- Email: [email protected]
Clinical applications of neurotoxin injections in Parkinson's disease and parkinson-plus syndromes: Experience of a neurology department
Abstracts / Toxicon 123 (2016) S2eS90
that the reorganization of BEA we observed reflects the disintegration of abnormal sensorimotor integration. We believe that the early transient clinical effect of BTTGS reflects the appearance of the process of liberation of neurons for maintaining other functions, including awareness when the “normalizing disintegration” covers all areas relevant for sensorimotor integration. Keywords: Consciousness; IncobotulinumtoxinA; Sensorimotor integration; Spasticity 217. IMPROVEMENT IN POSTSTROKE UPPER LIMB SPASTICITY PATTERNS AFTER TREATMENT WITH BOTULINUM TOXIN A: A PROSPECTIVE OBSERVATIONAL STUDY Dura c, Lluis a, *, Fernanda Maria Caballero b, Maria Jose Josep Valls-Sole ~ ana f, Guirao d, Montserrat Bernabeu e, Helena Bascun Irene Garcia g, Pascal Maisonobe h. a Hospital Clínic i Provincial de Barcelona, Barcelona, Spain; b Hospital Parc Taulí, Sabadell, Spain; c Hospital Germans Trias i Pujol, Badalona, Spain; d , Mataro , Spain; e Institut Guttmann, Badalona, Spain; Hospital de Mataro f Hospital de Sant Pau, Barcelona, Spain; g Ipsen Pharma, Medical Department, Barcelona, Spain; h Corporate Ipsen Biostatistics, BoulogneBillancourt, France * Corresponding author: Neurology Department, Hospital Clínic i Provincial de Barcelona, C/Villarroel, 170, 08036 Barcelona, Spain. E-mail address:[email protected].
Introduction and objectives: Botulinum toxin A (BoNT-A) is an effective treatment for poststroke spasticity. However, more data are needed to assess its beneficial effects in real-life clinical settings. The aim of this study was to evaluate functional changes in upper limb poststroke spasticity before and after treatment with BoNT-A. Methods: We conducted a postmarketing, multicenter, prospective, observational, longitudinal, open-label, single-cohort study in 37 BoNT-An€ aive adults (age 18 years), diagnosed with poststroke upper limb spasticity in Catalonia, Spain. The study enrollment period was December 19, 2012, to June 10, 2014. All patients received one cycle of BoNT-A injections. Patients were assessed at baseline (pre-BoNT-A treatment) and at 3-6 months posttreatment. The primary outcome measures, assessed at baseline and posttreatment, were changes in spasticity patterns. Additional study variables included the Modified Ashworth Scale (MAS) and Goal Attainment Scale (GAS). The Wilcoxon signed-rank test was used to test for differences. Results: Thirty-four of the 37 patients (92%) completed the study. Median age was 62 years (range, 33 to 86 years). Most subjects (70.6%) were males. At baseline, the most common spasticity patterns were elbow flexion (n¼24; 70.6%), shoulder adduction/internal rotation (n¼23; 67.6%), and wrist flexion (n¼22; 64.7%). The total number of spasticity patterns decreased from 110 (3.24/patient) at baseline to 102 (3.0/patient) posttreatment. The most commonly injected muscles were the flexor digitorum superficialis (50% of patients) and the flexor carpi radialis (47.1%). Overall MAS scores decreased significantly from baseline to final study visit (P<0.001), from a mean (SD) of 2.7 (0.8) at baseline to 2.2 (0.7) posttreatment, with the most significant decreases in elbow flexion (P¼0.0005) and shoulder adduction/rotation (P¼0.0005). Visual Analog Scale (VAS) pain scores improved significantly (P<0.0001) from a mean (SD) of 50.8 (35.7) to 17.4 (23.7). Most patients (28/34; 82.4%) achieved their primary GAS objective, with the most common being pain reduction (achieved in 14/17 patients; 82.4%) and improved self-care (7/8 patients; 87.5%). The mean unweighted GAS T-score also improved significantly, from 35.5 (5.7) at baseline to 55.0 (9.8) posttreatment (P<0.001). One nontreatment-related death was reported. Conclusions: In this sample of patients with severe spasticity, most subjects benefited from treatment with a single cycle of BoNT-A injections as evidenced by the significant improvements in both MAS and GAS scores. These data, obtained in a real-life setting, further support the use of BoNTA for the treatment of poststroke spasticity. Keywords: Botulinum toxin A; Goal attainment scaling; Spasticity patterns; Upper limb poststroke spasticity
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218. INTRANEURONAL DELIVERY OF PROTEIN THERAPEUTICS USING METALLOPROTEASE-INACTIVATED BOTULINUM NEUROTOXIN HETERODIMER AS MOLECULAR VEHICLE Edwin J. Vazquez-Cintron a, c, f, Luis Tenezaca a, f, Christopher A. Angeles a, Jacqueline M. Tremblay b, Phillip H. Beske c, Aurelia Syngkon a, Sabine Pellett d, William H. Tepp d, Michelle Debatis b, Jean Mukherjee b, George A. Oyler e, Philip A. Band a, f, g, Patrick M. McNutt c, Eric A. Johnson d, Charles B. Shoemaker b, Konstantin Ichtchenko a, *. a Department of Biochemistry and Molecular Pharmacology, New York University School of Medicine, New York, NY, USA; b Department of Infectious Diseases and Global Health, Tufts University Clinical and Translational Science Institute, North Grafton, MA, USA; c The United States Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, MD, USA; d Department of Bacteriology, University of Wisconsin, Madison, USA; e Synaptic Research LLC, Baltimore, MD, USA; f CytoDel LLC, New York, NY, USA; g Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, New York, NY, USA * Corresponding author: Department of Biochemistry and Molecular Pharmacology, New York University School of Medicine, New York, NY 10016, USA. E-mail address:[email protected].
Introduction and objectives: Current treatment for botulism relies on antitoxins that neutralize botulinum neurotoxins (Bunts) in circulation. Patients are often diagnosed after the toxin has accumulated inside neurons, where antitoxin is ineffective. There is a critical need for postexposure treatment to reverse symptoms of botulism once the toxin has entered neurons. We have bioengineered recombinant atoxic derivatives of Bunts to harness their exquisite ability to target the presynaptic compartment of neurons at the neuromuscular junction and to deliver single-domain, metalloprotease-neutralizing antibodies (sdAb) using a “Trojan horse” approach. Here we describe antidotes to wt BoNT/A (B8/C1ad) and wt BoNT/B (JLJG3/C1-ad), delivered via an atoxic BoNT/C1 derivative BoNT/C1-ad (C1-ad). Methods: B8/C1-ad and JLJG3/C1-ad were expressed using a baculovirus expression system. The LD50 was calculated using the standard murine bioassay. The effectiveness of the antidotes was investigated in vitro using primary neuronal cultures and analyzed by Western blot. A murine model was established to study the effectiveness of botulism therapeutics as a function of time of treatment administration post-wt BoNT exposure, and these data were compared with conventional antitoxin serum treatment. Statistics were derived using the Fisher’s exact test. Results: In vitro, B8/C1-ad and JLJG3/C1-ad partially blocked substrate cleavage in wt BoNT/A- or BoNT/B-intoxicated neuron cultures. The vehicle, C1-ad, showed no protection under similar conditions. The B8 sdAb alone was unable to bind wt BoNT/A holotoxin, but it bound LC/A. The JLJG3 sdAb alone provided partial protection in preincubation assays, because it was able to bind both wt BoNT/B holotoxin and LC/B. In vivo, mice were intoxicated with 2 LD50 of wt BoNT/A intraperitoneally and treated with a single 0.4 mg/kg dose of B8/C1-ad at 3, 6, 8, 12, 16, or 20 hours postintoxication. A single dose of B8/C1-ad prevented death (60% to 100% survival rate) at times when 1 U of conventional antitoxin treatment was ineffective (0% survival 12 hours postexposure). JLJG3/C1-ad was also tested in this model. When JLJG3/C1-ad was coadministered with up to 50 LD50 of wt BoNT/B toxin, mice were protected (100% survival). To compare JLJG3/C1-ad with conventional antitoxin, mice were intoxicated with 4 LD50 of wt BoNT/B and treated 2, 4, or 6 hours postexposure. At 2- and 4-hour time points, both JLJG3/C1-ad and antitoxin were equally potent (100% survival); at 6 hours postetime point, the JLJG3/C1-ad group showed 40% survival compared with 20% in the antitoxin group. Conclusions: B8/C1-ad is the first molecule shown to reverse botulism toxemia after respiratory symptoms have emerged in a murine model of botulism. It has a unique mode of action, in that C1-ad functions as a molecular vehicle to deliver single-domain antibodies to the presynaptic compartment of neurons in vivo. Both therapeutic fusion proteins described here demonstrate the potential for delivering single-domain antibodies to different intraneuronal targets, previously thought to be inaccessible. Further experiments are aimed to broaden this capability to
that the reorganization of BEA we observed reflects the disintegration of abnormal sensorimotor integration. We believe that the early transient clinical effect of BTTGS reflects the appearance of the process of liberation of neurons for maintaining other functions, including awareness when the “normalizing disintegration” covers all areas relevant for sensorimotor integration. Keywords: Consciousness; IncobotulinumtoxinA; Sensorimotor integration; Spasticity 217. IMPROVEMENT IN POSTSTROKE UPPER LIMB SPASTICITY PATTERNS AFTER TREATMENT WITH BOTULINUM TOXIN A: A PROSPECTIVE OBSERVATIONAL STUDY Dura c, Lluis a, *, Fernanda Maria Caballero b, Maria Jose Josep Valls-Sole ~ ana f, Guirao d, Montserrat Bernabeu e, Helena Bascun Irene Garcia g, Pascal Maisonobe h. a Hospital Clínic i Provincial de Barcelona, Barcelona, Spain; b Hospital Parc Taulí, Sabadell, Spain; c Hospital Germans Trias i Pujol, Badalona, Spain; d , Mataro , Spain; e Institut Guttmann, Badalona, Spain; Hospital de Mataro f Hospital de Sant Pau, Barcelona, Spain; g Ipsen Pharma, Medical Department, Barcelona, Spain; h Corporate Ipsen Biostatistics, BoulogneBillancourt, France * Corresponding author: Neurology Department, Hospital Clínic i Provincial de Barcelona, C/Villarroel, 170, 08036 Barcelona, Spain. E-mail address:[email protected].
Introduction and objectives: Botulinum toxin A (BoNT-A) is an effective treatment for poststroke spasticity. However, more data are needed to assess its beneficial effects in real-life clinical settings. The aim of this study was to evaluate functional changes in upper limb poststroke spasticity before and after treatment with BoNT-A. Methods: We conducted a postmarketing, multicenter, prospective, observational, longitudinal, open-label, single-cohort study in 37 BoNT-An€ aive adults (age 18 years), diagnosed with poststroke upper limb spasticity in Catalonia, Spain. The study enrollment period was December 19, 2012, to June 10, 2014. All patients received one cycle of BoNT-A injections. Patients were assessed at baseline (pre-BoNT-A treatment) and at 3-6 months posttreatment. The primary outcome measures, assessed at baseline and posttreatment, were changes in spasticity patterns. Additional study variables included the Modified Ashworth Scale (MAS) and Goal Attainment Scale (GAS). The Wilcoxon signed-rank test was used to test for differences. Results: Thirty-four of the 37 patients (92%) completed the study. Median age was 62 years (range, 33 to 86 years). Most subjects (70.6%) were males. At baseline, the most common spasticity patterns were elbow flexion (n¼24; 70.6%), shoulder adduction/internal rotation (n¼23; 67.6%), and wrist flexion (n¼22; 64.7%). The total number of spasticity patterns decreased from 110 (3.24/patient) at baseline to 102 (3.0/patient) posttreatment. The most commonly injected muscles were the flexor digitorum superficialis (50% of patients) and the flexor carpi radialis (47.1%). Overall MAS scores decreased significantly from baseline to final study visit (P<0.001), from a mean (SD) of 2.7 (0.8) at baseline to 2.2 (0.7) posttreatment, with the most significant decreases in elbow flexion (P¼0.0005) and shoulder adduction/rotation (P¼0.0005). Visual Analog Scale (VAS) pain scores improved significantly (P<0.0001) from a mean (SD) of 50.8 (35.7) to 17.4 (23.7). Most patients (28/34; 82.4%) achieved their primary GAS objective, with the most common being pain reduction (achieved in 14/17 patients; 82.4%) and improved self-care (7/8 patients; 87.5%). The mean unweighted GAS T-score also improved significantly, from 35.5 (5.7) at baseline to 55.0 (9.8) posttreatment (P<0.001). One nontreatment-related death was reported. Conclusions: In this sample of patients with severe spasticity, most subjects benefited from treatment with a single cycle of BoNT-A injections as evidenced by the significant improvements in both MAS and GAS scores. These data, obtained in a real-life setting, further support the use of BoNTA for the treatment of poststroke spasticity. Keywords: Botulinum toxin A; Goal attainment scaling; Spasticity patterns; Upper limb poststroke spasticity
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218. INTRANEURONAL DELIVERY OF PROTEIN THERAPEUTICS USING METALLOPROTEASE-INACTIVATED BOTULINUM NEUROTOXIN HETERODIMER AS MOLECULAR VEHICLE Edwin J. Vazquez-Cintron a, c, f, Luis Tenezaca a, f, Christopher A. Angeles a, Jacqueline M. Tremblay b, Phillip H. Beske c, Aurelia Syngkon a, Sabine Pellett d, William H. Tepp d, Michelle Debatis b, Jean Mukherjee b, George A. Oyler e, Philip A. Band a, f, g, Patrick M. McNutt c, Eric A. Johnson d, Charles B. Shoemaker b, Konstantin Ichtchenko a, *. a Department of Biochemistry and Molecular Pharmacology, New York University School of Medicine, New York, NY, USA; b Department of Infectious Diseases and Global Health, Tufts University Clinical and Translational Science Institute, North Grafton, MA, USA; c The United States Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, MD, USA; d Department of Bacteriology, University of Wisconsin, Madison, USA; e Synaptic Research LLC, Baltimore, MD, USA; f CytoDel LLC, New York, NY, USA; g Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, New York, NY, USA * Corresponding author: Department of Biochemistry and Molecular Pharmacology, New York University School of Medicine, New York, NY 10016, USA. E-mail address:[email protected].
Introduction and objectives: Current treatment for botulism relies on antitoxins that neutralize botulinum neurotoxins (Bunts) in circulation. Patients are often diagnosed after the toxin has accumulated inside neurons, where antitoxin is ineffective. There is a critical need for postexposure treatment to reverse symptoms of botulism once the toxin has entered neurons. We have bioengineered recombinant atoxic derivatives of Bunts to harness their exquisite ability to target the presynaptic compartment of neurons at the neuromuscular junction and to deliver single-domain, metalloprotease-neutralizing antibodies (sdAb) using a “Trojan horse” approach. Here we describe antidotes to wt BoNT/A (B8/C1ad) and wt BoNT/B (JLJG3/C1-ad), delivered via an atoxic BoNT/C1 derivative BoNT/C1-ad (C1-ad). Methods: B8/C1-ad and JLJG3/C1-ad were expressed using a baculovirus expression system. The LD50 was calculated using the standard murine bioassay. The effectiveness of the antidotes was investigated in vitro using primary neuronal cultures and analyzed by Western blot. A murine model was established to study the effectiveness of botulism therapeutics as a function of time of treatment administration post-wt BoNT exposure, and these data were compared with conventional antitoxin serum treatment. Statistics were derived using the Fisher’s exact test. Results: In vitro, B8/C1-ad and JLJG3/C1-ad partially blocked substrate cleavage in wt BoNT/A- or BoNT/B-intoxicated neuron cultures. The vehicle, C1-ad, showed no protection under similar conditions. The B8 sdAb alone was unable to bind wt BoNT/A holotoxin, but it bound LC/A. The JLJG3 sdAb alone provided partial protection in preincubation assays, because it was able to bind both wt BoNT/B holotoxin and LC/B. In vivo, mice were intoxicated with 2 LD50 of wt BoNT/A intraperitoneally and treated with a single 0.4 mg/kg dose of B8/C1-ad at 3, 6, 8, 12, 16, or 20 hours postintoxication. A single dose of B8/C1-ad prevented death (60% to 100% survival rate) at times when 1 U of conventional antitoxin treatment was ineffective (0% survival 12 hours postexposure). JLJG3/C1-ad was also tested in this model. When JLJG3/C1-ad was coadministered with up to 50 LD50 of wt BoNT/B toxin, mice were protected (100% survival). To compare JLJG3/C1-ad with conventional antitoxin, mice were intoxicated with 4 LD50 of wt BoNT/B and treated 2, 4, or 6 hours postexposure. At 2- and 4-hour time points, both JLJG3/C1-ad and antitoxin were equally potent (100% survival); at 6 hours postetime point, the JLJG3/C1-ad group showed 40% survival compared with 20% in the antitoxin group. Conclusions: B8/C1-ad is the first molecule shown to reverse botulism toxemia after respiratory symptoms have emerged in a murine model of botulism. It has a unique mode of action, in that C1-ad functions as a molecular vehicle to deliver single-domain antibodies to the presynaptic compartment of neurons in vivo. Both therapeutic fusion proteins described here demonstrate the potential for delivering single-domain antibodies to different intraneuronal targets, previously thought to be inaccessible. Further experiments are aimed to broaden this capability to