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The Beauty of Food Turning Back The Clock

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The Beauty of Food Turning Back The Clock Summary


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Laryngeal Movement Disorders Treatment with Botulinum Toxin

Botulinum toxin type A (BTX-A) is effective in treating a myriad of hyperkinetic disorders by partially denervating the muscle. The toxin is injected into muscle, diffuses, and is endocytosed into nerve endings. The toxin cleaves SNAP 25, a vesicle-docking protein essential for acetylcholine release into the neuromuscular junction (Aoki, 2001). When acetylcholine release is blocked, the muscle fibers become temporarily dener-vated. The effect is reversible within a few weeks new nerve endings sprout, which may provide synaptic transmission and some reduction in muscle weakness. These nerve endings are later replaced by restitution of the original end-plates (de Paiva et al., 1999). In ADSD, BTX-A injection, either small bilateral injections or a unilateral injection produces a partial chemodenerva-tion of the thyroarytenoid muscle for up to 4 months. Reductions in spasmodic muscle bursts relate to voice improvement (Bielamowicz and Ludlow, 2000). This therapy is effective in least 90...

Botulinum Toxin Mechanism Of Action

As previously mentioned, BTX is produced by Clostridium botulinum, a Gram-positive anaerobic bacterium. It is broken down into seven neurotoxins types A, B, C1, C2, D, E, F, and G. The neurotoxin types are structurally similar, but serologically and antigenically distinct (7). BTX effects in humans are mainly caused by types A, B, E, and rarely F. Types C and D affect animals only. Its molecule is synthesized as a single chain, which is then cleaved to form a two chain molecule with a disulfide bridge. Botulinum Toxin Types, Target Sites, and Discoverers Botulinum Toxin Types, Target Sites, and Discoverers

Clostridium Botulinum

Clostridium botulinum belongs to a Gram-positive Clostridium sp. It has two features that make it unique production of spores (C. botulinum produces spores, which are in practice resistant to all physical and chemical factors that destroy vegetative cells) Based on the serological properties of toxins (neurotoxins) produced by various strains of C. botulinum, the following serovars were identified A, B, C1, C2, D, E, F, G. C. botulinum strains are divided into four types (Hatheway, 1993) At present, G-toxin-producing C. botulinum is classified as a different species (C. argentinense). Neurotoxins may be also produced by C. butyricum (E toxin), C. barati (F toxin), and C. novyi (D and C1 toxins) (Eklund et al., 1974 Hall et al., 1985 McCroskey et al., 1986 Harvey et al., 2002). The classic foodborne botulism (FBB) poisoning occurs when a botulin toxin of food origin gets into the human body and is spread via gastrointestinal mucous membrane. An ingestion of C. botulinum cells or spores...

Clostridium Botulinum in the Environment

C. botulinum is widely distributed in the environment. The number of Clostridium-positive samples of soil and bottom sediments ranges from 3 to 100 . C. botulinum type A dominates in soil from the western states of the U.S., whereas type B is predominant in soil samples from the eastern states. C. botulinum type B is most frequently found in European soil, although type A predominates in Italy. In Japanese soil, types C, D or E are prevalent. C. botulinum type F dominates in Paraguayan soil (Dodds, 1993 a,b). Spores may be transferred from soil and plants to the sea via rainwater, causing the prevalence in coastal waters of the same C. botulinum types as on the land. Such a correlation was observed in Great Britain, where the type B predominates both in soil and in bottom sediments. Similarly, 71 offish and bottom-sediment samples collected in southern France were contaminated with type B, while C. botulinum type E was found only in 9.6 of samples (Fach et al., 2002). However, it is...

Clostridium Botulinum in Food

C. botulinum is frequently isolated from human and animal gastrointestinal tracts. Approximately 64 of samples of cow feces contain C. botulinum 73 of which are non-proteolytic type B and only less than 5 are type E or F (Dahlenborg et al., 2003). According to Dahlenborg et al. (2001), C. botulinum type B is isolated from 62 of pig feces. Such a frequent occurrence of C. botulinum in feces of farm animals leads to meat contamination with its spores. Prior to the introduction of modern methods of meat processing, meat products had been the most frequently implicated source of botulism outbreaks. The Latin word botulus means sausage, hence C. botulinum was named after the meat products that were suspected to be its main source. However, spores may penetrate soil and contaminate plants via animal feces. Since the 1950s, vegetable products, surprisingly, have been the most important vehicles of C. botulinum in the U.S. The 'vegetable cases' - caused only by type A (61.1 ) and type B (57.4...

Botulinum toxin and botulism

In addition to toxins from fungi, food may be contaminated with toxins produced by bacteria, such as botulinum toxin. Produced by the bacterium Clostridium botulinum, it is one of the two most potent toxins known to man, the other being ricin (see pp. 150-1). As little as one-hundred-millionth of a gram (i X 10-8 g) of the toxin about 0.00000000035 oz is lethal to a human. Fortunately the toxin is destroyed by heat, and so cooked food is unlikely to be contaminated (although the bacterial spores are quite resistant). The bacteria grow in the absence of air (they are anaerobic), therefore the foods most likely to be contaminated are those that are bottled or canned and eaten without cooking, for example raw or lightly cooked fish.

Botulinum Toxin Studied

Scott formed his own company, Oculinum, Inc., where he continued to study BTX-A. In 1978, Dr. Scott received permission from the FDA to test BTX-A in human volunteers (3). The original batch of 150 mg was used for more than 250,000 injections in humans. For many years, this was the only batch approved by the FDA, which requires batch approval for biological drugs. It was not until 1997 that the FDA approved a new bulk toxin source for use in the manufacture of BTX-A (4). The new product, today known as Botox, is comparable in clinical efficacy to the original Botox, but the higher specific potency reduces the amount of neurotoxin protein utilized, which in turn leads to a reduction in the production of antibodies. In 2000, the FDA approved Botox, manufactured by Allergan, Inc. (Irvine, CA), for the treatment of abnormal head positions and neck pain associated with cervical dystonia. At that time, the FDA also approved Myobloc for the same indication. Myobloc is...

Botulinum Toxin Type A Injection Procedure Figs 911

Over the last several years, botulinum toxin type A (BTX-A) has been increasingly used in the treatment of various medical conditions. Increasing literature supports the role of BTX-A in the treatment of chronic pain syndromes. Blockade of acetylcholine release from the presynaptic membrane plays an important role in relief of muscles spasms and myofascial pain syndromes. However, some animal models suggest alternative mechanisms for the analgesic The patients with plantar fasciitis had almost all of the aforementioned therapeutic measures with the exception of extracorporeal shock or surgery. The solution of BTX-A (Botox , Allergan, Inc.) was prepared by mixing 100 U with 1 cc bacteriostatic normal saline. We injected the patients of group A with 70 U BTX-A (0.7 cc) in two divided doses 40 U (0.4 cc) in the tender region of the heel medial to the base of the plantar fascia insertion and 30 U (0.3 cc) in the most tender point of the arch of the foot (between an inch anterior to the...

Botox targets nerves

Botulinum toxin is a mixture of six large molecules, each of which consists of two components. One binds to the walls of nerve cells which then allows the whole toxin molecule to be transported inside the cell (rather like a Trojan horse). Once inside the nerve cell, the second component destroys a protein, synaptobrevin. By destroying the protein, the toxin prevents the release of the substance acetylcholine from small packets at the ends of nerves. These nerves, attached to voluntary muscles, need acetylcholine to allow the flow of signals (or impulses) between the nerve and the muscle (see Figure 26). By preventing the release of acetylcholine, botulinum toxin causes paralysis of the muscle. If the muscles affected are vital to life, such as those involved with breathing, the outcome is fatal. Surprisingly perhaps, given its extreme toxicity, botulinum toxin was introduced into medical practice in 1983 to treat patients with squint. Since then its use has been expanded to include...

Jerome S Schwartz Phillip Song and Andrew Blitzer Introduction

This chapter describes the most common headache disorders with particular attention to migraine and tension-type headaches (TTHs). Because many of the routinely prescribed medications have inadequate efficacy and significant adverse effects, alternative treatment regimens are under investigation. Botulinum neurotoxin (BoNT) injection is becoming an accepted adjunct to the medication algorithm with which to treat these disorders. The proposed mechanism of action, pharmacokinetics, dosing, and safety profiles as well as injection techniques to treat common headache disorders are to be discussed in detail.

Postinjection Management

The headache relief from BoNT-A may take several weeks to reach maximal effect. Patients should maintain an accurate headache diary during the course of botulinum injections, documenting the time, severity, duration, location, and frequency of all headache events (42). Any medications taken to relieve acute breakthrough headaches should be noted. The patient should return for reevaluation at 4 to 6 weeks following the previous injection to document any

Frequency Of Injections

Repeated injections are necessary as the botulinum effect subsides. There is tremendous variation among patients with respect to optimal dosing frequency. Some patients experience relief well beyond the predicted pharmacokinetic duration of the drug. This suggests a possible neuromodulating effect of the toxin at the CNS level. In addition, the response to toxin injection may change over time, with some patients reporting greater therapeutic effect with repeat injections (46). Although the majority of patients require repeat injections at 3- to 4-month intervals, the headache diaries serve as a useful guide for the physician to direct future treatment.

Phillip Song Jerome S Schwartz and Andrew Blitzer Introduction

With the widespread use of botulinum toxin (BTX) and greater appreciation of its safety, physicians are increasingly aware of potential applications beyond dystonias, spasticity, and cosmetic denervation. Although most applications for BTX have focused on muscular denervation, autonomic denervation is currently being explored for a variety of clinical problems including excessive drooling, gustatory sweating, and hyperlacrimation. This chapter focuses on the role of BTX for uncontrolled salivation and gustatory sweating.

Btx Injection Procedure

Mix Botox 4 cc 0.9 sterile saline per 100-unit vial. 7. Draw up Botox into 4 1-cc syringes with 25-gage needle, then replace with 30-gage needle. After outlining the area to be treated with a marking pen, topical anesthetic can be applied to the area. Topical anesthesia containing lidocaine, such as ElaMax 5 cream is generally sufficient for treatment of the axilla. Other anesthesia options include the use of vibration and cooling. In our practice, if a patient cannot tolerate the procedure with topical anesthesia alone, a Zimmer cooler or ice is applied to each site immediately before each injection. The accepted diffusion rate from the point of injection of BTX-A in the axilla is approximately 2 cm. Hence each injection should be placed 2 cm apart to completely cover the entire area. These sites can be mapped out before injection using a marking pen to facilitate even placement of the product. The injections should be placed in the superficial dermis, approximately 2 to 3 mm deep....

Clinical Application Of Btx In The Treatment Of Lut Dysfunction

BTX-A, botulinum toxin type A DSD, detrusor-sphinter dyssynergia DSD+, DSD and related disorders (e.g., hypocontractility) AD, autonomic dysreflexia PVR, post void residual UPP, urethral pressure profile VP, voiding pressure Freq, frequency Urg, uregency UDI, urinary distress inventory CIC, clean intermittent catheterization QOL, quality of life UCP, urethral closing pressure Imp, improved. a Duration in some investigations limited by short-term study follow-up. bThree different protocols using Botox or Dysport. cProtocol using repeat injections. d Three different protocols used. Other investigation has evaluated the effect of BTX injection in the treatment of IC and has demonstrated contrasting results. Rackley et al. report the use of intravesical injection versus instillation of BTX (200 U) in the treatment of 10 patients with IC. Instillation of BTX was performed using 200 U diluted in 60 mL saline (3). Retrospective analysis of patient outcomes revealed that neither group...

Clinical Issues Related To Btx Injection

There is one investigation to date specifically designed to evaluate the efficacy of BTX in patients undergoing repeat injection. Grosse and colleagues reported 66 patients undergoing repeat BTX injection (Botox, 300 U Dysport, 750 U) in the treatment of neurogenic urinary tract dysfunction (69). All patients underwent one repeat injection, with a portion undergoing as many as six repeat injections. The interval between injections was approximately 10 months through the fourth injection. No difference was seen when comparing the difference between these intervals (injection 1 to 2, 2 to 3, 3 to 4). Major improvement of subjective satisfaction was seen in 71 of patients undergoing repeat injection and was comparable to the 74 rate observed following the initial injection. Major satisfaction percent increased to 96 and 89 in those undergoing a second and third repeat injection, respectively. This finding is not surprising as only one-half and one-fourth of patients underwent these...

Economic Considerations

From Therapeutic Uses of Botulinum Toxin Edited by G. Cooper Humana Press Inc., Totowa, NJ benefiting from repeated BTX treatments may require increased dosages for similar results. As the population of long-term BTX users increases, resistance and antibody formation will become a greater issue in the future. When increasing the dosage fails to elicit the desired response because of immunity, using a different BTX subtype may be an alternative. Although various strains of Clostridium BTX antigen serotypes have been produced and named from types A to G, only two types of BTX complex proteins are widely available in the United States Botox and Myobloc. Additional studies examining cross-reactivity between botulinum serotypes have demonstrated a primed immunological response forming antibodies between exposures of BTX-A followed by other serotypes in mice (6). Subjects exposed to fragments of BTX-A aimed at forming antibodies had their serum collected and subsequently exposed to another...

The Developing Role Of

When cosmetic BTX injections were first used to diminish forehead wrinkles, practitioners observed that their patients also had fewer episodes of migraine headaches (10). This serendipitous observation instigated clinical trials examining the efficacy of neurotoxin use for the treatment of migraine headaches. Initially, the efficacy of Botox injections for migraine prophylaxis was thought to be related to muscle relaxation. However, the level of efficacy of pain relief from injections did not significantly correlate with the level of weakness or muscle relaxation. Traditionally, migraines were thought to be caused by vasoconstriction followed by vasodilatation. Although the exact pathophysiology of migraines remains elusive, many clinicians now believe that migraines arise from increased sensitivity of cerebral structures in the dorsal raphe area of the brainstem. These sensitized cerebral structures, when reacting to stimuli, can trigger a cascade of responses that activate the...

Our Method Of Injection

Pyriformis Injection

We inject Botox or Myobloc under EMG guidance, selecting four points in the muscle that should reach different myoneural junctions (see Fig. 5). Each site receives either 75 U of Botox or 3125 U of Myobloc, adding up to 300 U of Botox or 12,500 of Myobloc. We use a 75- or 80-mm monopolar Teflon-coated 23 gauge injectible monopolar needle (e.g., of the type made by Chalgren Enterprises see Figs. 5 and 6). Botox and Myobloc are immunologically distinct. Therefore, if the patient has had Botox, then he or she is still very unlikely to have a reaction to Myobloc unless there is a history of botulism earlier in life. Alternating Botox and Myobloc over time is a wise course if multiple injections are necessary. The injection of Botox for PS is high-dose relative to many of its other uses. Nevertheless, it has resulted in no side effects to date, in more than 500 different instances of these multiple injection patterns.

Diagnosis And Evaluation Of Lut Dysfunction

Botulinum Toxin Injection Anal Sphincter

Potential targets of botulinum toxin injection classified by urological disorder. DO, detrusor overactivity IC, interstitial cystitis SU, sensory urgency BPH, benign prostatic hypertrophy DSD, detrusor-sphincter dyssynergia. Fig. 1. Potential targets of botulinum toxin injection classified by urological disorder. DO, detrusor overactivity IC, interstitial cystitis SU, sensory urgency BPH, benign prostatic hypertrophy DSD, detrusor-sphincter dyssynergia.

Treatment Approach

Masseter Muscle Injection

There are currently four formulations of BoNT-A (Botox , Dysport , Linurase , Xeomin , and Chinese toxin) and one type B complex (Myobloc ) approved for clinical use. Only Botox and Myobloc are currently available in the United States for injection. The three products have different dosing, safety, and efficacy characteristics and familiarity with each complex is essential before administration. There are no well established methodologies to calculate equivalent doses (39). Lyophilized BoNT-A (Botox, Allergan, Inc., Irvine, CA) is the only type A toxin currently available in the United States. Each vial contains 100 U of BoNT-A and requires dilution with 0.9 non-preserved saline. The authors typically dilute each vial with either 2 or 4 mL saline to prepare a 5.0 or 2.5 U per 0.1 mL stock, respectively. BoNT-B (Myobloc, Solstice Neurosciences, Inc., South San Francisco, CA) is available in 2500 and 5000 U mL vials prediluted with 0.05 human serum albumin.

Btxa For The Treatment Of Gastroparesis

From Therapeutic Uses of Botulinum Toxin Edited by G. Cooper Humana Press Inc., Totowa, NJ Fig. 1. Pyloric muscle injection of botulinum toxin type A in a patient with severe gastroparesis. (A) Top panel shows an endoscopic view of the pylorus before injection. (B) Bottom panel shows an injection catheter delivering botulinum toxin directly into the sphincter.

Protocol For Btx Injection

Published experience has utilized a total injection dose of 100 to 300 U (Botox) and 500 to 1000 U (Dysport). Because of the lack of significant literature regarding Dysport dosing, the following discussion will center on the Botox preparation. In one of the first published investigations of intravesical BTX injection for DO, Schurch and colleagues reported the use of varying doses, ranging from 200 to 300 U (30). The authors reported that the administration dose was based on a previous titration study demonstrating that this range was most likely to result in a complete blockade of acetylcholine at the detrusor level. Although a dose-response comparison was not formally conducted, the two patients failing to respond to treatment both received 200 U. As a result, the authors concluded that 300 U may be the optimal dose for DO. Fig. 2. Botulinum toxin injection sites, University of Chicago protocol. Reprinted from ref. 36, 2004, with permission from Elsevier. Fig. 2. Botulinum toxin...


Produced by the bacterium Clostridium botulinum, there are seven serotypes of BTX A, B, C1, D, E, F, and G. Regardless of the type, all BTXs cause chemodenervation and paralysis of muscles by inhibiting the release of acetylcholine from the presynaptic motor neuron. BTX type A (BTX-A) is currently the most commonly used serotype. Available as Botox in the United States (Allergan Inc., Irvine, CA) and Dysport in Europe (Ipsen Ltd., Maidenhead, UK), BTX-A inhibits release of acetylcholine by cleavage of synaptosome-associated protein-25, a presynaptic membrane protein required for fusion of neurotransmitter-containing vesicles. Because the onset of BTX-A's effect typically takes 3 to 7 days, patients must be informed at the time of treatment that improvement is not immediately noticed. For dosing purposes, 1 U Botox is equivalent to 3 to 5 U Dysport (4). Given the experience, safety, and FDA approval of Botox, it is the most widely used BTX preparation used by physicians. As such, all...

Treatment Algorithm

Although treatments are available, they usually provide little benefit and adequate treatment is often frustrating to both physician and patient alike. Patients should generally start with the least invasive from of therapy and progress to more complicated therapies as these other therapies fail. Approved therapies include topical medications, iontopheresis, systemic medications, botulinum toxin type A (BTX-A), and surgery. Topical therapies consist of aluminum chloride hexahydrate preparations that patients must apply consistently to achieve mild improvement of their condition. The most popular of these agents is a 20 solution (Drysol ), which is applied at night to the affected area and washed off in the morning. The mechanism of action of this group of topical agents is suggested to be related to plugging of the acrosy-ringium. The reduction in sweating is temporary and may be associated with irritation of the skin in the application areas. Antiperspirants containing aluminum...

Gustatory Sweating

BTX was first described as a treatment for Frey's syndrome by Drobik et al. in 1995 (26). Using 0.5 U cm2 intracutaneously, he reported a 12-month period of relief from gustatory sweating. Since this initial report, numerous studies have shown excellent efficacy in the use of BTX for this condition. Botox has been approved for on-label use for focal hyperhidrosis. Minor's starch iodine test is typically used to demarcate the treatment area. Iodine is applied to the skin and neck. After drying, starch is lightly applied to the iodine. Lemon drops or other acidic food is then given to stimulate perspiration and the face is inspected for black discoloration that indicates active sweating. A grid is then drawn with 1- to 1.5-cm markings throughout the affected area. We use 2.5 U Botox in 0.1 cc bacteriostatic normal saline for each square centimeter of affected skin. Dosages vary based on report. We have results lasting 6-24 months, with an average of 12.1 (32a). Restivo et al. reported...


From Therapeutic Uses of Botulinum Toxin Edited by G. Cooper Humana Press Inc., Totowa, NJ The literature reports a range of different dosages used for sialorrhea from 5 to 150 U with Botox and from 250 to 1000 U of Myobloc . Given our knowledge of botulinum effects in other body systems, individuals have different responses to toxin dosages. Injection technique also affects the dosages used. In our practice, we generally use a conservative dose of BTX for the initial dose (25 U Botox for the submandibular gland and 50 U for the parotids) with a follow-up dose as needed 2 weeks later. Patients and caretakers are advised to keep records of drooling as well as side effects. Treatment schedules are individualized to the patient needs. Although the biochemical effects of the toxin last 3 months, the range of therapeutic efficacy can vary considerably. Reported durations range from 1 to 7 months (7). In a report on 33 patients treated for salivary flow, Ellies et al. reported that the...

Anatomical Landmarks

Activating Cricothyroid Muscle

There are currently five formulations of BTX-A (Botox , Dysport , Linurase , Xeomin and Neuronox ) and one type B complex (Myobloc ) approved for clinical use. Only Botox Lyophilized BoNT-A (Botox, Allergan, Inc., Irvine, CA) is the only type A toxin currently available in the United States. Each vial contains 100 U of BTX-A, and requires dilution with 0.9 non-preserved saline. The authors typically dilute each vial with either 2 or 4 mL saline to prepare a 5.0 or 2.5 Botox U per 0.1 mL stock, respectively. Further dilutions are performed by adding additional saline, keeping a uniform volume of 0.1 mL. BTX-B (Myobloc, Solstice Neurosciences, Inc., South San Francisco, CA) is available in 2500 and 5000 U mL vials prediluted with 0.05 human serum albumin. Dosage determination is complicated by the variability in both physiological BTX response and patient preference. Individual doses of BTX-A for adductor SD may range from 0.005 to 30 U Botox per TA muscle, and the authors generally...

Clinical Experience

More recently, we have conducted several institutional review board-approved studies of specific nerve blocks, using neurotoxins of the botulinum bacterium. In the latest and most successful of these, we have used 300 U Botox or 12,500 U Myobloc. In our latest study with Myobloc, 89 of the patients were at least 50 improved on a visual analog scale of pain within 2 to 3 weeks (23,33). There are three reasons that 300 U Botox or 12,500 U Myobloc should be considered in the treatment of PS 1. In clinical experience, the injection of 300 U Botox or 12,500 U of Myobloc are, at this writing, the most effective treatment for PS. 3. Cost-benefit analysis of current data supports injection of 300 U Botox or 12,500 U Myobloc in the treatment of PS. 23. Fishman LM, Konnoth C, Rozner B. Botulinum neurotoxin type B and physical therapy in the treatment of PS a dose-finding study. Am J Phys Med Rehabil 2004 83 42-50. 26. Porta M. A comparative trial of botulinum toxin type A and methylprednisolone...


The etiologies and pathophysiological mechanisms of spasticity are varied and affect a wide array of patients. Although Botox has relatively few approved indications, its use has expanded over the past decade to include the treatment of spasticity, which has proven to be of great benefit in patients with disabling focal muscle overactivity. Appropriate patients must be chosen and functional goals must be clearly outlined and discussed with the patient and caregiver. Once defined, Botox may become part of an overall treatment protocol aimed at maximizing patient function. As further research provides a stronger scientific foundation, the use of BTX injection to treat spasticity as well as numerous other medical conditions will gain wider acceptance.

Toxins In Food The Past And The Present

As well as being used for intentional poisonings, toxic substances present in plants or spoiled foods have been the causes of accidental poisonings, frequently epidemic and leading to death. Medieval examples include ergot poisonings, known as ignis sacer (holy fire) or ignis Sancti Antonii (St. Anthony's fire) (a French outbreak in 994 A.D. led to over 40000 deaths), while contemporary poisonings may be caused by, for example, preserves containing Clostridium botulinum spores, poisonous mushrooms being mistaken for edible Agaricus campestris, or fish contaminated with mercury compounds (the Minamata disease outbreak in Japan in 1958).

Microbial Interactions

The interactions among the members of microbial populations on skin are undoubtedly important, but poorly understood. Some may involve more or less direct interactions via competition for available nutrients. It is generally accepted that free fatty acids on the skin surface are products of microbial metabolism and that they are inhibitory to some organisms, particularly potential pathogens. Corynebacteria are among the most active lipase producers on skin (9), but micrococci have also been shown to be important contributors of lipolytic activity (10). It has been suggested that fatty acids are an important mechanism by which Gram-positive bacteria on skin exert an inhibitory effect over Gramnegative bacteria (11). Conversely, it has been shown that suppressing Grampositive skin populations with antibiotics can be followed by overgrowth of Gram-negative bacteria (12). Antagonism also can occur via excretion of bacterio-cins, which are a chemically diverse group of substances produced...

Biological clocks See circadian rhythm jet lag

Botulism A serious form of food poisoning that selectively affects the central nervous system. The toxins are rapidly absorbed by the gastrointestinal tract and bind to brain tissue in fatal cases, death is often caused by a failure of the cardiac and respiratory centers in the brain. Botulism is caused by contamination with the botulin toxin, produced by the bacterium Clostridium botulinum, which thrives in improperly preserved foods (especially canned raw meat). C. botulinum is found as harmless inactive spores in air, water, and food when the spores are deprived of oxygen, however (such as inside a sealed can or jar), they begin to grow, producing one of the most deadly toxins known to humans 7 million times more deadly than cobra venom. Still, even inside a sealed jar, the spores will not grow if the food is very acidic, sweet, or salty (such as canned fruit juice, jams, and jellies, sauerkraut, tomatoes, and heavily salted hams). Canned foods that are susceptible to contamination...

Theoretical Perspectives in CVI Dermal Fibrosis and Ulcer Formation

The formation of venous ulcer and the mechanisms for dermal fibrosis are not known. In the early 1980s and through the 1990s various investigators proposed possible explanations for the underlying cause of advanced forms of dermal pathology in CVI patients. In 41 patients with venous ulcers, tissue biopsies were stained for fibrin. The tissues were found to have layers of fibrin around dermal capillaries of lipodermatosclerotic skin, but no fibrin was found in control normal skin. The pericapillary fibrin cuff observed in skin with lipodermatosclerosis was proposed to cause tissue fibrosis and hypoxia causing ulcer formation.17 A series of investigations on CVI patients determined that there were 24 fewer leukocytes leaving the dependent lower limb that was reversed upon elevation.18 This led to the hypothesis that leukocytes trapped in the microcirculation (dermal capillaries) resulted in tissue ischemia and venous ulceration.19 Growth factors are considered important mediators...

Alterations in Transforming Growth Factor Function

Transforming growth factor betal (TGF-pi) is an important growth factor with functional properties in regulating cell proliferation, extracellular matrix production, and immunosuppressive effects. A number of investigators have studied the role of TGF in patients with venous ulcer and lipodermatosclerotic skin changes. In an immunohistochem-ical study of venous ulcer and normal skin graft donor sites, in the venous ulcer biopsies there was increased a-2 mac-roglobulin, increased number of type I procollagen fibro blasts, and elevated immunoreactivity of TGF-pi within fibrin cuffs but not in the provisional matrix of the ulcer bed around the cuffs. In comparison, normal skin had restriction of a-1 macroglobulin to the vessel lumen, and procollagen and TGF-pi were present within the granulating matrix and adjacent to the wound margin. These data suggested that although TGF is present in venous ulcers it is distributed in the fibrin cuff and not available in the wound matrix due to...

Cytokine Regulation And Tissue Fibrosis

Leukocyte recruitment, ECM alterations, and tissue fibrosis are characteristic of chronic inflammatory diseases caused by alterations in TGF-P1 gene expression and protein production. To determine the role of TGF-P1 in CVI, dermal biopsies from normal patients and CEAP class 4, 5, and 6 CVI patients were analyzed for TGF-P1 gene expression, protein production, and cellular location.56 Quantitative RT-PCR for TGF-P1 gene expression was performed on 24 skin biopsies obtained from 24 patients. Patients were separated into four groups according to the ISCVS SVS classification for CVI normal skin (n 6), CEAP class 4 (n 6), CEAP class 5 (n 5), and CEAP class 6 (n 7). TGF-P1 gene transcripts for controls, Class 4, 5, and 6 patients were 7.02 7.33, 43.33 9.0, 16.13 7.67, and 7.22 0.56 x 10-14 moles g total RNA, respectively. The differences in TGF-P1 gene expression in Class 4 patients was significantly elevated compared to control and Class 5 and 6 patients (p < 0.05).56 An additional 38...

Definition of the Disease

The cause of hypothyroidism may be primary (thyroid dysfunction), secondary (pituitary dysfunction), or tertiary (hypothalamic dysfunction). Primary hypothyroidism is 1000-fold more common than secondary or tertiary causes.1 Hypothyroidism is associated with cold intolerance, weight gain, constipation, dry skin, bradycardia, hoarseness, and slow mental processing.1 In adults, the characteristic signs and symptoms of hypothyroidism may have an insidious onset. Chronic cutaneous changes include dry, puffy skin with a yellowish complexion as well as a thickening of the subcutaneous tissues due to accumulation of mucopolysaccharides. The hair becomes dry and brittle and is often sparse. The voice may deepen in pitch, and hypoventilation has been observed. Hypothyroid patients can show decreased pulse rate, decreased cardiac stroke volume, and decreased myocar-dial contractility that causes decreased cardiac output. Since peripheral metabolism is slowed, arteriovenous oxygen may not show a...

Role Of Matrix Metalloproteinases Mmps And Their Inhibitors In

As various proteases, cytokines or growth factors, cell-matrix interactions, and altered cell-cell contacts. TGF-Pt is a potent inducer of TIMP-1 and collagen production and inhibitor of MMP-1 through regulation of gene expression and protein synthesis. Several studies have demonstrated that prolonged and continuous TGF-Pt production causes tissue fibrosis by stimulating ECM production and inhibiting degradation by affecting MMP and TIMP production. Alterations in MMP and TIMP production may similarly modulate the tissue fibrosis of the lower extremity in CVI patients. Several investigators have reported that the gelatinases MMP-2 and -9 as well as TIMP-1 are increased in the exudates of patients with venous ulcers compared to acute wounds.70-72 However, analyses of biopsy specimens have demonstrated variable results. Herouy et al. reported that MMP-1, and -2 and TIMP-1 are increased in patients with lipodermatosclerosis compared to normal skin.73 In a subsequent investigation,...

Differential diagnosis

As far as pSS cutaneous involvement is concerned, cutaneous xerosis is an extraordinarily common problem, especially in the elderly, affecting at least 75 of the population aged 64 and older. Moreover, besides from elderly xerosis, pSS xerosis has also to be differentiated from dry skin secondary to underlying malignancy, renal insufficiency, obstructive biliary disease, hypothyroid-ism and idiopathic conditions (Vivino, 2001). Cutaneous vasculitis differential diagnosis includes both secondary vasculitis, due to infective agents, drugs or malignancies, and primary systemic vasculitis (mainly Mixed Crioglobulinaemia) (Gonzalez-Gay et al., 2003). Finally, annular erythema has to be differentiated from sub acute cutaneous lupus erythematosus (Katayama et al., 1991).

Dermatology Is Both Medicine And Surgery

Certain dermatologists also perform medical and surgical skin rejuvenation procedures in the form of cosmetic dermatology. Medical rejuvenation involves the use of tretinoin, apha-hydroxy acids, and topical anti-oxidants for the treatment of age-related skin changes. Surgical rejuvenation procedures include Botulinum toxin injection, soft tissue augmentation, chemical peels, dermabrasion, sclerotherapy, and laser skin resurfacing. Many people, of course, have heard about Botox, a cosmetic treatment method that falls under the special expertise of dermatologists. This technique involves the injection of very tiny amounts of purified botulism toxin into a targeted facial muscle. The injection causes a nerve blockage and subsequent immobilization of the facial muscle paralysis of the muscle prevents wrinkling of the skin when the patient smiles or frowns.

Misperceptions About Dermatology

The recent surge of media attention on dermatologists who provide Botox injections and lotions in their practices has left the general public with additional misconceptions. Cosmetic dermatology actually plays a small role in the field of dermatology, with the majority of dermatologists' time being spent on medical or noncosmetic surgical procedures.

Dideoxycytidine ddC See zalcitabine dideoxyinosine ddl See didanosine

People with HIV are usually advised to take a multiple vitamin-mineral supplement that supplies the basic level of nutrients most important to body function. Many nutritionists believe that additional supplements are necessary. Symptoms that may be related to nutrient deficiencies and may be reversible with appropriate supplementation include serious fatigue, memory loss or other cognitive dysfunction, skin problems, neuropathy, weight loss, loss of the senses of smell or taste, appetite loss, muscle pain or cramps, digestive problems, night blindness, canker sores, constipation, depression anxiety, menstrual cramps, and menopausal problems. Many other symptoms in people living with HIV may be related to nutrient deficiencies.

Dermatologys Origins And Future Directions

Despite the growth of dermatologic specialization, primary care physicians are playing an increasing role in the treatment of dermatologic maladies. More than one quarter of Americans seen by their primary care physician have a skin-related complaint, and dermatologic disorders account for 6 of all chief complaints.5 Primary care physicians are becoming more comfortable in treating basic and uncomplicated dermatologic diseases such as acne and fungal infections. (The use of isotretinoin, which can cause birth defects, for the treatment of acne remains within the control of the dermatologists.) Many patients prefer dermatologists for these problems because they can offer patients advice on general skin care as well as prescribe medicine. Some dermatologists welcome the involvement of primary care physicians for basic needs and have consequently shifted

Adverse skin reactions to drugs

Antimalarials are generally well tolerated when compared with other disease-modifying drugs. In terms of cutaneous reactions, antimalarials can induce urticaria, pruritus (Holme et al., 1999), alopecia, hair bleaching, dry skin, pigment changes, rashes, flares of psoriasis, and exfoliating lesions (Vine et al., 1996), as well as a Stevens-Johnsonlike syndrome (Kutz and Bridges, 1995). Most patients continue HCQ therapy in the long term, but 3 discontinue HCQ because of adverse cutaneous reactions (Salido et al., 2002).

Why Consider A Career In Dermatology

Medical students interested in this specialty should not let the extremely competitive nature of the field dissuade them. It is a specialty that can lead to a very rewarding career in medicine. From the wide variety of skin problems to the different types of patients, dermatology is full of diversity. If you are seeking a high-pressured specialty with critically ill patients, then look elsewhere. In dermatology, the results of treatment are very visible and apparent to both the doctor and the patient. Unlike lowering blood pressure or treating diabetes, the effects of treating a skin disorder are obvious it will either go away or stay. Many medical students like this clearly defined aspect of dermatology, which applies to each step in the diagnosis, treatment, and prevention of skin diseases.

Results of Tendon Reconstruction

Evaluating the results of complex tendon reconstruction is difficult because the variables are too numerous (age of the patient procedures used type of injury accompanying nerve, bone, or vascular injuries and especially associated skin problems). We prefer the Tubiana classification system12 because it is based on proximal inter-phalangeal joint movement, which in our opinion displays the principal effect of the flexor tendon transfer. The arithmetical addition of degrees between extension and flexion compared with the hypothetical maximum amplitude, which does not distinguish between the metacarpophalangeal joint and the proximal inter-phalangeal or the distal interphalangeal joints, seems inadequate for this sort of salvage situation. Metacarpophalangeal joint movement is rarely altered substantially.

Spasmodic Torticollis

Spasmodic torticollis is a syndrome that usually affects adults, and is characterized by an involuntary turning of the neck to one side. At first, some people may not notice that the head and neck are turned, but eventually the continued turning in one direction can be painful. Treatment may include medications or an injection of Botox, a medication derived from botulinum toxin that can ease the condition by temporarily interfering with the nerve muscle interaction. Blepharospasm An involuntary problem in which the eyelids close intermittently. It may occur so often it interferes with vision. The preferred treatment is Botox injections.

Facial Plastics Reconstructive Surgery

Tic surgery (if interested in cosmetic and reconstructive surgery of the entire body). Facial plastics-reconstructive surgery is a very popular fellowship among graduating residents. It is typically 1 year in duration, and provides focused surgical training in cosmetic facial surgery (rhinoplasty, otoplasty, facelift, blepharoplasty, Botox injection, implants, facial peels and der-mabrasion, hair transplants, etc.), reconstructive surgery (Mohs defects, auricular reconstruction, pedicled and free-tissue transfer and microvascular anastamoses for larger head and neck defects following oncologic resection), and rehabilitative surgery for facial nerve paralysis (free graft and nerve transfers, facial slings, upper lid gold weight placement), and many other procedures. Certification in this subspecialty requires successful completion of a clinical facial plastics fellowship followed by passage of the rigorous written and oral facial plastics-reconstructive surgical board examinations.

Toxins That Attack Synaptic Function

There are many different neurotransmitters in various regions of the nervous system. Usually, each neuron makes and releases only one specific neurotransmitter. Many toxins act on neurotransmitters to interfere with normal synaptic transmission. In this manner these toxins have a neurotoxic action. Following is a discussion of the important neurotransmitter, acetylcholine, and several compounds that affect its action. These include botulinum toxin, nicotine, muscarine, curare, and atropine. Also discussed are biogenic amines as neurotransmitters and the impact of certain drugs of abuse, such as amphetamine, on their activity. Finally, several amino acids serve as neurotransmitters. The actions of strychnine and tetanus toxin as inhibitors of glycine neurotransmitter behavior are discussed as examples of toxins that affect the amino acid type of neurotransmitter.

Pathways of transdermal delivery

In normal skin, the lipid morphology plays an important role in the barrier function of the stratum corneum.15 For the absorption of macromol-ecules from the skin, the pore size of the skin becomes very important. The effective pore size of ethanol-pretreated human epidermal membrane has been estimated to be between 22 and 54 A.16 Once a drug has crossed the epidermis, it can enter the systemic circulation via the papillary plexus in the upper dermis. Many models assume that this is the end point for percutaneous absorption, but it should be realized that some molecules will bypass the circulation and diffuse deeper into the dermis.12

The effect of MAP on the nutritional quality of fresh fruits and vegetables

Vitamin C is one of the most important vitamins in fruits and vegetables for human nutrition. More than 90 of the vitamin C in human diets is supplied by the intake of fresh fruits and vegetables. Vitamin C is required for the prevention of scurvy and maintenance of healthy skin, gums and blood vessels. Vitamin C, as an antioxidant, reduces the risk of arteriosclerosis, cardiovascular diseases and some forms of cancer (Simon, 1992). Ascorbate oxidase has been proposed as the major enzyme responsible for enzymatic degradation of l-ascorbic acid (AA). The oxidation of AA, the active form of vitamin C, to dehydroascorbic acid (DHA) does not result in loss of biological activity since DHA is readily reconverted to l-AA in vivo. However, DHA is less stable than AA and may be hydrolysed to 2,3-diketogulonic acid, which does not have physiological activity (Klein, 1987) and it has therefore been suggested that measurements of vitamin C in fruits and vegetables in relation to their...

The Good in Bad Fish Tacos

A healthy 34-year-old woman presented to the local emergency department with severe vomiting and diarrhea 8 hours after eating what she thought might be a bad fish taco at an outdoor taco stand at the local county fair. She was given fluids and supportive care. The vomiting and diarrhea resolved within 24 hours, and during the course of her hospital stay Clostridium botulinum was isolated from her stool.

Sports and Musculoskeletal Medicine

Physiatrists can subspecialize in the diagnosis and treatment of sports-related injuries or musculoskeletal problems. They primarily manage musculoskeletal diseases but are still very knowledgeable in general primary care-type sports medicine. These subspecialists also receive training in electrodiagnostic studies, trigger point injections, fluoroscopically guided spinal injections, acupuncture, and the use of botulinum toxin therapy. Their patients are athletes, workers, or any individuals with chronic disability.

Common Bioengineering Techniques Erythema Quantification Skin Color Reflectance

The color of the skin, and of any object, depends on the wavelength of the light and the optical characteristics of the surface. Different chromophores, mainly hemoglobin and melanin in healthy skin, absorb different wavelengths of light. Detailed insight into the complex optical principles of the skin and chromophores is provided by Pierard and by Kollias (11,12). Measurement of skin color reflectance is a suitable method for erythema quantification in addition to clinical assessment. It has been applied frequently in the grading of contact dermatitis and irritant and allergic patch-test reactions (13). Its value has also been proven in studies on the vulvar skin with respect to erythema quantification in irritant contact dermatitis (7). Skin color reflectance is especially suitable for serial measurements and also can be used for ethnic skin (14,15). However, the sensitivity of an experienced dermatologist's eye may still be superior to instrumental erythema quantification (12).

Cutaneous Blood Perfusion Laser Doppler Flowmetry

The laser Doppler flowmetry (LDF) is an excellent noninvasive technique for monitoring cutaneous blood perfusion. As an early indicator of inflammation and changes in the microcirculation, LDF has been applied in many fields of clinical medicine and dermatology in healthy skin as well as in inflammatory diseases (17), and also for research purposes in the vulvar skin (5,8,18,19). Monochromatic, coherent light is emitted onto the skin and reflected at different wavelengths by the tissue and by the moving red blood cells in small vessels. The reflected light is detected photoelectrically and a dimensionless output signal is generated, which is proportional to the red blood cell flow. The signal is then processed in a personal computer, and the perfusion level can be displayed and

The Effect Of Other Chemical Reactions

In meat curing, nitrite is traditionally used for developing the pink, heat-stable pigment. Its other important role is the inhibition of the outgrowth of Clostridium botulinum spores in pasteurized products and, in some countries, in several types of smoked fish. Nitrite also serves as an antioxidant and contributes positively to the development of the flavor of cured-meat. The undesirable side-effect, however, is the reaction of nitrite with amino groups of food constituents, leading to the formation of NNCs.

Flexible upper gastrointestinal endoscopy

Obstruction caused either by gastro-oesophageal tumours or by benign strictures can be relieved by dilatation using balloon or rigid dilators, and plastic or metal stents can then be introduced to maintain patency of the lumen. Pneumatic dilatation or endoscopic injection of botulinum toxin into the lower oesophageal sphincter may relieve obstruction caused by achalasia.

Bioengineering Methods Of Assessment

Visual inspection and scoring of vulvar irritation reactions may lack the sensitivity to recognize all cases of vulvar skin irritation, including low-grade dermatitis. The visual scoring system ranges from 0 to 4 normal skin, 0 slight redness, spotty or diffuse, 1 moderate, uniform redness, 2 intense redness, 3 and fiery erythema and edema, 4 (4,16). Various bioengineering instruments have enabled scientists to ascertain the vulva's unique skin characteristics objectively.

Sixth disease See roseola

For example, superfatted soaps contain excess fatty material and leave an oil residue on the skin, which is designed to improve mildness. Transparent soaps contain glycerin and varied amounts of vegetable fats. other soaps may be produced for specific purposes, such as oatmeal soap for skin that tends to break out. The choice of a proper soap demands on the child's age, skin texture, skin problems, and personal needs. All soaps are good at cleansing, but because of age, heredity, climate, and skin texture, there are many different methods of proper skin cleansing.

Perineal Hygiene Among Older Women

Tinea Tinea is a fungal infection of the feet, nails, and vulvar skin folds. Though a rare condition, its prevalence rises in older women because of diminished cellular immune responses (177). The most characteristic presentation is a ring-shaped eruption with an actively advancing border and scaly, healing center. However, any pruritic, scaly eruption of the vulva is suspect it should be scraped for microscopic examination and treated with antifungal therapy, if appropriate. Maintaining dry skin helps prevent this condition. Although no systematic trials exist on the impact of perineal hygiene on skin health, general guidelines have been developed for preventive care (184,185). The focus is on keeping the skin dry, maintaining a healthy skin pH, avoiding mechanical forces, and minimizing contact with urine and feces. The use of specially formulated perineal skin cleansers or disposable wipes is preferred over bar soap and a washcloth. The former avoid the high pH of most soap bars...

Meat and micronutrients 9111 Iron in meat

Thiamin and riboflavin are found in useful amounts in meats. Pork and its products including bacon and ham are one of the richest sources of thiamin. Pork contains approximately 5-10 times as much thiamin as do either beef or lamb. Thiamin aids the supply of energy to the body by working as part of a coenzyme that converts fat and carbohydrates into fuel. It also helps to promote a normal appetite and contributes to normal nervous system function. Typical servings of pork provide all the daily requirement of thiamin. Offal meats are good sources of riboflavin, for example, a single portion (100 g) of kidney or liver provides more than the daily requirement. Riboflavin, like thiamin, aids in supplying energy and also promotes healthy skin, eyes and vision.

Diagnostic investigations

Linear Scleroderma Hands

Among the first and most effective measures to be taken are skin care as dryness of the skin should be reduced by avoiding detergent soaps and by application of bath oils. Fingertip ulcerations may heal faster with the use of hydrocolloid membranes. They should be kept clean, which may require intermittent debridement.

Differential Diagnosis of Hyponatremia

Clinically, hyponatremia is often classified into three basic types depending on the ECF status of the patient (Table 11.1). Thus, a careful physical exam to assess the patient's volume status is critical. The exam should note signs of either excess volume (recent weight gain, edema, swelling) or decreased ECF (dry skin and mucous membranes, lack of skin targor, and flat jugular veins). Appropriate laboratory tests to help differentiate the hyponatremia include serum and urine electrolytes, serum and urine osmolality, and thyroid and adrenal hormones.

Eczematous And Papulosquamous Vulvar Dermatoses Contact Dermatitis Irritant andor Allergic

It is essential to restore the normal skin barrier and protect the skin from additional injury. Treatment begins with identification and withdrawal of the offending substance. To prevent recurrence, careful documentation of possible irritants or allergens is necessary. Women with vulvar dermatoses should be patch tested to define or rule out disease-causing agents (11).

The Skin as an Immunologic Organ

Are enclosed within an insoluble amalgam of proteins, crosslinked by transglutaminases and surrounded by a lipid envelope (Candi et al., 2005). Multiple sheets of ceramides and sphingolipids are generated by keratinocytes and discharged into the extracellular space. For this reason, molecules larger than 500 Da cannot easily penetrate into the normal skin, penetration of larger molecules can occur if they are lipophylic or if the skin is damaged (e.g., chronic or acute eczema) (Bos and Meinardi, 2000). The stratum corneum acts also as a biosensor, and can transfer information to the underlying living epidermal cells.

Description Of The Diseases

FIGURE 41.1 Anatomy of the normal skin (reprinted with permission from Wagner and Sohnle, 1995, Clin. Microbiol. Rev. 8, 317-335, American Society for Microbiology). FIGURE 41.1 Anatomy of the normal skin (reprinted with permission from Wagner and Sohnle, 1995, Clin. Microbiol. Rev. 8, 317-335, American Society for Microbiology).

Allergic Contact Dermatitis

In order to take into account the vulvar skin's increased permeability to potential allergens, a modified human repeat insult patch test (HRIPT) was developed. Standard patch testing, not repeat insult patch testing, involves the application of possible allergens to the normal skin of the back for two days under occlusion with readings taken at days 2 and 4 (24). The original HRIPT involved nine 24-hour applications of patches with 24-hour rest periods in between during the induction phase. The modified HRIPT increased the cumulative exposure duration by 67 , by increasing the number of applications to fifteen 24-hour patch applications (24 hours daily for five days, for three weeks). This increases the sensitivity of the HRIPT to evaluate sensitization in specialized skin, such as the vulva. It is important to maintain the rest periods in the induction phase to increase the effectiveness of the test. Also, the five-day repeated steps parallel use of some products that contact vulvar...

Bacterial Foodborne Pathogens

Clostridum botulinum C. botulinum is a gram-positive, spore-forming, toxin-producing, obligate anaerobe. Its natural habitat is soil and, therefore, its spores are frequently present on fresh fruits and vegetables. The disease associated Clostridium botulinum Staphylococcus aureus Bacillus cereus with ingestion of the toxins from C. botulinum is known as botulism. There are seven antigenically distinct types of botulinus toxin, each of which is designated by a letter (A-G). Types A, B, E, F, and G are the ones that are associated with human disease, with type A accounting for about 25 of outbreaks and type B 8 , although some regionality is seen with the various types within the United States. Botulinus toxin is heat-labile (5 minutes of boiling will destroy the toxin) and is produced at any temperature in which bacterial growth occurs. The majority of outbreaks have been traced to home-produced foods, especially vegetables, fish, fruits, and condiments. Commercial food sources are...

Toxic Substances From Bacteria

The most notorious toxin produced by bacteria outside the body is that of Clostridium botulinum. This kind of bacteria grows naturally in soil and on vegetable material. Under anaerobic or slightly aerobic conditions, it synthesizes an almost unbelievably toxic product. The conditions for generating this toxin most commonly occur as the result of the improper canning of food, particularly vegetables. Botulinum toxin binds irreversibly to nerve terminals, preventing the release of acetyl-choline the affected muscle acts as though the nerve were disconnected. The toxin actually consists of several polypeptides in the range of 200,000 to 400,000 molecular mass. Fortunately, these proteins are inactivated by heating for a sufficient time at 80 to 100 C. Botulinum poisoning symptoms appear within 12 to 36 h after ingestion, beginning with gastrointestinal tract disorders and progressing through neurologic symptoms, paralysis of the respiratory muscles, and death by respiratory failure.

The Role of Leukocytes

The involvement of leukocytes in CVI pathology requires leukocyte endothelial signaling for the cells to extravasate and enter the dermal tissue. A study evaluating changes in adhesion molecules in patients with severe lipodermatoscle-rosis and active ulceration by immunohistochemistry of biopsies adjacent to ulcerated skin demonstrated that increased expression of intracellular adhesion molecule-1 and vascular cell adhesion molecule-1 was present. In addition, the expression of leukocyte function-associated antigen-1 and very late activated antigen-4 was increased dramatically on perivascular leukocytes compared to healthy skin indicating that the upregulation of adhesion molecules in CVI patients are important mediators toward facilitating leukocyte endothelial adhesion, activation, and transendothelial migration.26

Borrel body See Bollinger bodies

Botox Proprietary name for Botulinum toxin type A, injected into the skin as a temporary treatment to make lines on the face less apparent. botulinolysin Cholesterol-binding toxin from Clostridium botulinum. botulinum toxin Neurotoxin (50 kDa seven distinct serotypes) produced by certain strains of Clostridium botulinum. The bacterium produces the toxin as a complex with a haemagglutinin that prevents toxin inactivation in the gut. Proteolysis in the body results in cleavage into two fragments A and B B binds to gangliosides and may stimulate the endocytosis of fragment A. The extremely high toxicity is due to the blockade of cholinergic synapses through inhibition of vesicle exocytosis. See Botox, botuli-nus toxin C2, C3, synaptobrevin, tetanus toxin. botulinus toxin C2 Binary toxin with binding subunit (100 kDa) and enzymatic subunit (50 kDa) that ADP-ribosylates monomeric G-actin and blocks the formation of microfilaments. Produced by C and D strains of Clostridium botulinum....

Preulcerative Cutaneous Changes

When skin at the border of chronic venous insufficiency is compared to normal skin in the same individual, the strong expression of ICAM-1 is seen in addition to a dense infiltration by T lymphocytes and macrophages. In some instances, the tissue also is infiltrated by an increased number of mast cells.14 This is the typical picture of a chronic inflammatory reaction with an upregulation of endothelial adhesion molecules and dermal infiltration by T lymphocytes and macrophages in the skin of patients with CVI.

The effect of ohmic heating on nutrient loss thermal destruction

The benefit of attaining food safety with less nutrient degradation using HTST processes such as ohmic heating or microwave heating is based on differences in the kinetics parameters (k, z, Ea) for bacterial spores compared to those for biochemical reactions.28 First, rate constants for microbial destruction are usually much larger than those for the chemical reactions responsible for nutrient degradation, and second, rate constants for microbial destruction are usually more sensitive to temperature increases (z(thiamin) 48, z(peroxidase) 36.1, and z(C. botulinum) 10 C).29 Methods for rapidly reaching the target temperatures therefore tend to destroy microorganisms while giving less time to compromise the nutrient content and other quality attributes.26,30 In fact, the slow heating rate associated with conventional retorting can activate protease to degrade myofibrillar proteins before the protease is eventually heat-inactivated.31 Tests for conventional heating showed9 that heating...

Dermal Fibroblast Function

Several studies have reported aberrant phenotypic behavior of fibroblasts isolated from venous ulcer edges when compared to fibroblasts obtained from ipsilateral thigh biopsies of normal skin in the same patients. Hasan et al. compared the ability of venous ulcer fibroblasts to produce I procollagen mRNA and collagen after stimulation with TGF-Pj.63 These authors were not able to demonstrate differences in I procollagen mRNA levels after stimulation with TGF-Pj between venous ulcer fibroblasts and normal fibroblasts (control) from ipsilateral thigh biopsies. However, collagen production was increased by 60 in a dose-dependent manner in controls whereas venous ulcer fibro-blasts were unresponsive. This unresponsiveness was associated with a four-fold decrease in TGF-Pt type II receptors. In a follow-up report, Kim et al. indicated that the decrease in TGF-Pt type II receptors was associated with a decrease in phosphorylation of the TGF-Pt receptor substrates SMAD 2 and 3 as well as p42...

Therapeutic Applications Of Exotoxins

Botulinum toxin and tetanus toxin (BT TT) are each a single protein that is organized as an AB exotoxin. The amino terminus of BT TT expresses endopepti-dase activity and constitutes the A domain, whereas the B domain possesses neuronal cell-specific receptor-binding activity. The specific association of the B domain with neuronal cells is responsible for the clinical manifestation of these neurotoxins. BT TT appear to enter neuronal cells by receptor-mediated endocyto-sis and to deliver the A domain to the cytosol, where it catalyzes the endoproteolytic cleavage of host proteins that are involved in vesicle fusion. Studies have shown that botulinum toxin can be introduced into the muscles surrounding the eye to temporarily reduce muscle spasms associated with several clinical disorders.

Pseudomonas aeruginosa P pyocyanea A

The cause of psoriasis is unknown, although researchers believe that some type of biochemical stimulus triggers the abnormal cell growth in the skin. While normal skin cells take a month to mature, patients with psoriasis have skin cells that over-multiply, forcing the cells to move up to the

Diseases That Cause Vulvar Pain Vulvar Vestibulitis

Vulvar Vestibulitis

Treatment strategies include applying a low-to-moderate-potency topical steroid ointment to decrease the inflammatory response. In addition, following strict vulvar skin care hygiene practices and using lukewarm water soaks of either baking soda or colloidal oatmeal help decrease inflammation and provide symptom relief. For some patients, the addition of oral calcium citrate daily in conjunction with a low-oxalate diet has proven helpful (26). Other non-steroidal options to help decrease the inflammatory response and T-cell function include an immune suppressor such as tacrolimus ointment, but the efficacy has not been documented. Numerous other topical medications have been used, such as estrogen cream and lidocaine gel, and other treatment modalities such as surgery and laser ablation have been employed for treatment as well (27). It is the authors' experience that vulvar vestibulitis disease is self-limiting and, thus, conservative management best serves the patient.

Toxins from sea creatures

A related sea creature, the sea wasp, is particularly dangerous and has been responsible for several deaths in Australia. Other sea creatures can be unexpectedly poisonous, for example cone snails which produce cono-toxins. Like tetrodotoxin and saxitoxin (see pp. 252-3), conotoxins stop the movement of ions such as sodium, potassium, and calcium, hence affecting the function of both nerves and muscles. Even humble seaweed can contain toxins, and that found in the Death Sea weed from the Caribbean and Hawaii, which is called palytoxin, is especially potent, being one of the most poisonous substances known. Based on the lethal dose in a mouse, the lethal dose in a human would be about 9 g. Although this is more than ten times the lethal dose of botulinum toxin, it is still extremely poisonous. The toxin works by creating pores in the membranes of nerves, allowing ions to flow in or out, which changes the electrical activity of nerves. It also causes red blood cells to rupture by...

Types of food additives

Some additives clearly serve an important function. Preservatives help to prevent food from spoiling and enable processed food to be stored for much longer. They reduce the likelihood of bacterial contamination in the food we eat. Sodium nitrite is added to cured meat, for example, to prevent the growth of organisms like Clostridium botulinum, which causes severe toxicity, botulism (see pp. 249-51). Preservatives also reduce chemical degradation and so allow food to have a longer shelf life. Other additives may also have a beneficial function, for example artificial sweeteners reduce the sugar intake of people who suffer from diabetes or obesity.

Alterations in Extracellular Remodeling and the Wound Fluid Environment

The abnormalities in structure and healing process seen in lipodermatosclerotic skin have also been attributed to MMP pathophysiology. A study where dermal biopsies were obtained from liposclerotic skin and compared to healthy skin and analyzed by immunohistochemistry, reverse tran-scriptase polymerase chain reaction, immunoblot, and zymography found that lipodermatosclerotic skin had increased expression of mRNA and protein for MMP-1, MMP-2, and TIMP-1, and increased levels of active MMP-

Dermatitis seborrheic

Dermatitis, seborrheic An extremely common form of eczema that causes scaling around the nose, ears, scalp, mid-chest, and along the eyebrows. There may be psoriasis-like plaques and secondary infection as a result of scratching. It is often misdiagnosed by non-physicians as simply dry skin. However, the flaking caused by this type of dermatitis is not caused by dryness.

Specialist Treatment of Essential Tremor

Botulinum toxin is another option for ET and is usually of greater benefit for tremor of the head or voice compared to its limited effectiveness for the upper limb. For ET of the head, botulinum toxin is most effective when the movement is horizontal. For ET of the voice, it can be injected into the vocal cords although this may cause mild, transient hypophonia or dysphagia, these problems usually resolve within several weeks after the injection. The beneficial effect tends to wane after four months, requiring a repeat injection. Only an experienced practitioner should inject botulinum toxin.

Autism Society of America Foundation ASAF

Aveeno bath A range of moisturizers, cleansers, and bath additives that are formulated from oatmeal, which has been used for centuries for its natural, soothing anti-itching action. All Aveeno products are specially formulated for dry and sensitive skin, and they are particularly effective in helping to relieve the itch associated with many skin conditions such as chicken pox, hives, rashes, psoriasis, poison ivy, and so on. Aveeno products are safe for children and babies.

Erosive Lichen Planus

Treatments for lichen planus include removing contact irritants and following the vulvar skin care hygiene guidelines thoroughly. Low-to-high-potency steroid ointments applied to the vulva and vaginal creams suppositories have been proven effective (29). In addition, recent case reports have shown that 0.1 tacrolimus (Protopic , Astellas Pharma U.S., Inc., Deerfield, IL, U.S.A.) or 0.1 pime-crolimus (Elidel , Allergan, Inc., Irvine, CA, U.S.A.) are also effective (30,31).

Pathogenicity Versus Latency

Antonsson, A., and Hansson, B.G. (2002). Healthy skin of many species harbours papillomaviruses, which are closely related to their human counterparts. J. Virol. 76 12537-12542. Antonsson, A., Erfurt, C., Hazard, K., Holmgren, V., Simon, M., Kataoka, A., Hossain, S., Hakangard., C, and Hansson, B.G. (2003). Prevalence and type spectrum of human papillomaviruses in healthy skin samples collected in three continents. J. Gen. Virol. 84 1881-1886.

Radiationresistant Microorganisms

In contrast to natural forms of relatively low-level radiation, microorganisms may be exposed to intense sources of radiation in the form of 7-irradiation (60Co and 137Cs) as a means of sterilization or by being in close proximity to nuclear reactors. It is mainly these forms of radiation that have been the sources of highly radiation-resistant extremophiles. The most well-studied of these is the bacterium Deinococcus radiodu-rans, which was first isolated in 1956 from tins of meat that had been irradiated with 7-rays. Although some microorganisms escape radiation damage by forming spores (e.g., Clostridium botulinum), D. radiodurans is resistant while in the exponential growth phase. The degree of resistance of these cells is illustrated by their ability to survive 3,000,000 rad, a dose that is sufficient to kill most spores (a lethal dose for humans is about 500 rad). As a consequence of the extreme radiation resistance of D. radiodurans and other microorganisms, biocides are...

Further Readings

F., Blitzer, A., and Stewart, C. (1998). Laryngeal dystonia (spasmodic dysphonia) Observations of 901 patients and treatment with botulinum toxin. Advances in Neurology, 78, 237-252. Brin, M. F., Stewart, C., Blitzer, A., and Diamond, B. (1994). Laryngeal botulinum toxin injections for disabling stuttering in adults. Neurology, 44, 2262-2266. Davidson, B., and Ludlow, C. L. (1996). Long term effects of botulinum toxin injections in spasmodic dysphonia. Otolaryngology-Head and Neck Surgery, 105, 33-42. Jankovic, J. (1987). Botulinum A toxin for cranial-cervical dystonia A double-blind, placebo-controlled study. Neurology, 37, 616-623. Lange, D. J., Rubin, M., Greene, P. E., Kang, U. J., Mosko-witz, C. B., Brin, M. F., et al. (1991). Distant effects of locally injected botulinum toxin A double-blind study of single fiber EMG changes. Muscle and Nerve, 14, 672-675. Ludlow, C. L. (1990). Treatment of speech and voice disorders with botulinum toxin. Journal of the American Medical...


Botulism toxins are a type of neurotoxin that attaches to the nerves, blocking the messages that are sent to the muscles. The C. botulinum spores (latent form of the bacteria) are found in air, water, and food they are harmless until deprived of oxygen (such as inside a sealed can or jar). If conditions are favorable, the spores will start to generate and multiply, producing one of the most deadly toxins known seven million times more deadly than cobra venom. Botulism can also occur if the C. botulinum bacteria in the soil enters the body through an open wound, although this is extremely rare.


The incidence of congenital hypothyroidism (cretinism), in iodine-sufficient countries, is approximately one in 4000 births and may be associated with the most severe neuropsychological abnormalities.1 This high incidence has resulted in the institution of neonatal screening programs in many developed countries. Clinical features include feeding problems, hypotonia, umbilical hernia, constipation, enlarged tongue, dry skin, characteristic facies, and open posterior fontanelle. On radiological examination, poor skeletal maturation can be seen as retardation in the appearance of ossification centers. Failure to institute early treatment with thyroid hormone leads to significant brain damage. Even with early therapy, there may still be a residual effect to lower the intelligence quotient.

Diaper rash 147

While babies vary in their susceptibility to diaper rash, skin inflammation in some infants can be severe. In general, breast-fed babies have a lower incidence of diaper rash than bottle-fed babies, and the resistance continues long after the baby has been weaned. In some infants, diaper rash is the first indication of sensitive skin heralding a long series of later skin problems, such as eczema.

Dioxin TCDD

Has no known uses, it is simply a contaminant. There is no doubt that it is the most poisonous substance produced by human activity. It is not, however, the most toxic chemical known (this dubious honour is reserved for the plant product ricin, closely followed by botulinum toxin, which is produced by a bacterium see pp. 151-2, 249-51).

Skin Symptoms

In many cases the skin exhibits evidence of exposure to toxic substances. The two main skin characteristics observed as evidence of poisoning are skin color and degree of skin moisture. Excessively dry skin tends to accompany poisoning by tricyclic antidepressants, antihistamines, and belladonna alkaloids. Among the toxic substances for which moist skin is a symptom of poisoning are mercury, arsenic, thallium, carbamates, and organophosphates. The skin appears flushed when the subject has been exposed to toxic doses of carbon monoxide, nitrites, amphetamines, monsodium glutamate, and tricyclic antidepressants. Higher doses of cyanide, carbon monoxide, and nitrites give the skin a cyanotic appearance (blue color due to oxygen deficiency in the blood). Skin may appear jaundiced (yellow because of the presence of bile pigments in the blood) when the subject is poisoned by a number of toxicants, including arsenic, arsine gas (AsH3), iron, aniline dyes, and carbon tetrachloride.


As a child gets older, the location of symptoms tends to change. In infants and young children, the dry skin is usually located on the face, outside of the elbows, and on the knees. In older children and adults, eczema tends to be on the hands and feet, the front of the arms, and on the back of the knees.

Bad to the Bone

A 26-year-old woman with a history of end-stage renal disease (ESRD) and congestive heart failure (CHF) secondary to Goodpasture's syndrome that was diagnosed 6 years ago, presented to her physician with a 6 week history of worsening skin problems. The patient had been receiving dialysis 3 times per week for 3 years. Additionally, she had been on vitamin D therapy for the past 6 months for suspected renal osteodystrophy. For the past 6 weeks the patient described induration and darkening of the skin on her inner thighs and abdomen, which had progressed. She now had necrotic tissue and decomposition of the eschar of both inner thighs and her abdomen, which were intensely painful. The patient denied any recent fever.


Later in the book I shall deal with one of the most toxic substances known, botulinum toxin, derived from the bacterium Clostridium botuli-num, which is occasionally found in food. A related bacterium, Clostridium perfringens, also produces a nasty toxin, called alpha toxin. Like Clostridium botulinum, the bacteria cannot live in the presence of air. The spores are found in soil and even in our intestines, but if they get into a deep wound, where oxygen is absent, they can infect it and cause gas gangrene. The toxin is an enzyme that destroys cell membranes. It is a particularly ingenious bacterium because it targets the immune system and the blood supply so as to reduce the supply of blood, and therefore oxygen, to the infected tissue. It improves its own chances of survival by making the environment conducive to it and by reducing the ability of the immune system to remove it.

Botulin Toxins

C. botulinum toxins belong to the AB group of toxins, which also includes diphtheria toxin, pseudomonas exotoxin A, anthrax toxin, Shiga(like) toxin, cholera toxin, pertussis toxin, and plant toxins, e.g., ricin. Moiety A has an enzymatic activity and usually modified cellular-target entering cytosol. Moiety B consists of one or more components and binds the toxin to surface receptors, and is responsible for translocation of the A component into cells. AB toxins are produced in a non-active form and are activated by a split between two cysteine residues within a region (Falnes and Sandvig, 2000). toxins affecting vesicular membrane and fusion apparatus which include neurotoxins of a specific metaloprotease character, seven types of C. botulinum neurotoxins (BoNTs) and one type of C. tetani neurotoxin (TeNT). toxins affecting actin cytoskeleton assembly (ADP-ribosyltransferase) which include C2 and C3 toxins produced by C. botulinum types C and D, C3 exoenzyme of C. botulinum types C...

CLI See clusterin

Clostridium Genus of Gram-positive anaerobic spore-forming bacilli commonly found in soil. Many species produce exotoxins of great potency, the best known being C. botulinum and C. tetani. Among the toxins produced by C. perfringens are perfringolysin (theta toxin), an alpha-toxin (phospholipase C), beta, epsilon and iota-toxins (act on vascular endothelium to cause increased vascular permeability), delta-toxin (a haemolysin) and kappa toxin (a collagenase).


Ichthyosis A family of at least 20 rare skin disorders characterized by dry, thickened rough, scaling, darkened skin triggered by too much keratin (the main protein component of skin). This group of genetic diseases ranges from mild generalized dry skin (ichthyosis vulgaris) to severe widespread thickened scaly dry skin (lamellar ichthyosis). The disorder's name is derived from the Greek word ichthus meaning fish because the appearance and condition of the skin resemble fish scales. It affects more than one million Americans.


Specific treatment of itching depends on the underlying cause, but in general cooling lotions such as calamine can ease the itch and irritation of the skin. Emollients can reduce skin drying and ease itching for those with dry skin. Soothing lukewarm baths in colloidal oatmeal or Aveeno bath can ease the itch caused by hives or skin rashes such as chicken pox or poison ivy.


Often, a laryngologist sees patients with a speech and language pathologist, who assists in the initial fiberoptic evaluation of the upper aerodigestive tract and larynx. Temporary medialization of the paralyzed vocal cord and Botulinum toxin injections for spastic vocal cords are two common office-based laryngologic procedures. Common surgical cases include endoscopic and microsurgical evaluation and dissection of laryngeal polyps, nodules, and other lesions laser surgery of laryngeal lesions and webs permanent medialization procedures for vocal cord paralysis and resection of laryngeal cancer, both endoscopically and via the neck in larger tumors.

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