Objectives In this study we perform a review of the literature on systemic muscle weakness after administration of botulinum toxin A, to describe the factors that predispose patients to this adverse event and to suggest strategies for prevention. Methods Our search criteria included the terms "Botulinum toxin, Abobotulinum toxin, Dysport ® , Onabotulinum toxin, Botox ® , Incobotulinum toxin and Xeomin ® , muscle weakness, generalized muscle weakness and respiratory distress." Statistical analysis was completed using IBM ® SPSS software. Results We identified 2029 articles and narrowed this to 38 articles referencing 63 specific cases (including two studies form our institution) and 11 case series. Our analysis of 11 case series suggested that systemic muscle weakness is a rare event with botulinum toxin A. Of the 63 cases identified, the most common indications for use were spasticity (49.2%) and neurogenic detrusor overactivity (22.2%). The median age was low at 34 years, and the majority were female (76.2%). Furthermore, 47.6% of the cases were associated with the abobotulinum toxin A formulation. On average, the doses administered were 3.2 times the recommended dose (standard deviation 1.9) suggested for the particular botulinum toxin A formulation and indication. If systemic muscle weakness did occur, indication for botulinum toxin A being upper tract gastrointestinal disorder was associated with more severe impairment (W 2 = 10.2, p = 0.001). Conclusion Based on data from the identified cases of systemic muscle weakness with botulinum toxin A, this adverse event was more common in female, younger, patients with spasticity or neurogenic detrusor overactivity indication or those receiving abobotulinum toxin A formulation and/or higher botulinum toxin A doses. A prevention strategy may include reducing the dose of botulinum toxin A to those recommended by the US FDA.
Operative classification of ventral abdominal hernias: new and practical classification. Yasser Selim. From the Ministry of Health.Background: Ventral hernias of the abdomen are defined as a noninguinal, nonhiatal defect in the fascia of the abdominal wall. Unfortunately, there is not currently a universal classification system for ventral hernias. One of the more accepted classification systems is that of the European Hernia Society (EHS). Its limitation is that it does not include individual patient risk factors and wound classification. The aim of this work was to find out the basic principles of hernia etiology and pathogenesis, clarify the factors that are important in treatment of ventral hernias, and categorize hernia patients according to those factors. Methods: This retrospective study included 238 patients who presented to our surgery department between 2010 and 2020. A full description of ventral hernias was made, including their type according to the EHS. In addition, abdominal wall components were assessed, including strength of rectus muscles, lateral abdominal muscles, and abdominal fascia, namely the linea alba. Patients with spontaneous hernias were grouped according to the size of the defect and the condition of the rectus abdominis muscles, the fascia and other abdominal muscles. Results: Patients were put into 6 clinical categories: type 1A, type 1B, type 2, type 3, type 4, and type 5. The grouping of patients was done according to the factors we believed affect the choice of surgical procedure and the prognosis of repair. Patients with types 1 and 2 have normal abdominal muscles, whereas those with types 3 and 4 have weak muscles and weak stretched fascia (linea alba). Type 5 includes incisional hernias. Conclusion: The primary purpose of any classification should be to improve the possibility of comparing different studies and their results. By describing hernias in a standardized way, different patient populations can be compared. Numerous classifications for groin and ventral hernias have been proposed over the past 5-6 decades. For primary abdominal wall hernias, there was agreement with EHS classification on the use of localization and size as classification variables.
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