Necrotising fasciitis as a complication of botulinum toxin injection

PURPOSE

To highlight the need for early diagnosis and treatment of the rare condition of necrotising fasciitis as a complication of botulinum toxin injection, and to illustrate that injections in immunocompromised patients carry a rare but serious risk.

RESULTS AND METHODS

A case report is presented of an 80-year-old woman suffering from blepharospasm and chronic myeloid leukaemia, who developed necrotising fasciitis 3 days after a botulinum toxin injection.

CONCLUSIONS

Chronic debilitating processes such as diabetes, alcoholism and polymyositis have been suggested as predisposing factors in the development of necrotising fasciitis. We believe this is the first reported case of necrotising fasciitis occurring secondary to a botulinum toxin injection. The fact that this infection extended through the fascial planes and led to the death of muscle was, probably, because an inoculum was introduced directly into the muscle at the time of botulinum toxin treatment. This may have led to its deep spread and difficulty in debriding the area. Chronic myeloid leukaemia does not in itself cause significant immunosuppression, but our patient was on anti-proliferative treatment and had a low leucocyte count, which may have been a predisposing factor in this case.

Tardive dyskinesia: a review

OBJECTIVE

To review recent research findings on tardive dyskinesia (TD) with relevance to clinical practice.

METHOD

TD is a syndrome of involuntary movements that can occur in association with chronic neuroleptic use. It is of unknown pathophysiology. It can be irreversible, is cosmetically disfiguring, and can be functionally disabling.

RESULTS

There is as yet no treatment of demonstrated efficacy for TD. It is an iatrogenic disorder whose incidence is increased by age and total cumulative dose of typical neuroleptics. It has been the source of successful litigation in some jurisdictions but, until very recently, there has been no effective antipsychotic agent without this effect.

CONCLUSION

This litigation in some jurisdictions has been a major impetus to the development of novel antipsychotic agents. It is less well known that a similar, possibly identical, movement disorder occurs spontaneously particularly in the elderly and in patients with schizophrenia, and that TD is often reversible.

Hunger perceptions and satiety responses among normal-weight bulimics and normals to a high-calorie, carbohydrate-rich food

The hunger perceptions and satiety responses to a high-calorie, carbohydrate-rich food among 10 normal-weight females who met the DSM-III criteria for bulimia were compared with 10 normal-weight females who denied a current or past history of eating or weight disorders. As indicated by self-report responses on the Hunger-Satiety Questionnaire, bulimics did not differ from the normals in their perceptions of hunger sensations. Differences, however, were detected in the responses following eating. Most notably, the bulimics reported feelings of irritability, nervousness, tenseness and depression which persisted 30 minutes later. These findings and directions for future research are discussed.

A components analysis of biofeedback in the treatment of fecal incontinence

Fecal incontinence is a socially disabling symptom for which rectosphincteric biofeedback has been reported to be dramatically effective. The most commonly employed biofeedback procedure incorporates three separate and potentially effective components: exercise of the external sphincter muscle, training in discrimination of rectal sensations, and training synchrony of the internal and external sphincter responses. This paper reports the results of single case experiments employed with eight incontinent patients to examine the contributions of each of these components. All eight patients improved, but only one required the biofeedback procedure as it was originally described. Three responded to sensory discrimination training, one to exercise training, and one to the training of synchronous sphincteric responses; three recovered independently of the effects of biofeedback. Despite the achievement of continence, the rectosphincteric reflexes following treatment continued to be abnormal in every case. These findings suggest that the character of the external sphincter response to rectal distension is an unreliable index of sphincter function and that exercise and sensory discrimination training procedures are effective for some cases of fecal incontinence.

Cognitive versus behavioral procedures in cognitive-behavior therapy: a critical review of the evidence

During the past decade there has been an increasing emphasis on cognition in psychology and behavior therapy. This movement has spawned several distinctive cognitive therapies. While those therapies do employ innovative cognitive treatment procedures, they often do so in the context of well-established behavioral treatment procedures which may or may not be acknowledged by the label "cognitive-behavior therapy". This paper addresses the question of whether cognitive therapy is an evolutionary or revolutionary development from behavior therapy and critically evaluates the evidence for the efficacy of procedures specific to cognitive therapy.

Vomiting as a learned weight-control technique in bulimia

Twenty-seven consecutive patients presenting with binge eating and vomiting were systematically questioned about the circumstances surrounding the onset of their vomiting habit. Twenty-four were able to specify and describe a particular incident to which they attributed the idea of vomiting as a weight-control method. The nature of the reported incidents supports the hypothesis that vomiting in those patients is a learned maladaptive behavior which is frequently inadvertently taught by well-meaning friends, relatives and professionals. These findings indicate the necessity of evaluating the risks as well as the benefits of public education.

External contingency management for chronic pain: critical review of the evidence

The use of operant conditioning to treat chronic pain has grown rapidly in the past 10 years. It usually occurs in a multidisciplinary inpatient setting with patients for whom nearly everything else has failed. The author reviews the theoretical rationale for this application of contingency management and evaluates the evidence for its efficacy. Although the evidence indicates considerable promise, particularly in improving physical functioning and reducing analgesic use, more definitive conclusions about the role of these methods in treatment of chronic pain are precluded by the methodological limitations of research in this area.

Gastric stasis and vomiting: behavioral treatment

A patient is described in whom gastric stasis and vomiting of 28-yr duration were successfully treated with behavior therapy. Failure of conventional medical treatment in the face of continued vomiting led to consideration for surgery. The need for surgery was obviated by the successful application of exposure and response prevention, which resulted in a complete elimination of vomiting. Changes were produced, not only in the overt behavioral manifestation (vomiting) but in gastrointestinal motility as well. Although there was a lag, gastric emptying returned to normal. The improvements were maintained at over 1-yr follow-up study.

Biofeedback and self-regulation in the treatment of diffuse esophageal spasm: a single-case study

Diffuse esophageal spasm is an uncommon esophageal motor disorder characterized clinically by chest pain and difficulty swallowing. A case is described in which failure of conventional medical treatment in the face of continued weight loss led to consideration for surgery. The need for surgery was obviated by the successful application of relaxation training, which resulted in a significant reduction in painful esophageal spasms, weight gain, and an improvement in psychological state; there was, however, no change in the underlying esophageal motor disorder. The use of a second coping strategy--double swallowing--had an additional beneficial effect, and clinical improvements were maintained and increased at 6-month follow-up. The rationale and the effects of this method at the physiological level are described. It is suggested that double swallowing is a promising new approach to helping patients cope with disordered esophageal motility and that its more general applicability warrants further study.

Crohn's disease: a review of the psychological and social outcome

A review of the psychosocial literature relating to Crohn's disease reveals that most available studies have been aetiologically oriented and that there are important gaps in our knowledge about the psychological and social concomitants of the disease. Some future research possibilities are discussed.