Quantifying how location and dose of botulinum toxin injections affect muscle paralysis

Despite the widespread use of botulinum toxin to treat muscle dystonias, no method exists to quantify muscle paralysis in either human or nonhuman models. In this study we examined how the location, dose, and volume of botulinum injection affects paralysis in the rat tibialis anterior muscle. Paralysis was quantified by electrically stimulating the nerve to the tibialis anterior and then staining sections of the muscle for glycogen. The areas of glycogen-containing fibers represented regions of botulinum action. The results showed that the most important injection technique is to inject botulinum directly into the motor endplate region of a muscle. Injections only 0.5 cm from the motor endplate resulted in a 50% decrease in paralysis. Increases in dose increased paralysis, however, some of that increase was simply due to the increased volume of injection. Thus, delivering toxin in small volumes near the MEP band of a muscle should produce the most effectiveparalysis. © 1993 John Wiley & Sons, Inc.     

Secondary correction of the unilateral cleft nose deformity with an endonasal technique

Summary Malposition of the nasal bone, septum and the alar cartilage are striking features of the unilateral cleft nose deformity. An endonasal technique (the extramucosal) was used in 26 patients, aged 13–38 (median 19), to correct aesthetic and functional problems. Twenty-four patients were secondary and two were tertiary. The patients were followed from 1–9 years. The pathological anatomy of the septum varied considerably, so different types of septoplasties had to be done. In 20 patients, satisfactory aesthetic and functional results were obtained in one operation. Secondary corrections were indicated in six patients. In cases with no gross scarring in or around the alar cartilage, the form and position of this cartilage will be more normal once the alar cartilages have been undermined and the deviation of the nasal bone and the septum is corrected.     

Electro-encephalographic disturbances due to chronic toxin abuse in young people, with special reference to glue-sniffing

A study was carried out in order to document any abnormalities in the electro-encephalogram (EEG) that might appear in young adolescents who have deliberately inhaled the range of volatile substances loosely referred to as 'glue'. The EEGs of a group of 'street children' being assisted in a Johannesburg shelter were examined. The records were analysed for any clinical abnormalities and also subjected to spectral analysis in order to examine the overall characteristics of frequency, power and spatial distribution. The EEGs clearly revealed that, although at the time of the examination the subjects were ostensibly abstinent, both clinical and normative evidence of continuing brain disturbance was present. It was concluded that glue sniffing is likely to have long term electrocerebral sequelae.     

The in vitro fertilisation programme at Tygerberg Hospital and the University of Stellenbosch. Five years' experience, April 1983-January 1988

The results of the in vitro fertilisation programme at Tygerberg Hospital for the period April 1983 to January 1988 are presented. Of the 1117 laparoscopies performed, 825 patients reached the transfer stage. A live-birth rate of 9.3% was achieved. The pregnancy rate after transfer of 4 embryos was 25.9% compared with 15.4% after 2 embryos and 10.8% after 3 embryos (P = less than 0.0001). The multiple pregnancy rate was 2.8% in the group receiving 2 embryos and 11.7% and 10.4% in those receiving 3 and 4 embryos, respectively. Of the 77 successful pregnancies (90 babies), 1 baby died at 34 weeks' gestation as the result of abruptio placentae due to preeclampsia and 1 cot death occurred. The only congenital abnormality encountered was a cleft palate.     

Failure of coconut oil to accelerate psoriasis clearance in narrow-band UVB phototherapy or photochemotherapy

Despite a widely held belief that the use of emollients prior to broad-band UVB irradiation accelerates clearance of psoriasis, only one single-blind controlled study exists in support of this. No similar study has been carried out with photochemotherapy (PUVA) or narrow-band UVB (311–313 nm) phototherapy. As some emollients absorb UV radiation, and thereby inhibit psoriasis clearance, there is a need to identify emollients suitable for pre-irradiation use. Coconut oil may be useful in this respect. In two randomized groups of patients with chronic plaque psoriasis undergoing either routine PUVA(n=14) or narrow-band UVB phototherapy (n=15), a single-blind controlled (half-body) study was undertaken to assess the died of pre-irradiation application of coconut oil. Patients were given PUVA twice weekly, or TL-01 therapy thrice weekly. The initial UV dose was 70% of previously determined minimal phototoxic (MPD) or minimal erythema doses (MED), with 40% incremental steps at each visit (reduced if adverse effects occurred). Psoriasis severity was scored on each side after every three treatments. No significant acceleration of psoriasis clearance was seen in either group. We do not, therefore, recommend the routine use of emollients prior to PUVA or TL-01 therapy when using near erythemogenic irradiation regimens.     

The nature and extent of aggressive behaviour amongst people with learning difficulties (mental handicap) in a single health district

ABSTRACT. This paper describes the method and results of a survey of aggressive behaviour amongst people with learning difficulties. The study was confined to a single health district in the South Western Region of the UK with a general population of about 370000. At the time of the survey, the Handicap Register for the district recorded 1362 people as having a learning difFiculty. The overall prevalence of aggressive behaviour amongst people with learning difficulties for whom base population data was available was 17.6%. The lowest rate was identified amongst day facilities (9.7 %) and the highest in hospitals within the district (38.2%). The prevalence rate amongst those attending schools for children with severe learning difSculties was 12.6%. Proportionately more males than females were reported to present problems of aggressive behaviour. The gender difference appeared to be largely accounted for by the disproportionate number of men identified within day facilities. There was no significant evidence of an association between the person's gender and the presence aggressive behaviour within schools or hospitals. The results indicated that, although physical and verbal aggression were the most frequently reponed behaviours, many of the sample were also said to engage in other forms of challenging behaviour, particularly self-injurious, ritualistic, stereotypical and withdrawn behaviour. The risk of a serious or very serious injury to another person was very low; 0.7% or six people with learning difiSculties firom the district were reponed to be currently presenting such a risk. Similarly, only 2% of the base population (n=18) were reponed to be extremely difficult to manage. The implications of the findings are discussed.     

A reassessment of the peritoneal lavage leukocyte count in blunt abdominal trauma

Nine hundred and three patients undergoing diagnostic peritoneal lavage (DPL) over a 6-year period were retrospectively reviewed to evaluate the utility of the white blood cell (WBC) count in the lavage fluid. Eleven patients (1.2%) had dialysate WBC counts greater than 500/mm3, with erythrocyte counts less than 10(5)/mm3. Nine of these patients who were lavaged within 4 hours of injury had no intra-abdominal pathology. Two patients, lavaged after 4 hours, demonstrated intra-abdominal injury. Two hundred twenty-three patients (24.7%) had grossly clear dialysate which was not sent for laboratory analysis. None of these patients required laparotomy. We conclude that the WBC count in DPL fluid is of no diagnostic value in victims of blunt abdominal trauma who are lavaged within 4 hours of injury. In addition, laboratory analysis of clear dialysate is not required in these patients.     

Gonadoblastoma in an anatomically normal man: a case report and literature review

Gonadoblastoma, a rare gonadal neoplasm, presents most frequently in phenotypic female or phenotypically male patients with dysgenetic gonads or undescended testes. To date, only 2 cases of gonadoblastoma have been reported in anatomically normal male patients with scrotal testes. Both of these patients presented with testicular masses and germ cell tumors. We report a case of a genotypically and phenotypically normal, fertile man with descended testes who on evaluation for chronic orchialgia had a gonadoblastoma unaccompanied by a germ cell neoplasm. The tumor was nonpalpable and was initially discovered on scrotal ultrasound.     

Gallstone dissolution

Many methods are available for gallstone dissolution, including oral bile salts; cholesterol solvents such as mono-octanoin or methyl tert-butyl either; and calcium or pigment solvents such as EDTA and polysorbate. Which of these approaches will be appropriate for an individual patient depends on the type of stones; whether they are in the gallbladder or the bile ducts; whether access to the biliary tree is available; the patient's age and general medical condition; and the availability of necessary expertise. In the US, both chenodeoxycholate and ursodeoxycholate are now available. Ursodeoxycholate is more expensive but appears to produce fewer side effects and may be more efficacious. These agents are most effective in thin women with small floating, radiolucent cholesterol stones in a functioning gallbladder. Only about half of the small subset of patients will experience partial or complete dissolution of stones within a year. Stone recurrence and the potential toxicity of long-term therapy are problems with this approach. Therefore, for most patients, cholecystectomy, either in the traditional fashion or using a laparoscopic approach (see article later in this issue by Gadacz et al), is the most cost-effective and perhaps the safest option. Intragallbladder instillation of methyl tert-butyl ether probably will be applicable only to a small subset of patients, and treatment is likely to be followed by a high recurrence rate. In patients with retained common duct cholesterol stones and access to the biliary tree, mono-octanoin therapy is advantageous in that it can be initiated as soon as cholangiography demonstrates no extravasation. In properly selected patients, a 90% success rate with this technique can be expected within 7 days.