herpetic infection should be made promptly, and antiviral therapy should be initiated to minimize the risk of complications. Further research is needed to better understand the pathogenesis and risk factors for herpes following Botox injection and to develop strategies for preventing and managing this complication.

Are we underestimating urinary retention following intravesical onabotulinumtoxinA in women with overactive bladder and a history of prior pelvic surgery?

AIMS: This study's purpose is to review the rates of urinary retention requiring intermittent catheterization (IC) post intravesical OnabotulinumtoxinA (BTN/A) injection for idiopathic overactive bladder from a single practicing specialist urological surgeon. METHODS: We performed a retrospective review of a single Australian urologist to identify the rate of intermittent catheterization in our clinical setting. Logistic regression was used to assess associations between requirement of IC and risk factors for urinary retention. RESULTS: Ninety-four patients were included after inclusion and exclusion criteria were applied and the average age was 69.7 years (SD 17.2) and all participants were female. Thirty-six percent (n = 34) of patients required IC. Of patients requiring IC, 32% had a prior urethral sling, 35% had prior vaginal prolapse surgery, and 29% had a preoperative urinary tract infection (UTI). There was strong evidence of univariate associations between IC and prior sling (odds ratio [OR]: 5.26, 95% confidence interval [CI]: 1.64-16.55, p = 0.005), preoperative UTI (OR: 4.25, 95% CI: 1.31-13.08, p = 0.016) and prior vaginal prolapse surgery (OR: 4.91, 95% CI: 1.64-14.72, p = 0.005). Evidence that prior sling patients were more likely to require IC remained strong in a multivariable model (OR: 7.35, 95% CI: 1.59-34.11, p = 0.011). CONCLUSION: Prior urethral sling surgery, prior vaginal prolapse surgery, and positive preoperative UTI, despite treatment, were found to be associated with a higher rate of initiation of intermittent catheterization. The rate of IC initiation of 36% was higher than reported in prior clinical trials.

Predictors for adverse events following intravesical botulinum toxin injections in men.

INTRODUCTION: Intravesical botulinum toxin A (BTX-A) has been long established as treatment for overactive bladder and neurogenic bladder dysfunction. However, most published data are reported among a female cohort. Adverse events such as intermittent self-catheterization (ISC) and urinary tract infections (UTIs) play a large role in discontinuation of therapy. There is currently limited information regarding predictive factors to appropriately counsel male patients. MATERIALS AND METHODS: We retrospectively collected data on male patients undergoing their first intravesical BTX-A therapy from January 2016 to July 2021 in two high-volume centers. Data included demographics, past medical and surgical history, and urodynamic parameters. Patients were excluded if they had a long-term catheter or ISC before initiation of therapy. RESULTS: A total of 69 men were included in the study with a median age of 66 years. There were 18 patients with neurogenic bladder dysfunction. Thirty men had urge incontinence secondary to radical prostatectomy or bladder outflow surgery. Overall rates of ISC were 43.5%. Predictors for ISC included a baseline postvoid residual (PVR) ≥ 50 mL (odds ratio [OR]: 4.2, 95% confidence interval [CI]: 1.36-13.03, p = 0.01), BTX-A dose >100 units (OR: 4.2, 95% CI: 1.36-13.0, p = 0.01). Stress urinary incontinence was protective against ISC (OR: 0.20, 95% CI: 0.04-1.00, p = 0.049) as well as history of prostatectomy/bladder outflow obstruction (BOO) surgery (OR: 0.16, 95% CI: 0.05-0.47, p < 0.001). A multivariable logistic regression model with these factors yielded a c-statistic of 0.80 (optimism-adjusted = 0.75). An enlarged prostate was the only predictor for UTI among our male cohort (OR: 8.0, 95% CI: 2.03-31.5, p = 0.003). CONCLUSIONS: This is the first study assessing risk factors of adverse events among men following BTX-A injection. High PVR and BTX-A dose of >100U were predictors of requiring ISC after BTX-A. Stress incontinence, previous radical prostatectomy, and BOO surgery were all protective against needing ISC post-BTX-A. An enlarged prostate was associated with development of UTI. These factors can be used to assist in counseling male patients regarding their risk of ISC and UTI.

The impact of postinjection urinary tract infection on efficacy of intravesical onabotulinumtoxinA-A secondary analysis.

OBJECTIVES: To compare treatment response in women who did and did not develop a urinary tract infection (UTI) within 14 days after intravesical onabotulinumtoxinA injections for treatment of refractory urgency urinary incontinence (UUI). METHODS: This is a secondary analysis of women who received Onabotulinumtoxin A in the Refractory Overactive Bladder: Sacral Neuromodulation vs Botulinum Toxin Assessment (ROSETTA) Trial. Participants were grouped by presence or absence of UTI within 14 days of injection. UTI was defined as symptomatic with positive urine culture per the primary ROSETTA protocol. Our primary outcome was change from baseline in mean number of UUI episodes based on monthly 3-day bladder diaries averaged over 6 months. We performed t tests and chi-square/Fisher's exact for continuous and categorical variables. A p value of <0.05 was considered statistically significant. RESULTS: Of 187 participants in the onabotulinumtoxinA arm, 10 (5.3%) experienced UTI within 14 days of injection, and 177 (94.7%) did not. At baseline, groups did not differ in demographics, mean UUI episodes per day (no UTI [5.37 ± 2.65] vs. UTI [6.40 ± 3.02], p = 0.24), or other diary parameters. For our primary outcome, groups did not differ in the change in mean daily UUI episodes at 1 month (no UTI [-4.29 ± 2.75] vs. UTI [-3.74 ± 2.01]; mean difference [95% confidence interval, CI] -0.55 [-2.39 to 1.28], p: 0.55) or 6 months (no UTI [-3.63 ± 2.89] vs. UTI [-2.15 ± 3.18]; mean difference [95% CI] -1.48 [-3.44 to 0.48], p: 0.14). CONCLUSIONS: UTI within 14 days after intravesical injection of onabotulinumtoxinA for refractory UUI was not significantly associated with inferior treatment response at 1 or 6 months.

OnabotulinumtoxinA alters inflammatory gene expression and immune cells in chronic headache patients.

Occipital headache, the perception of pain in the back of the head, is commonly described by patients diagnosed with migraine, tension-type headache, and occipital neuralgia. The greater and lesser occipital nerves play central role in the pathophysiology of occipital headache. In the clinical setup, such headaches are often treated with onabotulinumtoxinA, a neurotoxin capable of disrupting ability of nociceptors to get activated and/or release proinflammatory neuropeptides. Attempting to understand better onabotulinumtoxinA mechanism of action in reducing headache frequency, we sought to determine its effects on expression of inflammatory genes in injected occipital tissues. To achieve this goal, we injected 40 units of onabotulinumtoxinA into four muscle groups (occipitalis, splenius capitis, semispinalis capitis, and trapezius muscles-all located on one side of the occiput) of patients with chronic bilateral occipital headache scheduled for occipital nerve decompression surgery 1 month later. At the time of surgery, we collected discarded muscle, fascia and periosteum tissues from respective locations on both sides of the neck and occiput and performed targeted transcriptome analyses to determine expression level of inflammatory genes in onabotulinumtoxinA-injected and onabotulinumA-uninjected tissues. We found that (i) onabotulinumtoxinA alters expression of inflammatory genes largely in periosteum, minimally in muscle and not at all in fascia; (ii) expression of inflammatory genes in uninjected periosteum and muscle is significantly higher in historical onabotulinumA responders than historical non-responders; (iii) in historical responders' periosteum, onabotulinumA decreases expression of nearly all significantly altered genes, gene sets that define well recognized inflammatory pathways (e.g. pathways involved in adaptive/innate immune response, lymphocyte activation, and cytokine, chemokine, NF-kB, TNF and interferon signalling), and abundance of 12 different immune cell classes (e.g. neutrophils, macrophages, cytotoxic T-, NK-, Th1-, B- and dendritic-cells), whereas in historical non-responders it increases gene expression but to a level that is nearly identical to the level observed in the uninjected periosteum and muscle of historical responders; and surprisingly (iv) that the anti-inflammatory effects of onabotulinumA are far less apparent in muscles and absent in fascia. These findings suggest that in historical responders' periosteum-but not muscle or fascia-inflammation contributes to the pathophysiology of occipital headache, and that further consideration should be given to the possibility that onabotulinumA mechanism of action in migraine prevention could also be achieved through its ability to reduce pre-existing inflammation, likely through localized interaction that lead to reduction in abundance of immune cells in the calvarial periosteum.

Predictors of favorable outcome after pyloroplasty for gastroparesis: should response to pyloric dilation or Botox injection be used as a marker of surgical outcome?

INTRODUCTION: Pyloroplasty and gastric peroral endoscopic myotomy (G-POEM) are effective surgeries for gastroparesis. The primary aim of this study was to evaluate outcomes of pyloroplasty and G-POEM in patients with gastroparesis and determine factors associated with favorable outcome. The secondary aim was to assess the utility of clinical response to preoperative pyloric dilation or botulinum toxin injection (Botox) on surgical outcome, a factor conventionally used as a favorable marker. METHODS: There were 204 patients who underwent pyloroplasty (n = 177) or G-POEM (n = 27) for gastroparesis at our institution from 2014 to 2021. Demographic and clinical parameters were analyzed to assess their impact on surgical outcome. A subgroup of patients who had pyloric dilation or Botox injection were assessed separately. Favorable outcome was defined as patient reported complete resolution of the predominant gastroparesis symptom. RESULTS: Favorable outcome was achieved in 78.4% of patients (pyloroplasty: 79.7% and G-POEM: 70.4%, p = 0.274). Among 61 patients where pre- and postoperative gastric emptying studies (GES) were available, mean 4-hour retention significantly improved from 33.5 to 15.0% (p < 0.001) and 77.0% of patients achieved normalization. Favorable outcome was not significantly impacted by etiology of gastroparesis (p = 0.120), GERD (p = 0.518), or primary gastroparesis symptom (p = 0.244). Age ≥ 40 was a significant predictor of favorable surgical outcome on multivariate analysis [OR: 2.476 (1.224-5.008), p = 0.012]. Among the patients who had preoperative dilation (n = 82) or Botox injection (n = 46), response to these interventions was not a predictor of favorable surgical outcome (p = 0.192 and 0.979, respectively). However, preoperative Botox injection, regardless of response to injection, was associated with favorable surgical outcome [OR: 3.205 (CI 1.105-9.299), p = 0.032]. CONCLUSION: Symptomatic improvement after pyloroplasty or G-POEM is independent of etiology of gastroparesis, GERD, and primary symptom. Response to dilation or Botox are not markers of response to surgery. However, patients who receive Botox are 3.2 times more likely to improve postoperatively.

Gastric per-oral endoscopic myotomy versus pyloric injection of botulinum toxin for the treatment of gastroparesis: our institutional experience and a systematic review of the literature.

INTRODUCTION: Gastric Per-Oral Endoscopic Myotomy (GPOEM) has been developed as an effective treatment option for patients with medically refractory gastroparesis. Other endoscopic options, such as pyloric injection of botulinum toxin (Botox), is often performed with limited efficacy. The purpose of this study was to evaluate GPOEM for the treatment of gastroparesis and compare its efficacy to Botox injection results reported in the literature. METHODS: A retrospective review was conducted to identify all patients who underwent a GPOEM for the treatment of gastroparesis between September 2018 and June 2022. Changes in Gastric Emptying Scintigraphy (GES) studies and Gastroparesis Cardinal Symptom (GCSI) scores from the preoperative to postoperative period were analyzed. In addition, a systematic review was conducted to identify all publications reporting the outcomes of Botox injections for the treatment of gastroparesis. RESULTS: A total of 65 patients (51 female, 14 male) underwent a GPOEM during the study period. Twenty-eight patients (22 female, 6 male) had both preoperative and postoperative GES studies in addition to GCSI scores. The etiologies of gastroparesis were diabetic (n = 4), idiopathic (n = 18), and postsurgical (n = 6). Fifty percent of these patients had undergone previous failed interventions including Botox injections (n = 6), gastric stimulator placement (n = 2), and endoscopic pyloric dilation (n = 6). Outcomes showed a significant decrease in GES percentages (mean difference = - 23.5%, p < 0.001) and GCSI scores (mean difference = - 9.6, p = 0.02) postoperatively. In the systematic review for Botox, transient mean improvements in postoperative GES percentages and GCSI scores were reported at 10.1% and 4.0, respectively. CONCLUSION: GPOEM leads to significant improvement in GES percentages and GCSI scores postoperatively and is superior to Botox injection results reported in the literature.

Assessing comprehension of online information in the United States for third-line treatment of overactive bladder.

INTRODUCTION AND HYPOTHESIS: Overactive bladder (OAB) affects up to 43% of women. Treatment ranges from lifestyle modification to invasive therapies. Nearly 75% of patients report using the internet to gain health information creating a need for interpretable, online resources. This study is aimed at evaluating the readability of online resources for OAB treatment in the US population. METHODS: Google and Bing were queried regarding "sacral neuromodulation," "peripheral tibial nerve stimulation (PTNS)," and "bladder botox." The first 20 results from each search engine were assessed, representing over 90% of accessed search results. Websites were categorized as institutional/reference, commercial, nonprofit, or personal. The Gunning fog (GF), Simple Measure of Gobbledygook (SMOG), and Dale-Chall (DC) validated readability scores were used to assess results. RESULTS: Sacral neuromodulation yielded 27 eligible results. The associated mean readability scores correlated with levels of college senior (GF), high school junior (SMOG), and college level (DC). PTNS yielded 31 eligible results. The associated mean readability scores correlated with levels of college senior (GF), high school senior (SMOG), and college level (DC). Bladder botox yielded 17 eligible results. The associated mean readability scores correlated with levels of college sophomore (GF), high school junior (SMOG), and college level (DC). There was no difference between the therapies regarding readability. Sixty-one percent of websites were institutional/reference, 24% were commercial, 13% were nonprofit, and 2% were personal. CONCLUSIONS: High levels of reading comprehension are required by the general US population to understand OAB information obtained through the internet. These findings highlight a need for simplification of online resources pertaining to OAB.

Evaluation of the effect of botulinum toxin injection in aggravating or improving seborrheic dermatitis symptoms: A prospective, single-arm clinical trial.

INTRODUCTION: Considering the proven therapeutic effect of botulinum toxin and the pathophysiology of seborrheic dermatitis, conflicting hypotheses have been put forward regarding the effect of injection of this toxin on the improvement or exacerbation of seborrheic dermatitis. Because of the lack of consistent studies investigating this relationship, we decided to conduct this study to investigate the effect of local botulinum toxin injection on sebum production and improvement or worsening of seborrheic dermatitis lesions. METHOD: This study was a prospective, single-arm clinical trial that involved the injection of botulinum toxin into 20 patients with complaints of skin wrinkles and simultaneous symptoms of seborrheic dermatitis. The trial was conducted at a dermatology clinic between March 2019 and March 2021. Two important characteristics of these patients were seborrheic dermatitis on the face or scalp and a referral for botulinum toxin injection to remove facial wrinkles. The Seborrheic Dermatitis Area and Severity Index (SDASI) was used to determine the severity of symptoms. RESULTS: In study of 20 patients with an average age of 40 years, despite the decrease in the average scores of all examined criteria of seborrheic dermatitis symptoms in study, 1 month after botulinum toxin injection, no significant effect of using this toxin was seen on the improvement of patients' symptoms (p value >0.05). CONCLUSION: Despite the emphasis of many studies on the effectiveness of botulinum toxin in reducing the activity of sebaceous glands, the use of botulinum toxin as a therapeutic modality for control the symptoms of seborrheic dermatitis is not suggested by this study. Conducting studies in which the location and technique of injection and the follow-up intervals of patients in them are based on the standard of other studies, are the suggestions made by comparing the results and method of the current study with other studies.

OnabotulinumtoxinA Injections for the Treatment of Myofascial Pelvic Pain: 12-Year Experience at a Tertiary Care Academic Center.

OBJECTIVE: The aim of this study was to highlight the safety of OnabotulinumtoxinA (BTA) injections, with or without concurrent pudendal nerve block, in treating women with myofascial pelvic pain (MFPP). DESIGN: This was a retrospective cohort study. SETTING: The review was conducted in a tertiary care academic center. Participants/Materials: We conducted a chart review of patients who were diagnosed with MFPP and treated with BTA with or without pudendal nerve block between January 2010 and February 2022. METHODS: BTA was injected transvaginally into the pelvic floor muscle group. The primary outcomes were adverse events after BTA injections, and the secondary outcome was the effect of concomitant pudendal nerve block at the time of BTA injections. RESULTS: The cohort included 182 patients; 103 (56.6%) received BTA injections with pudendal nerve block, and 79 (43.4%) received BTA alone. There were no significant demographic differences between the two groups. Post-treatment complications of BTA administration included worsening of pelvic pain (11.5%), constipation (6.6%), urinary tract infection (2.7%), urinary retention (3.8%), and fecal incontinence (2.7%). No statistical difference was noted in the number of phone calls, patient-initiated electronic messages, emergency room visits, or clinic visits for both groups within 30 days post-treatment. The mean number of total injections was 1.6 in the BTA-only group and 1.7 in the BTA with pudendal block group (p = 0.421). Median time to re-intervention with a second BTA injection was 6.0 months; 5.6 months in the BTA with pudendal block group; and 6.8 months in the BTA-only group, p = 0.46. There were 63 re-intervention events after BTA injections. LIMITATIONS: Limitations of our study include the retrospective design making it vulnerable to missing or incomplete data available for review. CONCLUSION: OnabotulinumtoxinA is beneficial in treating women with MFPP; with a duration of therapeutic effect of approximately 6 months. The use of a concurrent pudendal nerve block did not impact clinical outcomes.

Evaluation of biochemical changes and treatment efficacy in patients with bruxism following botulinum toxin or splint therapy: a randomized clinical trial.

OBJECTIVES: This clinical study aims to analyze the levels of cortisol, dehydroepiandrosterone (DHEA), and tumor necrosis factor alpha (TNF-α) in the gingival crevicular fluid (GCF) of persons with bruxism and to compare the efficacy of botulinum toxin (botox) and occlusal splint treatments through biomarkers. MATERIALS AND METHODS: A total of 40 patients with bruxism were selected according to the clinical examination and anamnesis of which 20 received occlusal splint treatment and 20 botox treatment. GCF samples were taken from the patients before and after treatment. Cortisol, DHEA, and TNF-α levels were measured by enzyme-linked immunosorbent assay test. The change in measurements between time and groups and the time-group interaction were tested by repeated measures ANOVA. RESULTS: There was a statistically significant difference between the cortisol levels before and after treatment in both groups (p = 0.001). In individuals with bruxism, a statistically significant decrease in cortisol levels was observed after both treatments (p < 0.05), while DHEA levels increased after treatment but were not statistically significant (p > 0.05). There was no statistically significant difference between TNF-α intra-group measurements (p > 0.05). CONCLUSIONS: Stress and inflammatory biomarkers were found to be associated with bruxism. Cortisol levels decreased in people with bruxism after treatment with both occlusal splint and botox. CLINICAL RELEVANCE: Both splint and botox treatments were effective for bruxism by reducing the stress levels.

Use of botulinum toxin in aesthetic medicine and gynaecology: current approaches, controversies, and future directions.

This review looks at the use of botulinum toxin in the gynaecological field with the aim of determining what needs to be further investigated to achieve a standardized application. Numerous studies have been conducted to explore how botulinum toxins (BoNT) can be applied, and it is becoming popular for treating various disorders such as chronic pelvic pain, vestibulodynia, and vaginism. However, the exact dosage and ideal location for injections still need to be clarified. The objective of this study is to point out which aspects need to be more carefully studied to ensure a consistent use of BoNT in gynaecology.