Pharmacotherapy with botulinum toxin: harnessing nature's most potent neurotoxin.

Botulinum toxin (BTX), a potent biologic neurotoxin, commonly is associated with lethal outbreaks of food poisoning; however, it also plays a role as a therapeutic agent. Since the 1970s physicians have investigated BTX therapy in patients with neurologic disorders. The number of applications greatly expanded over the years to include certain focal dystonias (blepharospasm, torticollis, laryngeal dystonias, writer's cramp), strabismus, and a wide variety of other indications (gastrointestinal disorders, cosmetic wrinkle correction, spasticity, hyperhidrosis). BTX's safety and efficacy are reviewed.

Formal swallowing evaluation and therapy after traumatic brain injury improves dysphagia outcomes.

BACKGROUND: The incidence of swallowing dysfunction after brain injury is unknown. The efficacy of dysphagia therapy is also unknown. We reviewed our experience to define the incidence of swallowing dysfunction and efficacy of therapeutic intervention. METHODS: Patients with brain injury sustained between January of 1996 and December of 1997 were reviewed. All were screened with trials of oral intake. Abnormal findings were confirmed with a videofluoroscopic swallow study. Standard therapies included diet, posture, and behavior modifications. RESULTS: A total of 47 patients were evaluated. Bedside evaluations were normal in 14 patients, 2 patients had overt aspiration and underwent gastrostomy, and 31 patients were referred for a videofluoroscopic swallow study (66%). The videofluoroscopic swallow study was abnormal in 22 of 31 patients (71%). Of these, 4 additional patients required gastrostomy, 13 patients had laryngeal penetration or minor aspiration responsive to dysphagia therapy and were fed. Five other patients had silent aspiration and were fed by means of nasogastric tube; these five patients responded to dysphagia therapy and were able to resume oral intake. CONCLUSION: Dysphagia is common after severe head injury. With formal swallowing service intervention, aspiration is avoided. Therapeutic interventions can be used to restore oral intake.

Complications associated with infusion pumps implanted for spasticity.

Implanted infusion pumps are an effective method for delivering medications into the intrathecal space to reduce spasticity. Complications can occur with the surgical aspect of implantation, as well as with the hardware. We describe an 8-year experience with the implantation of 34 infusion pumps in 30 patients in whom either morphine or baclofen was used to control spasticity. The overall incidence of total complications was 62%; 24% in the Infusaid pumps, and 167% in the Medtronic pumps. The incidence and types of complications are important in informed consent as well as in the selection of pumps and connectors.

Plasma lipid and lipoprotein concentrations in symptomatic postpolio patients.

This study reports lipid and lipoprotein concentrations in postpolio patients seen in our postpolio clinic who were evaluated for complaints of progressive weakness, fatigue, and/or pain. Concentrations of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglycerides (TG) were determined after an overnight fast. Sixty-four patients (24 men and 40 women) with a mean age of 48 +/- 10 years were studied. Mean (+/- SD) lipid concentrations (mg/dL) for men and women, respectively, were 220 +/- 46 and 213 +/- 43 for TC; 38.5 +/- 8.6 and 59.1 +/- 18.1 for HDL-C; 148 +/- 46 and 129 +/- 36 for LDL-C; and 205 +/- 107 and 105 +/- 55 for TG. Hyperlipidemia was found in 16 of 24 men and 10 of 40 women. In the men, mean HDL-C concentration was in the lowest decile of our hospital laboratory's reference range, whereas mean TC/HDL-C ratio was elevated above the recommended value. It is suggested that lipid and lipoprotein concentrations be evaluated in postpolio patients because a high prevalence of lipid/lipoprotein disorders was found in our subjects. Further research is needed on this topic.

Psychologic characteristics of polio survivors: a preliminary report.

Ninety-three men and women with histories of polio were administered the Symptom Check List-90 Revised (SCL-90R), Psychosocial Adjustment to Illness Scale-Self Report (PAIS-SR), and a questionnaire about their polio histories. The SCL-90R and PAIS-SR are measures of emotional and psychosocial functioning. Two samples were used: a clinic sample (n = 71) and a postpolio support group sample (n = 22). Initial results for both on the SCL-90R and PAIS-SR indicated elevated scores on a number of subscales. SCL-90R subscale elevated scores for men included those for somatization, depression, anxiety, hostility, and phobia, whereas for women there were elevations on measures of somatization, depression, anxiety, and psychoticism. Elevations were found in the following subscales on the PAIS-SR (pooling men and women): health care orientation, social environment, and extended family relationships. Men scored slightly, but not significantly, higher than women in the SCL-90R except for the hostility subscale, in which the difference was significant (p less than 0.05). Symptom profiles indicated psychologic distress. Comparisons with variables associated with polio and its late effects (such as severity of initial polio, use of an iron lung during initial illness, number of involved limbs, etc) were not statistically significant.

Symptoms and clinical impressions of patients seen in a postpolio clinic.

A retrospective study was performed to identify symptoms and clinical findings in postpolio patients seen in a postpolio clinic. Charts of 79 consecutive patients (28 men and 51 women) with histories and examinations compatible with the diagnosis of poliomyelitis were reviewed. The average current age of our patients was 47.3 +/- 10.4 years; the average age at onset of acute polio was 10.4 +/- 9.4 years; and the average number of years since function was first noticed to decline was 7.8 +/- 6.4 years. The most common symptoms acknowledged were progressive weakness (87%), muscle pain (86%), fatigue (86%), decreased activity level (78%), joint pain (77%), and back pain (70%). The clinical impression in most of these patients was arthritis/arthralgia (71% of the patients) or muscle overuse or myofascial pain (71%). Eleven (14%) had evidence of nerve compression, although 39% complained of sensory loss. Five patients had respiratory problems that required evaluation. Recommendations proved helpful for 78% of those seen at follow-up. These recommendations included pacing, energy conservation (planning, use of wheelchair or motorized scooter), gentle stretching or strengthening exercise, use of orthotic devices, weight loss or nutritional counseling, gentle aerobic exercise, use of a cane, and use of adaptive equipment.

Control of spasticity by implantable continuous flow morphine pump.

Continuous flow pumps are being used for the delivery of morphine sulfate to the intrathecal and epidural space for control of pain. We have encountered several patients who had a combination of pain and spasticity or who had spasticity so intense that it was the source of pain. One to two milligrams of intrathecal morphine dramatically relieved their spasticity and pain. Three such patients have subsequently undergone pump implantation with prolonged control of their spasticity. This has initiated a formal clinical investigation directed at determining the physiological mechanism of this phenomenon, as well as its long term efficacy.

Intermittent catheterization to obtain catheter-free bladder function in spinal cord injury.

The intermittent bladder catheterization technique has been proposed as an effective way of eliminating the need for an inlying. Foley catheter in patients with neurovesical dysfunction following spinal cord injury. In the study reported here, a group of 41 male patients with spinal cord injuries achieved a catheter-free state with this method. Of these 41 patients, 19 have been followed for 1 year. Data obtained from the 19 patients are presented here for comparison with data from other recent studies. In the present study, the patients' fluid intake was restricted to 2,000 cc daily. A detrusor reflex was triggered by lower abdominal percussion followed by a Credé maneuver. A 6-hour catheterization schedule was used unless autonomic dysreflexia required more frequent catheterizations. Ascorbic acid, methenamine mandelate and nitrofurantoin were routinely administered, and specific antibiotics were also given following trial off-catheter, depending on the results of urine cultures and sensitivity studies. All patients achieved a catheter-free state in an average time of 17.1 days; no late failures have occurred. Two patients developed vesicoureteral reflux, but no evidence of hydronephrosis was observed. At 1 year only 16% of the patients were found to have infected urine, as compared to 100% at initiation of the trial off-catheter.