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Norheim AJ, Borud E, Mercer JB, de Weerd L, Weiss T, Wilsgaard T. Botulinum Toxin A in the treatment of frostbite sequelae - results from a blinded, early-phase, comparative trial. Int J Circumpolar Health 2023; 82:2189556. [PMID: 36919578 PMCID: PMC10026811 DOI: 10.1080/22423982.2023.2189556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/22/2023] [Accepted: 03/07/2023] [Indexed: 03/16/2023] Open
Abstract
INTRODUCTION Freezing Cold Injuries (FCI) have been associated with long-term sequelae including vasospasm. The aims of the pilot study are to explore the research methodology and investigate the tolerability and safety of treatment with Botulinum Toxin-A (BTX-A) in FCI Sequelae. METHODOLOGY This pilot study tests the logistics, the treatment setting and the follow-up procedure in an early-phase, double-blinded, randomized, controlled trial study-design. The variables in the study were subjective symptoms, peripheral micro-vascularization/rewarming, somatosensory responsiveness, and generic measure of health status. RESULTS No major challenges or difficulties were noticed according to the protocol or the study methodology. The monitoring of tolerability and safety of treatment with BTX-A did not reveal any major unwanted and/or adverse reactions among the patients in the pilot study and no challenges occurred during data collection of endpoints. The study revealed an inaccuracy of the 2nd degree FCI diagnosis and uncover a need for relevant and sufficient clinical information for FCI classification. CONCLUSIONS This pilot study showed the study methodology with minor adjustments is feasible in a future full-scale clinical trial. The recruitment process needs to be more refined to ensure that the eligible study participants are a homogenous group of FCI patients.
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Affiliation(s)
- Arne Johan Norheim
- National Research Centre of Complementary and Alternative Medicine (NAFKAM), Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Einar Borud
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - James Brian. Mercer
- Medical Imaging Group. Institute for Clinical Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Louis de Weerd
- Department of Plastic Surgery and Hand Surgery, University Hospital of North Norway, Tromsø, Norway
| | - Thomas Weiss
- Clinical Psychology, Jena University, Jena, Germany
| | - Tom Wilsgaard
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
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Silva GPD, Garcia C, Silva RSD, Klaser BW, Arenhart S, Menin Á, Lima AAD, Padilha VS. Tetanus in a canine: clinical and therapeutic aspects. CIÊNCIA ANIMAL BRASILEIRA 2023. [DOI: 10.1590/1809-6891v24e-73825e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
Abstract
Abstract Tetanus is a serious and rare disease in small animals, of an acute nature and mediated by the action of the neurotoxin tetanospasmin, from the bacillus Clostridium tetani. This report describes a case of tetanus in a canine, with emphasis on its clinical and therapeutic aspects, in addition to its clinical recovery. A canine, female, Pitbull breed, five months old, in status epilepticus, was attended at the Veterinary Hospital of the University of Passo Fundo. After stabilizing the patient, the animal was found in a trestle position, with generalized spastic paralysis, risus sardonicus, trismus, erect tail and ears, and difficulty in expanding the thorax. The presumptive diagnosis of tetanus was established based on the anamnesis, clinical signs, and laboratory findings. The established supportive treatment included hydro electrolytic replacement, antitetanus serum, antibiotic therapy, analgesia, myorelaxant and anticonvulsant drugs. The patient's intensive management was carried out with urethral and gastroesophageal probing, changes of position every two hours, and reduction of environmental stimuli. Physiotherapy and acupuncture were also used to complement the treatment and accelerate recovery. The patient was discharged one month after the beginning of the treatment, presenting satisfactory evolution. In the present case, the clinical examination in association with the characteristic clinical signs of the disease, added to the detailed anamnesis, was essential for the presumptive diagnosis of tetanus. In addition, intensive management, drug treatment, physiotherapy, and acupuncture enabled the evolution of the clinical condition to cure.
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Affiliation(s)
| | | | | | | | | | - Álvaro Menin
- Universidade Federal de Santa Catarina (UFSC), Brazil
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Silva GPD, Garcia C, Silva RSD, Klaser BW, Arenhart S, Menin Á, Lima AAD, Padilha VS. Tétano em um canino: aspectos clínicos e terapêuticos. CIÊNCIA ANIMAL BRASILEIRA 2023. [DOI: 10.1590/1809-6891v24e-73825p] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Resumo O tétano é uma doença grave e rara em pequenos animais, de caráter agudo e mediada pela ação da neurotoxina tetanospasmina, proveniente do bacilo Clostridium tetani. Neste relato descreve-se um caso de tétano em um canino, com ênfase em seus aspectos clínicos e terapêuticos, além da sua recuperação clínica. Foi atendido no Hospital Veterinário da Universidade de Passo Fundo, um canino, fêmea, da raça Pitbull, com cinco meses, em status epilepticus. Após a estabilização da paciente, constataram-se animal em posição de cavalete, com paralisia espástica generalizada, risus sardonicus, trismo, cauda e orelhas eretas e dificuldade em expandir o tórax. O diagnóstico presuntivo de tétano foi firmado a partir da anamnese, sinais clínicos e achados laboratoriais. O tratamento suporte estabelecido incluiu reposição hidroeletrolítica, soro antitetânico, antibioticoterapia, analgesia, fármacos miorrelaxantes e anticonvulsivantes. O manejo intensivo da paciente foi realizado com sondagem uretral e nasoesofágica, trocas de decúbito a cada duas horas e diminuição de estímulos ambientais. A fisioterapia e a acupuntura também foram utilizadas para complementar o tratamento e acelerar a recuperação. A paciente recebeu alta médica um mês após o início do tratamento, apresentando evolução satisfatória. No presente caso, o exame clínico em associação aos sinais clínicos característicos da doença, acrescidos da anamnese minuciosa foram fundamentais ao diagnóstico presuntivo de tétano. Além disso, o manejo intensivo, o tratamento medicamentoso, assim como a realização de fisioterapia e acupuntura, possibilitaram a evolução do quadro clínico à cura.
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Affiliation(s)
| | | | | | | | | | - Álvaro Menin
- Universidade Federal de Santa Catarina (UFSC), Brazil
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Lalaurie CJ, Splevins A, Barata TS, Bunting KA, Higazi DR, Zloh M, Spiteri VA, Perkins SJ, Dalby PA. Elucidation of critical pH-dependent structural changes in Botulinum Neurotoxin E. J Struct Biol 2022; 214:107876. [PMID: 35738335 DOI: 10.1016/j.jsb.2022.107876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 06/13/2022] [Accepted: 06/16/2022] [Indexed: 10/18/2022]
Abstract
Botulinum Neurotoxins (BoNT) are the most potent toxins currently known. However, they also have therapeutic applications for an increasing number of motor related conditions due to their specificity, and low diffusion into the system. Although the start- and end- points for the BoNT mechanism of action are well-studied, a critical step remains poorly understood. It is theorised that BoNTs undergo a pH-triggered conformational shift, activating the neurotoxin by priming it to form a transmembrane (TM) channel. To test this hypothesis, we combined molecular dynamics (MD) simulations and small-angle x-ray scattering (SAXS), revealing a new conformation of serotype E (BoNT/E). This conformation was exclusively observed in simulations below pH 5.5, as determined by principal component analysis (PCA), and its theoretical SAXS profile matched an experimental SAXS profile obtained at pH 4. Additionally, a localised secondary structural change was observed in MD simulations below pH 5.5, in a region previously identified as instrumental for membrane insertion for serotype A (BoNT/A). These changes were found at a critical pH value for BoNTs in vivo, and may be relevant for their therapeutic use.
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Affiliation(s)
- Christophe J Lalaurie
- Department of Biochemical Engineering, Bernard Katz Building, University College London, Gordon Street, London WC1H 0AH, UK
| | - Andrew Splevins
- Evox Therapeutics Ltd, Oxford Science Park, Medwar Center, Oxford, England OX4 4HG, UK; Ipsen Bioinnovation, 102 Park Drive, Milton Park, Abingdon, Oxfordshire OX14 4RY UK
| | - Teresa S Barata
- FairJourney Biologics, 823 Rua do Campo Alegre, Porto, Porto 4150-180, Portugal; Ipsen Bioinnovation, 102 Park Drive, Milton Park, Abingdon, Oxfordshire OX14 4RY UK
| | - Karen A Bunting
- Ipsen Bioinnovation, 102 Park Drive, Milton Park, Abingdon, Oxfordshire OX14 4RY UK
| | - Daniel R Higazi
- Ipsen Biopharm Ltd., Wrexham Industrial Estate, 9 Ash Road, LL13 9UF, UK
| | - Mire Zloh
- UCL School of Pharmacy, University College London, 29-39 Brunswick Square, London WC1N 1AX, UK
| | - Valentina A Spiteri
- Department of Structural and Molecular Biology, Division of Biosciences, Darwin Building, University College London, Gower Street, London WC1E 6BT, UK
| | - Stephen J Perkins
- Department of Structural and Molecular Biology, Division of Biosciences, Darwin Building, University College London, Gower Street, London WC1E 6BT, UK
| | - Paul A Dalby
- Department of Biochemical Engineering, Bernard Katz Building, University College London, Gordon Street, London WC1H 0AH, UK.
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Tambasco N, Filidei M, Nigro P, Parnetti L, Simoni S. Botulinum Toxin for the Treatment of Hemifacial Spasm: An Update on Clinical Studies. Toxins (Basel) 2021; 13:toxins13120881. [PMID: 34941718 PMCID: PMC8706367 DOI: 10.3390/toxins13120881] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 11/25/2021] [Accepted: 12/02/2021] [Indexed: 11/16/2022] Open
Abstract
Hemifacial spasm (HFS) is a movement disorder characterized by involuntary contractions of the facial muscles innervated by the seventh cranial nerve. Generally, it is associated with a poor quality of life due to social embarrassment and can lead to functional blindness. Moreover, it is a chronic condition, and spontaneous recovery is rare. Intramuscular injections of Botulinum Toxin (BoNT) are routinely used as HFS treatment. METHODS We reviewed published articles between 1991 and 2021 regarding the effectiveness and safety of BoNT in HFS as well as any reported differences among BoNT formulations. RESULTS The efficacy of BoNT for HFS treatment ranged from 73% to 98.4%. The mean duration of the effect was around 12 weeks. Effectiveness did not decrease over time. Adverse effects were usually mild and transient. The efficacy and tolerability of the different preparations appeared to be similar. Among the studies, dosage, injected muscles, intervals of treatment, and rating scales were variable, thus leading to challenges in comparing the results. CONCLUSIONS BoNT was the treatment of choice for HFS due to its efficacy and safety profile. Further studies are needed to investigate the factors that influence the outcome, including the optimal timing of treatment, injection techniques, dosage, and the best selection criteria for formulations.
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Affiliation(s)
- Nicola Tambasco
- Movement Disorders Center, Neurology Department, Perugia General Hospital and University of Perugia, 06129 Perugia, Italy;
- Neurology Department, Perugia General Hospital and University of Perugia, 06129 Perugia, Italy; (M.F.); (L.P.); (S.S.)
- Correspondence:
| | - Marta Filidei
- Neurology Department, Perugia General Hospital and University of Perugia, 06129 Perugia, Italy; (M.F.); (L.P.); (S.S.)
| | - Pasquale Nigro
- Movement Disorders Center, Neurology Department, Perugia General Hospital and University of Perugia, 06129 Perugia, Italy;
| | - Lucilla Parnetti
- Neurology Department, Perugia General Hospital and University of Perugia, 06129 Perugia, Italy; (M.F.); (L.P.); (S.S.)
| | - Simone Simoni
- Neurology Department, Perugia General Hospital and University of Perugia, 06129 Perugia, Italy; (M.F.); (L.P.); (S.S.)
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Poulain B, Lemichez E, Popoff MR. Neuronal selectivity of botulinum neurotoxins. Toxicon 2020; 178:20-32. [PMID: 32094099 DOI: 10.1016/j.toxicon.2020.02.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 02/03/2020] [Accepted: 02/10/2020] [Indexed: 12/12/2022]
Abstract
Botulinum neurotoxins (BoNTs) are highly potent toxins responsible for a severe disease, called botulism. They are also efficient therapeutic tools with an increasing number of indications ranging from neuromuscular dysfunction to hypersecretion syndrome, pain release, depression as well as cosmetic application. BoNTs are known to mainly target the motor-neurons terminals and to induce flaccid paralysis. BoNTs recognize a specific double receptor on neuronal cells consisting of gangliosides and synaptic vesicle protein, SV2 or synaptotagmin. Using cultured neuronal cells, BoNTs have been established blocking the release of a wide variety of neurotransmitters. However, BoNTs are more potent in motor-neurons than in the other neuronal cell types. In in vivo models, BoNT/A impairs the cholinergic neuronal transmission at the motor-neurons but also at neurons controlling secretions and smooth muscle neurons, and blocks several neuronal pathways including excitatory, inhibitory, and sensitive neurons. However, only a few reports investigated the neuronal selectivity of BoNTs in vivo. In the intestinal wall, BoNT/A and BoNT/B target mainly the cholinergic neurons and to a lower extent the other non-cholinergic neurons including serotonergic, glutamatergic, GABAergic, and VIP-neurons. The in vivo effects induced by BoNTs on the non-cholinergic neurons remain to be precisely investigated. We report here a literature review of the neuronal selectivity of BoNTs.
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Affiliation(s)
- Bernard Poulain
- Université de Strasbourg, CNRS, Institut des Neurosciences Cellulaires et Intégratives, Strasbourg, France
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Finocchiaro A, Marinelli S, De Angelis F, Vacca V, Luvisetto S, Pavone F. Botulinum Toxin B Affects Neuropathic Pain but Not Functional Recovery after Peripheral Nerve Injury in a Mouse Model. Toxins (Basel) 2018; 10:toxins10030128. [PMID: 29562640 PMCID: PMC5869416 DOI: 10.3390/toxins10030128] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 03/13/2018] [Accepted: 03/15/2018] [Indexed: 12/12/2022] Open
Abstract
Clinical use of neurotoxins from Clostridium botulinum is well established and is continuously expanding, including in treatment of pain conditions. Background: The serotype A (BoNT/A) has been widely investigated, and current data demonstrate that it induces analgesia and modulates nociceptive processing initiated by inflammation or nerve injury. Given that data concerning the serotype B (BoNT/B) are limited, the aim of the present study was to verify if also BoNT/B is able not only to counteract neuropathic pain, but also to interfere with inflammatory and regenerative processes associated with the nerve injury. Methods: As model of neuropathic pain, chronic constriction injury (CCI) of the sciatic nerve was performed in CD1 male mice. Mice were intraplantarly injected with saline (control) or BoNT/B (5 or 7.5 pg/mouse) into the injured hindpaw. For comparison, another mouse group was injected with BoNT/A (15 pg/mouse). Mechanical allodynia and functional recovery of the injured paw was followed for 101 days. Spinal cords and sciatic nerves were collected at day 7 for immunohistochemistry. Results and Conclusions: The results of this study show that BoNT/B is a powerful biological molecule that, similarly to BoNT/A, can reduce neuropathic pain over a long period of time. However, the analgesic effects are not associated with an improvement in functional recovery, clearly highlighting an important difference between the two serotypes for the treatment of this chronic pain state.
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Affiliation(s)
- Alba Finocchiaro
- National Research Council of Italy-CNR, Institute of Cell Biology and Neurobiology-IBCN, 00143 Roma, Italy.
- Department of Psycology, PhD School of Behavioural Neuroscience, Sapienza University, 00185 Roma, Italy.
| | - Sara Marinelli
- National Research Council of Italy-CNR, Institute of Cell Biology and Neurobiology-IBCN, 00143 Roma, Italy.
- IRCCS Santa Lucia Foundation, 00143-Roma, Italy.
| | | | - Valentina Vacca
- National Research Council of Italy-CNR, Institute of Cell Biology and Neurobiology-IBCN, 00143 Roma, Italy.
- IRCCS Santa Lucia Foundation, 00143-Roma, Italy.
| | - Siro Luvisetto
- National Research Council of Italy-CNR, Institute of Cell Biology and Neurobiology-IBCN, 00143 Roma, Italy.
- IRCCS Santa Lucia Foundation, 00143-Roma, Italy.
| | - Flaminia Pavone
- National Research Council of Italy-CNR, Institute of Cell Biology and Neurobiology-IBCN, 00143 Roma, Italy.
- IRCCS Santa Lucia Foundation, 00143-Roma, Italy.
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Abstract
Botulinun neurotoxin (BoNT) has emerged as one of the most multipurpose therapeutic agents in modern medicine with more clinical applications than any other drug currently on the market. Initially developed in the treatment of strabismus and neurologic movement disorders, the use of botulinun neurotoxin has been expanding during the past 3 decades to include the treatment of a variety of ophthalmologic, gastrointestinal, urologic, orthopedic, dermatologic, dental, secretory, painful, cosmetic, and other conditions. In addition to onabotulinumtoxinA (Botox), abobotulinumtoxinA (Dysport), incobotulinumtoxinA (Xeomin), and RimabotulinumtoxinB (Myobloc or NeuroBloc) there are other novel botulinun neurotoxin products currently in development. With a better understanding of the cellular mechanisms of botulinun neurotoxin and advances in biotechnology, future botulinun neurotoxin products will likely be even more effective and customized to the specific indication and tailored to the needs of the patients. © 2017 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, Texas, USA
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Ayyar BV, Atassi MZ. Effects of membrane properties on the binding activities of the H N and H C heavy-chain domains of botulinum neurotoxin A. BIOCHIMICA ET BIOPHYSICA ACTA-PROTEINS AND PROTEOMICS 2016; 1864:1678-1685. [PMID: 27596061 DOI: 10.1016/j.bbapap.2016.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 08/15/2016] [Accepted: 09/01/2016] [Indexed: 10/21/2022]
Abstract
Binding behaviors of the HN and the HC domains of BoNT/A were investigated individually to identify if there exist any differences in their interaction with the cell membrane. Recombinant fragments corresponding to both BoNT/A HN and HC regions were prepared (HN519-845 and HC967-1296) and their binding to synaptic proteins was verified. The binding behaviors of these heavy-chain domains were analyzed by treating the Neuro 2a, a murine neuroblastoma cell line, with compounds known to alter membrane properties. Cholesterol depletion and lipid raft inhibition increased the binding of HN519-845 to Neuro 2a cells without affecting HC967-1296-cell interaction. Sphingolipid depletion decreased the binding of cells to both HC967-1296 and HN519-845 whereas, loading exogenous GD1a, on to the Neuro 2a cells, increased the binding of both the peptides to cells. Microtubule disruption of the Neuro 2a cells by nocodazole decreased the binding of both HC967-1296 and HN519-845 to the treated cells. Inhibition of the clathrin-mediated endocytosis using dynasore, chlorpromazine or potassium (K+) depletion buffer lowered the binding of both HC967-1296 and HN519-845 to the cells, but seemed to exert a more pronounced effect on the binding of HC967-1296 than on the binding of HN519-845. Results indicate that while both the HN and HC domains are involved in the binding of the toxin to neuronal cells there are differences in their behavior which probably stem from their respective amino acid composition and structural location in the toxin three-dimensional structure along with their intended role in translocation and internalization into the cells.
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Affiliation(s)
- B Vijayalakshmi Ayyar
- Department of Biochemistry and Molecular Biology, Baylor College of Medicine, Houston, TX 77030, USA
| | - M Zouhair Atassi
- Department of Biochemistry and Molecular Biology, Baylor College of Medicine, Houston, TX 77030, USA; Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX 77030, USA.
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Mehlan J, Brosig H, Schmitt O, Mix E, Wree A, Hawlitschka A. Intrastriatal injection of botulinum neurotoxin-A is not cytotoxic in rat brain - A histological and stereological analysis. Brain Res 2015; 1630:18-24. [PMID: 26562665 DOI: 10.1016/j.brainres.2015.10.056] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 10/30/2015] [Accepted: 10/31/2015] [Indexed: 12/29/2022]
Abstract
Parkinson's disease (PD) is caused by progressive degeneration of dopaminergic neurons in the substantia nigra pars compacta, resulting in a deficiency of dopamine in the striatum and an increased release of acetylcholine by tonically active interneurons. Botulinum neurotoxin-A (BoNT-A) is well known for blocking transmitter release by cholinergic presynaptic terminals. Treating striatal hypercholinism by local application of BoNT-A could be a possible new local therapy option of PD. In previous studies of our group, we analyzed the effect of BoNT-A injection into the CPu of 6-OHDA lesioned hemiparkinsonian rats. Our studies showed that BoNT-A application in hemiparkinson rat model is capable of abolishing apomorphine induced rotations for approximately 3 months. Regularly occurring axonal swellings in the BoNT-A infiltrated striata were also discovered, which we named BoNT-A induced varicosities (BiVs). Résumé: Here we investigated the long-term effect of the injection of 1ng BoNT-A into the right CPu of naive Wistar rats on the number of ChAT-ir interneurons as well as on the numeric density and the volumetric size of the BiVs in the CPu. Significant differences in the number of ChAT-ir neurons between the right BoNT-A treated CPu and the left untreated CPu were not detected up to 12 month post BoNT-A injection. The numeric density of BiVs in the treated CPu reached a maximum 3 months after BoNT-A treatment and decreased afterwards, whereas the volume of single BiVs increased steadily throughout the whole time course of the experiment.
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Affiliation(s)
- Juliane Mehlan
- Department of Anatomy, Rostock University Medical Center, Gertrudenstraße 9, 18057 Rostock, Germany
| | - Hans Brosig
- Department of Anatomy, Rostock University Medical Center, Gertrudenstraße 9, 18057 Rostock, Germany
| | - Oliver Schmitt
- Department of Anatomy, Rostock University Medical Center, Gertrudenstraße 9, 18057 Rostock, Germany
| | - Eilhard Mix
- Department of Neurology, Rostock University Medical Center, Gehlsheimer Straße 20, 18147 Rostock, Germany
| | - Andreas Wree
- Department of Anatomy, Rostock University Medical Center, Gertrudenstraße 9, 18057 Rostock, Germany
| | - Alexander Hawlitschka
- Department of Anatomy, Rostock University Medical Center, Gertrudenstraße 9, 18057 Rostock, Germany.
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