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Jost WH, Kaňovský P, Hast MA, Hanschmann A, Althaus M, Patel AT. Pooled Safety Analysis of IncobotulinumtoxinA in the Treatment of Neurological Disorders in Adults. Toxins (Basel) 2023; 15:353. [PMID: 37368654 DOI: 10.3390/toxins15060353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 04/27/2023] [Accepted: 05/18/2023] [Indexed: 06/29/2023] Open
Abstract
The pooled incidences of treatment-emergent adverse events (TEAEs) were examined by indication using the integrated clinical database of Merz-sponsored, placebo-controlled, or repeat-dose studies of incobotulinumtoxinA in adults with cervical dystonia, blepharospasm, limb spasticity, sialorrhea, or essential tremor of the upper limb. Overall incidences of TEAEs, serious TEAEs, TEAEs leading to discontinuation, fatal TEAEs, TEAEs of special interest (TEAESIs; indicating possible toxin spread), and treatment-related (TR) events were determined for incobotulinumtoxinA and placebo after a single injection and for repeated dose cycles of incobotulinumtoxinA. The most frequent events after a single dose of incobotulinumtoxinA are summarized. After a single cycle, incidences of overall TEAEs were similar between incobotulinumtoxinA and the placebo in most indications, although between-indication differences were observed. Few TEAEs led to incobotulinumtoxinA discontinuation; there were no fatal TEAEs with incobotulinumtoxinA. In general, repeated cycles did not increase the incidence of any event. The most frequent TR-TEAEs were indication-dependent, including dysphagia for indications affecting the head or neck. The TR-TEAESIs across all indications were most commonly muscular weakness, dysphagia and dry mouth. Overall, the results of this pooled analysis support and extend the favorable safety and tolerability profile of incobotulinumtoxinA for the treatment of adult neurological disorders established by individual clinical studies.
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Affiliation(s)
| | - Petr Kaňovský
- Faculty of Medicine and Dentistry and University Hospital, Palacký University Olomouc, 779 00 Olomouc, Czech Republic
| | | | | | | | - Atul T Patel
- Kansas City Bone and Joint Clinic, Overland Park, KS 66211, USA
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Jost WH, Bäumer T, Berweck S, Laskawi R, Spittau B, Steffen A, Winterholler M. [Therapy of Sialorrhea with Botulinum Toxin - An Update]. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2022; 90:222-232. [PMID: 35453157 DOI: 10.1055/a-1802-3867] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The most important salivary glands are the paired parotid and submandibular glands. Adults produce 1 to 1.5 liters of saliva which are then regularly swallowed. When the act of swallowing is disturbed, salivation occurs. More rarely, the cause can be found in increased saliva production, for example, when caused through medication. Sialorrhea impairs the quality of life substantially and is frequently often socially stigmatizing. Therapy includes conservative measures such as functional dysphagia therapy, oral or transdermal application of anticholinergics, as well as, in selected cases, radiation and surgical measures. Over the last 20 years, local injection of botulinum toxin has been successfully applied in the treatment of this condition. With approval of incobotulinumtoxinA toxin for children and adults, this procedure will become the therapy of choice for chronic sialorrhea. The results of the phase III registration trials have demonstrated high efficacy and good safety of the injection treatment in both children and adults.
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Affiliation(s)
| | - Tobias Bäumer
- Institut für Systemische Motorikforschung, CBBM, Sektion Zentrum für Seltene Erkrankungen, UKSH, Universität zu Lübeck, Lübeck, Germany
| | - Steffen Berweck
- Schön Klinik Vogtareuth, Vogtareuth, Germany.,Dr von Haunersches Kinderspital Kinderklinik und Kinderpoliklinik der Ludwig Maximilian Universitat München, München, Germany
| | - Rainer Laskawi
- Georg-August-Universitat Göttingen HNO-Klinik, Göttingen, Germany
| | - Björn Spittau
- Anatomie und Zellbiologie, Medizinische Fakultät OWL, Universität Bielefeld, Bielefeld, Germany
| | - Armin Steffen
- Universitätsklinikum Schleswig-Holstein Campus Lübeck HNO Klinik, Lübeck, Germany
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Jost WH, Bäumer T, Laskawi R, Slawek J, Spittau B, Steffen A, Winterholler M, Bavikatte G. Therapy of Sialorrhea with Botulinum Neurotoxin. Neurol Ther 2019; 8:273-288. [PMID: 31542879 PMCID: PMC6858891 DOI: 10.1007/s40120-019-00155-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Indexed: 12/11/2022] Open
Abstract
Botulinum neurotoxin (BoNT) is considered the treatment of choice for various symptoms and diseases such as focal dystonia and focal spasticity. The effects of BoNT on the salivary glands have also been known for years, but their use was limited because of a lack of approval studies. Now the indication of sialorrhea is approved in some countries for incobotulinumtoxinA, such as the USA and Europe, and therapy could also become the treatment of choice. According to the pivotal study, a dose of 100 units of incobotulinumtoxinA, which is divided into the parotid and submandibular glands, is recommended. RimabotulinumtoxinB is approved in the USA only. To define the value of this therapy, we must consider anatomy, physiology, and available therapies. Therapy includes conservative measures such as functional dysphagia therapy, oral or transdermal application of anticholinergics, and, in selected cases, radiotherapy and surgical procedures. A combination of different approaches is optional. On the basis of the evidence and clinical experience, BoNT injections will be the first line of pharmacotherapy for chronic sialorrhea.
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Affiliation(s)
| | - Tobias Bäumer
- Paediatric and Adult Movement Disorders and Neuropsychiatry, Institut of Neurogenetics, University of Lübeck, Lübeck, Germany
| | - Rainer Laskawi
- ENT Department, University Medical Center, Göttingen, Germany
| | - Jaroslaw Slawek
- Neurology Department, Medical University of Gdansk, Gdańsk, Poland
| | - Björn Spittau
- Center for Transdisciplinary Neurosciences Rostock (CTNR), University of Rostock, Rostock, Germany
| | - Armin Steffen
- Department for Otorhinolaryngology, University of Lübeck, UKSH, Lübeck, Germany
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Morgante F, Bavikatte G, Anwar F, Mohamed B. The burden of sialorrhoea in chronic neurological conditions: current treatment options and the role of incobotulinumtoxinA (Xeomin®). Ther Adv Neurol Disord 2019; 12:1756286419888601. [PMID: 31819763 PMCID: PMC6883364 DOI: 10.1177/1756286419888601] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 10/08/2019] [Indexed: 12/11/2022] Open
Abstract
Sialorrhoea is a frequent symptom of neurological diseases (e.g. Parkinson’s
disease, motor neuron disease, cerebral palsy, and stroke) and is defined as
excessive saliva accumulation leading to unintentional loss of saliva from the
mouth. Sialorrhoea increases the overall burden on the patient and their
caregivers, the impact of which can be both physical and psychosocial.
Treatments for sialorrhoea range from lifestyle and behavioural guidance, to
medications, surgery or radiation. Nonpharmacological interventions include
advice on posture, swallowing control, cough management, dietary changes, eating
and drinking techniques, and behavioural modification; however, these
conservative measures may be ineffective for people with progressive
neurological conditions. The pharmacological treatment of sialorrhoea is
challenging because medications licensed for this purpose are limited, but
treatments can include anticholinergic drugs and botulinum toxins. Surgical
treatment of sialorrhoea is typically reserved as a last resort for patients.
IncobotulinumtoxinA (Xeomin®) is the first botulinum toxin type A to receive US
and UK marketing authorization for the symptomatic treatment of chronic
sialorrhoea due to neurological disorders in adults. In this review, we discuss
and compare the frequency and method of administration, location of treatment
delivery, approximate annual costs and main side effects of botulinum toxin and
different anticholinergic drugs. Management of patients with chronic
neurological conditions requires input from multiple specialist teams and thus a
multidisciplinary team (MDT) approach is considered fundamental to ensure that
care is consistent and tailored to patients’ needs. To ensure that adult
patients with neurological conditions receive the best care and sialorrhoea is
well managed, we suggest a potential clinical care pathway for sialorrhoea with
a MDT approach, which healthcare professionals could aspire to.
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Affiliation(s)
- Francesca Morgante
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, United Kingdom; Department of Experimental and Clinical Medicine, University of Messina
| | - Ganesh Bavikatte
- Department of Rehabilitation Medicine, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Fahim Anwar
- Department of Rehabilitation Medicine, Cambridge University Hospital NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Biju Mohamed
- Department of Medicine and Gerontology, University Hospital of Wales, Cardiff, UK
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Weikamp JG, Schinagl DAX, Verstappen CCP, Schelhaas HJ, de Swart BJM, Kalf JG. Botulinum toxin-A injections vs radiotherapy for drooling in ALS. Acta Neurol Scand 2016; 134:224-31. [PMID: 26803950 DOI: 10.1111/ane.12559] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Botulinum neurotoxin (BoNT) injections in the salivary glands and radiotherapy (RT) on these glands are commonly used to alleviate severe drooling in patients with amyotrophic lateral sclerosis (ALS). This study compares BoNT type A with RT based on patient-rated evaluations. MATERIALS & METHODS A prospective randomized controlled pilot study to compare RT (n = 10; on the parotid and the posterior part of the submandibular glands) with BoNT-A treatment (n = 10; in the parotid glands only, because of the risk of increasing oropharyngeal weakness) in patients with ALS. The primary outcome was the drooling status (burden of drooling), and our secondary interests were the degree of salivation, global change of drooling after treatment, and level of satisfaction with the treatment and negative experiences. RESULTS There were no statistically significant between-treatment differences for the drooling status after treatment. Only at twelve weeks more saliva reduction was achieved by RT (P = 0.02). Patients treated with RT also described more transient negative experiences (like pain in mandible) directly after treatment. Subgroup analysis showed that patients with very severe dysphagia (no oral intake) were less satisfied and experienced a lower global change of drooling after treatment. CONCLUSIONS This pilot study showed no significant difference in the burden of drooling between the treatments. However, with RT more saliva reduction was achieved, including negative experiences directly after treatment, but without the risk of decreasing oropharyngeal function. In addition, patients with very severe dysphagia do not seem to benefit from either treatment.
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Affiliation(s)
- J. G. Weikamp
- Radboud University Medical Centre; Donders Centre for Neuroscience (DCN); Department of Rehabilitation/Speech-Language Pathology; Nijmegen The Netherlands
| | - D. A. X. Schinagl
- Radboud University Medical Centre; Department of Radiotherapy; Nijmegen The Netherlands
| | - C. C. P. Verstappen
- Canisius Wilhelmina Ziekenhuis; Department of Neurology; Nijmegen The Netherlands
| | | | - B. J. M. de Swart
- Radboud University Medical Centre; Donders Centre for Neuroscience (DCN); Department of Rehabilitation/Speech-Language Pathology; Nijmegen The Netherlands
| | - J. G. Kalf
- Radboud University Medical Centre; Donders Centre for Neuroscience (DCN); Department of Rehabilitation/Speech-Language Pathology; Nijmegen The Netherlands
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Raheja D, Stephens HE, Lehman E, Walsh S, Yang C, Simmons Z. Patient-reported problematic symptoms in an ALS treatment trial. Amyotroph Lateral Scler Frontotemporal Degener 2016; 17:198-205. [PMID: 26824413 DOI: 10.3109/21678421.2015.1131831] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
This study was undertaken to determine which symptoms are perceived to be most problematic for patients with ALS and how their severity changes over time. A retrospective study was performed of data from a randomized, double-blind, placebo-controlled trial of ceftriaxone in ALS. Participants completed the ALS Specific Quality of Life Instrument (ALSSQoL) at baseline and at intervals up to 96 weeks. Ten ALSSQoL items ask participants to rate how problematic symptoms are (the subjective feeling of burden of these symptoms), ranging from 0 (no problem) to 10 (tremendous problem). Six are non-bulbar (pain, fatigue, breathing, strength and ability to move, sleep, and bowel and bladder) and four are bulbar (eating, speaking, excessive saliva, and mucus). Results revealed that there were 82 subjects (56% males, mean age 53 ± 10.3 years) with ALSSQoL data for weeks 0 and 96. All 10 symptoms became more problematic over time. For non-bulbar symptoms, strength/ability to move and fatigue were the most problematic. Speaking was the most problematic bulbar symptom. In conclusion, although all the symptoms in the ALSSQoL were acknowledged as problematic, some had greater impact than others. All became more problematic over time. This should help prioritize research into symptom management, and assist individual clinicians in their approach to patient care.
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Affiliation(s)
- Divisha Raheja
- a Department of Neurology , The Pennsylvania State University College of Medicine , Hershey Pennsylvania
| | - Helen E Stephens
- a Department of Neurology , The Pennsylvania State University College of Medicine , Hershey Pennsylvania
| | - Erik Lehman
- b Department of Public Health Sciences , The Pennsylvania State University College of Medicine , Hershey Pennsylvania
| | - Susan Walsh
- c ALS Association Greater Philadelphia Chapter , Harrisburg Pennsylvania
| | - Chengwu Yang
- d Department of Public Health Sciences & Office for Scholarship in Learning and Education Research , Hershey Pennsylvania , USA , and
| | - Zachary Simmons
- e Departments of Neurology and Humanities , The Pennsylvania State University College of Medicine , Hershey Pennsylvania , USA
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Orsini M, Leite MAA, Chung TM, Bocca W, de Souza JA, de Souza OG, Moreira RP, Bastos VH, Teixeira S, Oliveira AB, Moraes BDS, Matta AP, Jacinto LJ. Botulinum Neurotoxin Type A in Neurology: Update. Neurol Int 2015; 7:5886. [PMID: 26487928 PMCID: PMC4591494 DOI: 10.4081/ni.2015.5886] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 08/17/2015] [Indexed: 11/22/2022] Open
Abstract
This paper reviews the current and most neurological (central nervous system, CNS) uses of the botulinum neurotoxin type A. The effect of these toxins at neuromuscular junction lends themselves to neurological diseases of muscle overactivity, particularly abnormalities of muscle control. There are seven serotypes of the toxin, each with a specific activity at the molecular level. Currently, serotypes A (in two preparations) and B are available for clinical purpose, and they have proved to be safe and effective for the treatment of dystonia, spasticity, headache, and other CNS disorders in which muscle hyperactivity gives rise to symptoms. Although initially thought to inhibit acetylcholine release only at the neuromuscular junction, botulinum toxins are now recognized to inhibit acetylcholine release at autonomic cholinergic nerve terminals, as well as peripheral release of neuro-transmitters involved in pain regulation. Its effects are transient and nondestructive, and largely limited to the area in which it is administered. These effects are also graded according to the dose, allowing individualized treatment of patients and disorders. It may also prove to be useful in the control of autonomic dysfunction and sialorrhea. In over 20 years of use in humans, botulinum toxin has accumulated a considerable safety record, and in many cases represents relief for thousands of patients unaided by other therapy.
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Affiliation(s)
- Marco Orsini
- Centro Universitário Augusto Motta, Bonsucesso , Rio de Janeiro, Brasil ; Universidade Federal Fluminense, Departamento de Neurologia, Niterói , Rio de Janeiro, Brasil
| | | | - Tae Mo Chung
- Universidade de São Paulo - USP , São Paulo, Brasil
| | - Wladimir Bocca
- Universidade Federal de São Paulo - UNIFESP , São Paulo, Brasil
| | | | | | | | | | | | | | | | - André Palma Matta
- Universidade Federal Fluminense, Departamento de Neurologia, Niterói , Rio de Janeiro, Brasil
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Hawkey NM, Zaorsky NG, Galloway TJ. The role of radiation therapy in the management of sialorrhea: A systematic review. Laryngoscope 2015; 126:80-5. [PMID: 26152655 DOI: 10.1002/lary.25444] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2015] [Indexed: 12/11/2022]
Abstract
PURPOSE Up to 80% of patients with Parkinson disease and 30% of patients with amyotrophic lateral sclerosis (ALS) suffer from sialorrhea. Patients who fail medical and surgical therapy should be considered for external beam radiation therapy (EBRT). In this study, we conduct a systematic review to determine the dose and techniques used that result in greatest efficacy and lowest toxicity for the administration of EBRT in patients with Parkinson disease or ALS-associated sialorrhea. METHODS AND MATERIALS This review included 216 patients from four prospective and six retrospective studies published from 1998 to 2014, with ALS or Parkinson disease who were treated with electron or photon EBRT for sialorrhea. RESULTS A total of 216 patients were treated with EBRT from 10 studies. The indication for EBRT was failure of alternative medical treatment in all ALS patients. For patients with Parkinson disease, EBRT was the primary mode of treatment in 68% of cases. Overall, 176 (81%) of 216 patients treated with EBRT for sialorrhea reported symptomatic improvement from baseline. The most common target was the inferior two-thirds of the bilateral parotid glands and the entire bilateral submandibular glands. The total number of patients who experienced short-term toxicity was 86 of 216 patients (40%). The total number of patients who experienced long-term toxicity was 24 of 207 (12%). CONCLUSIONS EBRT is an effective treatment for sialorrhea in patients suffering from ALS or Parkinson disease. Treatment to the bilateral submandibular glands and caudal parotid glands is the most common field arrangement.
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Affiliation(s)
- Nathan M Hawkey
- Tulane University School of Medicine, New Orleans, Louisiana, U.S.A
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, U.S.A
| | - Thomas J Galloway
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, U.S.A
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Paganoni S, Karam C, Joyce N, Bedlack R, Carter GT. Comprehensive rehabilitative care across the spectrum of amyotrophic lateral sclerosis. NeuroRehabilitation 2015; 37:53-68. [PMID: 26409693 PMCID: PMC5223769 DOI: 10.3233/nre-151240] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease) is a neurodegenerative disease that results in progressive muscle weakness and wasting. There is no known cure and the disease is uniformly fatal. PURPOSE This review discusses current concepts in ALS care, from breaking the diagnosis to end-of-life care. People with ALS have several multidisciplinary needs due to a complex and dynamic disease process. They benefit from rehabilitation interventions that are individualized and have the goal of optimizing independence, function, and safety. These strategies also help minimize symptomatic burden and maximize quality of life. CONCLUSION Patient-centered, multidisciplinary care has a significant impact on the life of people with ALS and is the current standard of care for this patient population.
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Affiliation(s)
- Sabrina Paganoni
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Massachusetts General Hospital and Boston VA Healthcare System, Boston, MA, USA
| | - Chafic Karam
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Nanette Joyce
- Department of Physical Medicine and Rehabilitation, Neuromuscular Section, University of California, Davis School of Medicine, Sacramento, CA, USA
| | - Richard Bedlack
- Duke University School of Medicine and Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Gregory T Carter
- Department of Physical Medicine and Rehabilitation, St Luke's Rehabilitation Institute, Spokane, WA, USA
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Møller E, Daugaard D, Holm O, Winge K, Bardow A, Lykkeaa J, Belhage B, Bakke M. Repeated treatments of drooling with botulinum toxin B in neurology. Acta Neurol Scand 2015; 131:51-7. [PMID: 25270197 DOI: 10.1111/ane.12309] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To investigate efficacy, saliva flow, and composition in repeated BoNT-B treatments of drooling. MATERIALS AND METHODS Seventeen neurological patients (median 66 years), referred for treatment of drooling participated in this observational study. Median total doses of 4000 units botulinum toxin type B (BoNT-B, Neurobloc(®)) were injected with at least 3 months intervals into parotid and submandibular glands using ultrasound guidance. Measures of drooling and saliva collection for analysis were obtained before treatment, and 6, 12, and eventually 18 weeks after. RESULTS Number of treatment series in each patient was 1-7. Compared to baseline, saliva flow rate and drooling were reduced 30-70% 6 weeks after treatment in the first series, while sodium, chloride, and total protein increased 20-80% (t-tests; P < 0.05). After 12 weeks, drooling was still significantly reduced, saliva flow tended to be, and saliva composition was back to baseline. Frequent side effects were viscous saliva and dry mouth. Due to fading effect in eight patients, individual decisions were taken to change from BoNT-B to BoNT-A. Similarly, the outcome was significantly reduced over time in six patients completing five subsequent BoNT-B treatment series (ANOVA; P < 0.05). CONCLUSION In the first series, BoNT-B treatment resulted in marked reduction of drooling and saliva flow rate with some relapse after 12 weeks. The viscous saliva was ascribed to increased total protein content and compensatory mechanisms related to ß-adrenergic receptor-specific actions. With patients needing long-term treatment, it should be noted that the efficacy of repeated BoNT-B may fade with time.
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Affiliation(s)
- E. Møller
- Department of Neurology; Bispebjerg Hospital; Copenhagen University Hospital; Copenhagen Denmark
- Department of Odontology; Faculty of Health and Medical Sciences; University of Copenhagen; Copenhagen Denmark
| | - D. Daugaard
- Department of Neurology; Bispebjerg Hospital; Copenhagen University Hospital; Copenhagen Denmark
| | - O. Holm
- Department of Radiology; Bispebjerg Hospital; Copenhagen University Hospital; Copenhagen Denmark
| | - K. Winge
- Department of Neurology; Bispebjerg Hospital; Copenhagen University Hospital; Copenhagen Denmark
| | - A. Bardow
- Department of Odontology; Faculty of Health and Medical Sciences; University of Copenhagen; Copenhagen Denmark
| | - J. Lykkeaa
- Department of Odontology; Faculty of Health and Medical Sciences; University of Copenhagen; Copenhagen Denmark
| | - B. Belhage
- Department of Anaestesiology; Bispebjerg Hospital; Copenhagen University Hospital; Copenhagen Denmark
| | - M. Bakke
- Department of Odontology; Faculty of Health and Medical Sciences; University of Copenhagen; Copenhagen Denmark
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