INTRODUÇÃO: A paralisia facial de longa duração cursa com déficit funcional e estético, responsáveis por distúrbios psicológicos e prejuízo na qualidade de vida. Mesmo técnicas cirúrgicas modernas de reanimação conseguem restabelecer apenas parcialmente a movimentação emocional e a simetria entre as hemifaces. A toxina botulínica tipo A provoca paralisia muscular flácida reversível, corrigindo desequilíbrios entre músculos agonistas hipoativos e antagonistas relativamente hiperativos. Não há na literatura séries padronizadas com mais de 10 pacientes com paralisia facial tratados por meio da aplicação de toxina botulínica no lado são a fim de obter maior simetria na dinâmica facial na região da boca. MÉTODOS: Este estudo prospectivo teve como objetivo avaliar o efeito do tratamento adjuvante com toxina botulínica no lado são de 25 pacientes com paralisia facial de longa duração, previamente tratados cirurgicamente. O tempo de seguimento foi de 6 meses. Foram métodos de avaliação escala clínica padronizada, grau de satisfação do paciente, Índices de Função Física (IFF) e de Bem-Estar Social (IBES) e eletromiografia de superfície. A dose total de toxina botulínica variou de 15 a 69 U, média 37,9 ± 5,4 U. Dezesseis pacientes apresentaram efeitos adversos com duração média de 14,1 ± 7,3 dias, incluindo dificuldade para articular palavras, beber, mastigar e se adaptar à redução do sorriso. RESULTADOS: 1) Houve redução significante da assimetria entre as hemifaces, de 48,4% após 1 mês e 16,8% aos 6 meses. O ganho de simetria após 1 mês ocorreu em decorrência da diminuição do movimento do lado são, combinada à melhora da avaliação do lado paralisado. Aos 6 meses, com a perda do efeito clínico da toxina botulínica, a nota do lado são voltou a ser semelhante à do pré-tratamento. A redução de assimetria nessa fase ocorreu devido à melhora significante do lado paralisado em relação ao pré-tratamento. 2) A avaliação subjetiva do paciente em relação à simetria apresentou aumento significante, 1 mês e 6 meses em relação ao pré-tratamento. 3) Houve aumento do IFF ao longo do tempo, porém não significante. O IBES apresentou aumento significante aos 6 meses, comparado ao pré-tratamento. 4) Um mês após a aplicação, o efeito da toxina botulínica levou à diminuição significante do potencial de ação do lado não-paralisado. Após 6 meses, o valor voltou a ser semelhante ao do pré-tratamento. CONCLUSÕES: O tratamento proposto permitiu, com técnica minimamente invasiva, obter melhor simetria facial estática, evidenciada pela posição do ângulo da boca, do filtro labial, dos sulcos nasogenianos, do nariz e do supercílio, e melhor simetria dinâmica, principalmente ao sorrir, falar, na exposição dos dentes e na movimentação facial como um todo. Mesmo após a perda do efeito clínico da droga aos 6 meses, houve 18% de melhora da avaliação clínica do lado paralisado em relação ao pré-tratamento, e melhora dos índices de satisfação e qualidade de vida dos pacientes. / INTRODUCTION: Long-standing facial paralysis presents with functional and aesthetic deficits, which are responsible for psychological disturbances and life quality impairment. Even after modern facial reanimation surgical techniques, the emotional movement and the symmetry of the hemifaces is only partially restablished. Botulinum toxin type A causes reversible flacid muscle paralysis, thus correcting imbalances among hypoactive agonists and relatively hyperactive antagonists. There are no standardized series in the literature with more than 10 facial paralysis patients treated with botulinum toxin injection in the non-paralysed side in the mouth area, with the objective of obtaining better dynamic facial symmetry. METHODS: This prospective study had the objective of evaluate, with 6 months follow-up, the effects of the adjuvant treatment using botulinum toxin in the healthy hemiface of 25 patients with long-standing facial paralysis, previously treated surgically. The methods of evaluation were a standardized clinical scale, the patients degree of satisfaction, the Physical Function and Social/well-being Function subscales of the Facial Disability Index and surface electromyography. Total botulinum toxin dose varied from 15 to 69 U, mean 37,9 ± 5,4 U. Sixteen patients presented adverse effects with mean duration time 14,1 ± 7,3 days, including difficulty in speaking, drinking, eating and adapting to the reduced smile. RESULTS: 1) There was significant reduction of facial asymmetry, of 48,4% at 1 month and of 16,8% at 6 months post-treatment. The better symmetry 1 month post-treatment was consequent to reduced movement on the non-paralysed side combined to better evaluation on the paralysed side. At 6 months, the non-paralysed side had similar grading than that of pre-treatment, showing absence of clinical effect of the toxin. At this time, the asymmetry reduction was due to significant increase in the evaluation of the paralysed side in relation to the pre-treatment. 2) Patients satisfaction with facial symmetry showed significant increase, 1 month and 6 months post-treatment. 3) The Physical Function Index increased, but not significantly. The Social/well-being Function Index showed significant increase at 6 months compared to pre-treatment. 4) There was significant decrease in the action potential of the non-paralysed side one month post-injection of the botulinum toxin. After 6 months, the value returned to baseline. CONCLUSIONS: The proposed treatment allowed, with minimally invasive technique, better facial symmetry at rest, evidenced by better mouth, nose and brow position, and on facial movement as a whole, especially when smiling, speaking or exposing teeth. Even after the loss of the clinical effect of the drug at 6 months, there was an 18% increase in the clinical evaluation of the paralysed side in relation to pre-treatment, and increase in the satisfaction and quality of life indexes.

Notre objectif était de rechercher une méthode d’évaluation musculaire afin de déterminer des facteurs de non réponse tissulaire à une injection de toxine botulique (TB) dans un muscle spastique, chez l’adulte post AVC et chez l’enfant paralysé cérébral (PC). Une étude de reproductibilité et 3 revues systématiques de la littérature ont été réalisées. Les mesures échographiques de l’épaisseur et de l’angle des pennation des fibres du muscle gastrocnémien médial en 2D sont reproductibles. La mesure du module d’élasticité par Shear Wave Ultrasound Elastography délivre une information fiable sur la rigidité du muscle gastrocnémien médial spastique au repos.L’analyse du devenir du muscle post-injection rapporte que la TB participe au remodelage du muscle spastique avec une atrophie persistante, répétition d’injections dépendante.L’étude de l’impact des traitements adjuvants à la TB chez l’enfant PC montre que le renforcement musculaire intensif, y compris des muscles injectés, permet de lutter contre l’atrophie sans renforcer la spasticité. Les plâtres d’allongement permettent d’optimiser le fonctionnement articulaire mais les preuves sur la diminution de la raideur musculaire restent faibles. Dans la description des facteurs pronostics d’efficacité, plus de la moitié des patients identifiés comme secondairement non-répondeurs à la TB dans la spasticité des membres ne sont pas immunisés contre la TB. Les anticorps neutralisants ne sont donc pas la principale cause de non-réponse secondaire. Une évaluation de la qualité musculaire échographique comme facteur pronostic de réponse à la TB et pour mesurer l’impact des traitements adjuvants devrait être réalisée régulièrement afin de déterminer à quel moment ces traitements ne sont plus favorables au système musculaire. / The aim was to investigate a muscle evaluation method to determine tissue factors leading to non-responsiveness to an injection of botulinum toxin (BTX) into a spastic muscle in adult post stroke and children with cerebral palsy (CP). A reproducibility study and 3 systematic literature reviews were carried out. 2D ultrasound measurements of thickness and pennation angle of medialis gastrocnemius muscle fibers are reproducible. Measurement of the modulus of elasticity by shear wave ultrasound elastography provides a reliable information about the rigidity of the spastic medial gastrocnemius muscle at rest.Analysis of the post-injection muscle fate found that BTX participates in the remodeling of the spastic muscle with persistent atrophy that is dependent on the repetition of the injections.Analysis of the impact of BTX adjuvant therapies in CP children showed that intensive muscle strengthening, including of the injected muscles, may help combat atrophy without increasing spasticity. Stretching casts are used to optimize joint function, but there is little evidence for a reduction in muscle stiffness. In the description of prognostic efficacy factors, more than half of patients identified as secondariy non-responders to BTX in limb spasticity tests were not immunized against BTX. Neutralizing antibodies were therefore not the main cause for secondary non-responsiveness. An ultrasound evaluation of muscle quality as a prognostic factor for BTX response and to measure the impact of adjuvant treatments must be regularly performed to determine when these treatments are no longer favourable for the muscle system.

Un 1er travail a étudié les effets osseux mandibulaires de l’injection unilatérale dans les muscles masticateurs de toxine botulique (BTX) chez le rat adulte. Ceci entraine une perte osseuse mandibulaire condylienne et alvéolaire homolatérale importante. Une hypertrophie osseuse de l’enthèse d’insertion mandibulaire du muscle digastrique a été observée et pourrait correspondre à une étiologie pour les tori. Les effets de la BTX sur le cartilage articulaire condylien mandibulaire dans le même modèle animal ont été recherchés par analyse microtomographique du cartilage articulaire après augmentation de contraste à l’acétate d’uranyle. Aucune différence d’épaisseur cartilagineuse n’a été mise en évidence entre les groupes contrôles et BTX.Le 3ème travail a consisté en l’étude histologique et microtomographique des tori mandibulaires chez l’homme.Les tori sont différents des exostoses des os longs par plusieurs caractéristiques (dont l’absence de Fe et Al dans la matrice osseuse) et une asymétrie du remodelage osseux a été mise en évidence.La 4ème partie a consisté en l’étude de la qualité osseuse et de la microvascularisation alvéolaire dans un modèle animal d’ostéonécrose mandibulaire (ONM) aux bisphosphonates (BP). Des signes cliniques et microtomographiques d’ONM ont été observés dans la majorité des cas. La minéralisation osseuse était plus élevée après imprégnation en BP. La microvascularisation osseuse alvéolaire apparaissait augmentée après avulsion dentaire chez les animaux contrôles mais pas chez les animaux ayant reçu des BP témoignant ainsi d’un effet anti angiogénique in vivo des BP qui pourrait jouer un rôle dans la physiopathologie de l’ONM. / First, bone changes at the mandible were studied after a unilateral botulinum toxin (BTX) injection in masticatory muscles in adult rats. A major alveolar and condylar bone loss was evidenced. The occurrence of a hypertrophic bone metaplasia at the digastric muscle enthesis was evidenced as well. This could constitute an etiological factor for tori. Then, condylar articular cartilage changes at the mandible were studied in the same BTX animal model, using microtomography after contrast enhancement of cartilage with uranyl acetate. Cartilage thickness measurement showed no difference when comparing control and BTX groups.A third work studied mandibular tori in human using histologic and microtomographic techniques. Tori appeared different from long bone exostoses by several characteristics (absence of Fe and Al in the bone matrix) and a specific asymmetric bone remodeling was evidenced.The fourth part consisted in the study of alveolar mandibular vascularization and quality of the bonematrix in an animal model of osteonecrosis of the jaws(ONJ) after bisphosphonates (BP) injections. Clinical and microtomographic signs of ONJ were found in mostof the cases. An increased mineralization of the alveolar bone was observed after BP impregnation. Microvascularization was increased after tooth extraction in the alveolar bone of control animals but it was impaired in ZA treated rats. Such an in vivo antiangiogenic effect of BPs could play a role in the pathophysiology of ONJ.

Made available in DSpace on 2016-04-29T14:15:57Z (GMT). No. of bitstreams: 1 Fabio Alexandre Gomes.pdf: 956469 bytes, checksum: 482e43f44da0c0f47c3fe7987c5c3397 (MD5) Previous issue date: 2010-10-20 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / This thesis aims to propose and make people consider the experiences of families, participant professionals and users of orthopedic services. All these characters are part of the Association of Support for Children with Orthopedic Disabilities. The central thesis sought to learn the process of fighting for the right of access to treatment with botulinum toxin, which resulted in the implementation of the Reference Center of Botulinum Toxin in São José dos Campos. In this trajectory I have collected information through qualitative research and documentary. In this search I found singular and collective characters and their experiences and narratives, which allowed me to meet their daily realities and meanings attributed by each character, highlighting their political dimension that contributed to the process of guaranteeing the right for treatment experienced by each character. The narratives describe and reflect primarily the care that families have with their children and this generates a concern and commitment in the fight so that their children can enjoy a life trajectory that guarantees them autonomy, which must be experienced in everyday life. We will discuss the obstacles to this population caused by prejudices and difficulties to achieve the realization of basic social rights. We will also present the contribution of professional practice in connection with the characters, establishing a process of reflection of daily life and the construction of citizenship / Esta dissertação tem como objetivo propor e trazer para reflexão as experiências de famílias, profissionais partícipes e de um usuário do serviço de ortopedia. Todos estes sujeitos participantes da Associação de Apoio à Criança com Deficiência Ortopédica. O foco central da dissertação buscou conhecer o processo de luta pelo direito de acesso ao tratamento com a toxina botulínica, que resultou na implantação do Centro de Referência de Toxina Botulínica na cidade de São José dos Campos. Nessa trajetória coletei informações através de pesquisa qualitativa e documental. Nesta busca encontrei sujeito singular e coletivo, suas experiências e narrativas, o que me possibilitou conhecer suas realidades cotidianas, significados atribuídos pelos sujeitos, destacando sua dimensão política que contribuíram no processo de garantia do direito ao tratamento vivenciado pelos sujeitos. As narrativas descrevem e refletem primeiramente o cuidado que as famílias têm com seus filhos e este gerando uma preocupação e comprometimento na luta para que seus filhos possam usufruir de uma trajetória de vida que lhes garanta autonomia, a qual deve ser vivenciada no cotidiano da vida. Vamos discorrer sobre os entraves causados a essa população através de preconceitos e das dificuldades para se conseguir a efetivação de direitos sociais básicos. Também apresentaremos a contribuição da prática profissional na articulação com os sujeitos, estabelecendo um processo de reflexão da vida cotidiana e da construção da cidadania

A aplicação de toxina botulínica A no lado não paralisado (LNP) é feita para tratar a assimetria resultante da paralisia facial (PF). As unidades de toxina onabotulinica A (Ona) e toxina abobotulinica A (Abo) não são equivalentes. Comparou-se a taxa de conversão de 1:3 em pacientes com PF. Cinquenta e cinco pacientes (idade entre 16 e 67 anos, 43 mulheres), com PF de longa duração foram tratados de forma aleatória com a aplicação de Ona (n = 25) ou Abo (n = 30) no LNP. Efeitos adversos, simetria facial, satisfação subjetiva e Índice de Incapacidade Facial (IIF) foram avaliados após 1 e 6 meses. Os resultados mostraram que a incidência de efeitos adversos foi maior com Abo (93,3% vs. 64,0%, p = 0,007). Avaliação Clínica do LNP diminuiu após 1 mês e aumentou novamente aos 6 meses, sem diferenças entre os grupos. A nota do lado paralisado (LP) foi menor no grupo Ona antes do tratamento, mas semelhante em ambos os grupos depois do tratamento. A nota do LP aumentou depois de 1 mês, e aos 6 meses foi ainda maior que a nota de prétratamento em ambos os grupos. A avaliação subjetiva melhorou em todos os momentos em comparação com a nota do pré-tratamento e diferiu entre os dois grupos apenas em 1 mês, quando o grupo Abo ficou um pouco mais paralisado. Índice de Função Física (IFF) e Índice de Bem-Estar Social (IBES), subescalas do Índice de Incapacidade Facial (IFF), entre os dois grupos não foram diferentes. Concluímos que ambas as toxinas reduziram a assimetria de forma eficiente em pacientes com FP. Os efeitos adversos foram maiores com Abo na equivalência de 1:3 / Botulinum toxin A injection into the nonparalyzed side (NPS) is used to treat asymmetry resulting from facial palsy (FP). OnabotulinumtoxinA (ONA) and abobotulinumtoxinA (ABO) units are not equivalent. We compared the conversion ratio of 1:3 in patients with FP. Fifty-five patients (aged 16-67 years, 43 women) with long-standing FP were randomly treated with either ONA (n = 25) or ABO (n = 30) injections into the NPS. Adverse effects, facial symmetry, subjective satisfaction, and Facial Disability Index (FDI) were assessed after 1 and 6 months. The results showed that the incidence of adverse effects was higher with ABO (93.3% vs. 64.0%, p = 0.007). Clinical scores of the NPS decreased after 1 month and increased again at 6 months, with no betweengroup differences. Scores of the paralyzed side were lower in the ONA group before treatment, but similar in both groups thereafter. The paralyzed side scores increased after 1 month, and at 6 months were still higher than the pretreatment scores in both groups. Subjective assessment improved at all time points compared to pretreatment score and differed between the two groups only at 1 month, when the ABO group was a bit too paralyzed. The Physical Function and Social/Well-Being Function subscales of the FDI did not differ between the two groups. We conclude that both toxins efficiently reduced asymmetry in patients with FP. Adverse effects were higher with ABO at an equivalence ratio of 1:3

Obwohl die Struktur und das Ausmaß dendritischer Verzweigungen eine wichtige Rolle bei der Informationsübertragung neuronaler Zellen spielen, ist bislang wenig über die Bausteine und Molekularmechanismen des Dendritenwachstums bekannt. Unter der Verwendung primär dissoziierter hippocampaler Zellkulturen embryonaler Mäuse untersuchte ich frühe Stadien des Zellfortsatzwachstums. Dabei konnte ich SNAP-25 (synaptosomal associated protein of 25 kDA), ein Schlüsselprotein der regulierten Exozytose, nicht nur in Axonen und terminalen Axonendigungen, sondern auch anhand von Doppelimmunmarkierungen mit den dendritischen Markern Transferrin-Rezeptor und MAP-2 in Dendriten lokalisieren. Die spezifische Inaktivierung von SNAP-25 durch Botulinumneurotoxin A (BoNT/A) führte zur Hemmung des Axonwachstums und des Vesikelrecyclings in terminalen Axonendigungen. Darüberhinaus wurde auch das Wachstum dendritischer Fortsätze von Körner- und Pyramidenzellen durch BoNT/A signifikant gehemmt. Daraus läßt sich schließen, daß SNAP-25, im Gegensatz zu Synaptobrevin, an konstitutiven Prozessen in den Axonen und Dendriten hippocampaler Neurone beteiligt ist. / Structure and dimension of the dendritic arbor are important determinants of information processing by the nerve cell, but mechanisms and molecules involved in dendritic growth are essentially unknown. I investigated early mechanisms of dendritic growth using mouse fetal hippocampal neurons in primary culture, which form processes during the first week in vitro. I detected a key component of regulated exocytosis, SNAP-25 (synaptosomal associated protein of 25 kDa)., in axons and axonal terminals as well as in dendrites identified by the occurrence of the dendritic markers transferrin receptor and MAP2. Selective inactivation of SNAP-25 by botulinum neurotoxin A (BoNTA) resulted in inhibition of axonal growth and of vesicle recycling in axonal terminals. In addition, dendritic growth of hippocampal pyramidal and granule neurons was significantly inhibited by BoNTA. These observations indicate that SNAP-25, but not synaptobrevin, is involved in constitutive axonal growth and dendrite formation by hippocampal neurons.

This study investigated factors associated with two mortality events: avian botulism in waterfowl and mortality associated with hatching asynchrony in prefledgling Franklins gulls (Larus pipixcan). The initial focus of my research was on the spatiotemporal relationship between mortality of Franklins gulls and the onset of botulism outbreaks in waterfowl, and the suitability of gull carcasses for proliferation and toxigenesis of Clostridium botulinum. From 1999 to 2001, dead hatch-year Franklins gulls were by far the most abundant carcasses, and the only source of toxin-laden maggots found on transects prior to the occurrence of avian botulism in waterfowl. Nest density was a significant predictor of hatch-year gull carcass density. High density of toxic material from gull carcasses prior to the onset of botulism in waterfowl coincided with high densities of susceptible birds; hence, mortality of Franklins gulls has the potential to be a major initiating factor for botulism outbreaks at Eyebrow Lake, Saskatchewan. The causes of gull mortality were conditions or diseases associated with starvation, stress, or immunosuppression, and most mortality occurred in third-hatched chicks. To separate effects of laying order from effects of hatching asynchrony on prefledgling survival, a cross-fostering experiment was conducted to create clutches containing asynchronously hatching eggs of the same laying order, and of similar egg mass, egg volume, and female quality. Hatching order, independent of laying order, significantly affected survival to fledging, whereas laying order had no observable effect, indicating that intraclutch variation in egg quality does not predetermine the fate of prefledglings, and may be less important than hatching asynchrony for survival of prefledgling Franklins gulls. Relationships among hatching asynchrony, laying order, mass, corticosterone, immune function, growth, and survival at two stages of development were complex. Hatching asynchrony significantly affected early and late prefledgling survival, and was directly or indirectly associated with mass, corticosterone level, and cell-mediated immune responses at early and later stages of development. Both hatching asynchrony and mass appeared to play key roles in mediating life history trade-offs among cell-mediated immune function, growth, and survival. In contrast to cell-mediated immune responses, primary humoral immune response was not directly affected by hatching order or mass, nor was it associated with survival to fledging. Rather, it was associated with laying order, neonatal testosterone, corticosterone at 2 weeks, growth of leg length, and clutch initiation date, illustrating the importance of examining more than one branch of the immune system in studies of life history trade-offs. This study is a step toward using a multipronged and multidisciplinary approach to demonstrate interactions and trade-offs among life history traits, the physiological mechanisms that produce these relationships, and how these relationships may change depending on stage of development.

This study investigated factors associated with two mortality events: avian botulism in waterfowl and mortality associated with hatching asynchrony in prefledgling Franklins gulls (Larus pipixcan). The initial focus of my research was on the spatiotemporal relationship between mortality of Franklins gulls and the onset of botulism outbreaks in waterfowl, and the suitability of gull carcasses for proliferation and toxigenesis of Clostridium botulinum. From 1999 to 2001, dead hatch-year Franklins gulls were by far the most abundant carcasses, and the only source of toxin-laden maggots found on transects prior to the occurrence of avian botulism in waterfowl. Nest density was a significant predictor of hatch-year gull carcass density. High density of toxic material from gull carcasses prior to the onset of botulism in waterfowl coincided with high densities of susceptible birds; hence, mortality of Franklins gulls has the potential to be a major initiating factor for botulism outbreaks at Eyebrow Lake, Saskatchewan. The causes of gull mortality were conditions or diseases associated with starvation, stress, or immunosuppression, and most mortality occurred in third-hatched chicks. To separate effects of laying order from effects of hatching asynchrony on prefledgling survival, a cross-fostering experiment was conducted to create clutches containing asynchronously hatching eggs of the same laying order, and of similar egg mass, egg volume, and female quality. Hatching order, independent of laying order, significantly affected survival to fledging, whereas laying order had no observable effect, indicating that intraclutch variation in egg quality does not predetermine the fate of prefledglings, and may be less important than hatching asynchrony for survival of prefledgling Franklins gulls. Relationships among hatching asynchrony, laying order, mass, corticosterone, immune function, growth, and survival at two stages of development were complex. Hatching asynchrony significantly affected early and late prefledgling survival, and was directly or indirectly associated with mass, corticosterone level, and cell-mediated immune responses at early and later stages of development. Both hatching asynchrony and mass appeared to play key roles in mediating life history trade-offs among cell-mediated immune function, growth, and survival. In contrast to cell-mediated immune responses, primary humoral immune response was not directly affected by hatching order or mass, nor was it associated with survival to fledging. Rather, it was associated with laying order, neonatal testosterone, corticosterone at 2 weeks, growth of leg length, and clutch initiation date, illustrating the importance of examining more than one branch of the immune system in studies of life history trade-offs. This study is a step toward using a multipronged and multidisciplinary approach to demonstrate interactions and trade-offs among life history traits, the physiological mechanisms that produce these relationships, and how these relationships may change depending on stage of development.

No description available.

Spasticity is highly prevalent in neurological conditions involving upper motor neuron lesions (UMNL). Lower limb spasticity is known to impair gait and limit participation in physical activity. Multimodal interventions including botulinum toxin A, orthoses, and physiotherapy have shown longer lasting improvements compared to unimodal interventions. Studies to date, however, have not examined the long term efficacy of this multimodal intervention nor have they examined the impact across a breadth of domains necessary to comprehensively and fully understand its impact. The aim of this study was to investigate the efficacy of a multimodal intervention to treat lower limb spasticity in adults using a longitudinal mixed-methods approach, including a comprehensive set of outcome measures spanning the domains of the International Classification of Functioning, Disability and Health (ICF) model. Seven-teen participants with chronic UMNL were included in the analysis as per inclusion criteria and showed improvements at 6 and 12 months, compared to baseline, within all domains of the ICF model. / Graduate / 0571 / 0382 / 0384 / jazkim@uvic.ca