Botox

More evidence suggests that Botox can spread from its injection site

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Despite its popularity, Botox – or botulinum toxin – is one of the deadliest substances on Earth, with just 160 nanograms enough, on average, to kill an 80-kg human.

That’s not a problem for people who use it therapeutically in small doses – assuming it stays where it’s meant to. But new research has shown for the first time that the toxin is capable of spreading between nerve cells, and moving from its injection site.

Before you freak out, in the tiny doses doctors currently use on patients, that’s nothing to be worried about – there’s 0.73 nanograms per 100 unit vial, and most people get around 10 units per session.

Research has shown that Botox is safe for the majority of patients, and it also has some pretty important medical benefits.

By causing localised paralysis, the drug is capable of not only smoothing frown lines, but also treating migraines, muscle dysfunction, and even helping with weight loss.

But evidence that Botox can spread along nerve cells is worthy of further investigation, seeing as the drugs only entered the market based on the idea that they couldn’t spread.

“The idea was that they are safe to use, they stay where they are injected, and you don’t have to worry about toxin going to the central nervous system and causing weird effects,” said team leader Edwin Chapman from the University of Wisconsin-Madison.

Now, Chapman and his team have “shown unambiguously the existence of a second entry pathway that takes some of the toxin molecules to other neurons”,he says.

This isn’t the first time researchers have suspected that Botox can spread.

Back in 2009, the US Food and Drug Administration (FDA) added a warning to the drug information that stated, “Botulinum toxin may spread from the area of injection to produce symptoms consistent with botulism,” – which is the name given to the condition that results from being exposed to too much of the toxin, or the Clostridium botulinum bacteria that produces it.

“Understand that swallowing and breathing difficulties can be life-threatening and there have been reports of deaths related to the effects of spread of botulinum toxin,” the FDA cautioned.

Doctors have also seen some strange results that suggest Botox is capable of affecting other parts of the body.

“In many cases, after an injection for a disabling spasm of neck muscles called cervical dystonia, there is no change in muscle tone but the patient finds relief and is perfectly happy,” said one of the researchers, Ewa Bomba-Warczak. “That result can’t be explained by the local effects.”

But despite this speculation, no one had ever actually caught Botox in the act of spreading between nerve cells – until now.

To figure this out, the researchers grew mouse neurons in the lab, and kept each neuron in a dish connected by small channels that allowed them to communicate via their long ‘tails’ called axons.

The researchers then injected Botox into one of the nerve cells, the way doctors would clinically, and watched on a molecular level where it travelled.

They watched as the botulinum toxin stopped the nerve cells from communicating with muscles and caused local paralysis. But then they also saw the toxin move to nerve cells in neighbouring wells through the axons.

“Every time one fraction of the toxin acts locally (on the first nerve cell it contacts), another fraction acts at a distance,” said Chapman. “It’s unknown how far they travel, which likely depends on the dose of toxin and other factors.”

A lot more research needs to be done to find out exactly how and why this is happening, and to verify that it’s actually happening in humans, and not just in the lab. So don’t give up your Botox injections just yet.

But the good news is that if we can better understand how the toxin works on the molecular level, we might be able to find a way to stop it from spreading, while maintaining its therapeutic effects – something Chapman suggests would make the drug even more appealing to doctors.

“I have a hard time imagining that any physician is going to want to inject something they know can move about when they have an option to use something that stays put,” said Chapman. “It’s an exciting prospect, supplanting a $2 billion drug with a safer drug.”

Botox may prevent irregular heartbeat after bypass surgery.

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Botox — known for reducing facial wrinkles — may also prevent irregular heart rhythms when injected into fat surrounding the heart after bypass surgery, according to research in the American Heart Association journal Circulation: Arrhythmia and Electrophysiology.

Botulinum toxin, commonly known as Botox, is produced by Clostridium botulinum bacteria. When a small amount of Botox is injected into a muscle, it blocks nerve signals that tell muscles to contract.

Atrial fibrillation, also called AFib, is a quivering or irregular heartbeat (arrhythmia) that can lead to blood clots, stroke, heart failure and other heart-related complications.

“About a third of all patients undergoing bypass surgery will develop atrial fibrillation, putting them at higher risk for cardiovascular complications,” said Jonathan S. Steinberg, M.D., senior study author and Adjunct Professor of Medicine at the University of Rochester and Director of the Arrhythmia Institute in the Valley Health System in Ridgewood, New Jersey. “Atrial fibrillation is also always associated with lengthened hospitalization and that means increased healthcare costs.”

In two Russian hospitals, researchers randomly assigned 60 patients to receive Botox or saline injections. The injections were made in the four major fat pads surrounding the heart. To avoid bias, neither patients nor doctors knew whether the injections contained Botox or saline.

Researchers found that:

  • In the 30 days following surgery, those who received Botox injections during heart bypass surgery had a 7 percent chance of developing AFib, compared to 30 percent chance in patients who received saline.
  • One year after surgery, none of the patients who received Botox had AFib, compared to 27 percent of the patients who received saline.
  • No complications from the Botox injections were reported. But complications from the bypass surgery were similar in both groups, including time in intensive care and on a breathing machine, and infection rate.

The results must be replicated in larger studies before Botox injections are routinely used to prevent AFib after bypass surgery, researchers said. If confirmed in heart bypass patients, Botox injections could also help prevent AFib in people undergoing valve repair or replacement. About half of those patients will develop AFib after surgery.

“This first-in-man study has opened a whole new line of thinking and research,” Steinberg said. “In the near future, botox injections may become the standard of care for heart bypass and valve patients, but we’re not quite there yet.”

‘Baron of Botox’ Dr Fredric Brandt Dead at Age 65

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Fredric Brandt, MD, a world-renowned dermatologist, died at his home in Coconut Grove, Florida, on April 5. The 65-year-old hanged himself, according to the Miami, Florida, police.

His publicist, Jacquie Tractenberg, told the Washington Post he had been suffering from depression and was upset by a recent episode of Tina Fey’s Netflix comedy series, “Unbreakable Kimmy Schmidt,” in which Martin Short appeared to parody him. Short’s character had thinning blonde hair with a receding hairline, exaggerated cheekbones, and a face so frozen his speech was distorted.

“It definitely bothered him. It was a very mean portrayal,” she told the Post, but added, “He didn’t kill himself because of that one particular show.”
Dr Brandt was a pioneer in the use of onabotulinum toxin A (Botox Cosmetic, Allergan) and collagen fillers. He had dermatology practices in Manhattan, New York, and Coral Gables, Florida. “He was a giant in this field…he was recognized as a world leader in cosmetic medicine,” Roy G. Geronemus, MD, director, Laser and Skin Surgery Center of New York, told Medscape Medical News. “He really took the science and made it an art.”

“He was a brilliant and caring physician. He really helped transform the techniques for the approach towards the aging face and body,” he said.

Dubbed the “Baron of Botox” and the “King of Collagen,” Dr Brandt had reportedly used more Botox Cosmetic and collagen fillers than any other dermatologist in the world. His celebrity clients included the singer Madonna, television talk-show host Kelly Ripa, and comedian Joy Behar.


Dr Fredric Brandt.
Dr Geronemus said he has known Dr Brandt since 1978, when they were both at the University of Miami in Florida. Dr Brandt was a medical resident and Dr Geronemus was a medical student there. The two dermatologists had worked together for 20 years. Dr Brandt treated patients at the Laser and Skin Surgery Center of New York in Manhattan at the time of his death.

Loved by Patients and Colleagues.

“The staff that we shared absolutely loved him. He was very creative in making everyone feel like a part of his family. His staff were his family, his patients were his family. The response that we’re getting from his patients with his death is truly overwhelming. His patients are just devastated,” Dr Geronemus said.

Dr Brandt would often relax his patients by singing to them as he was treating them, Dr Geronemus said. “He was very, very knowledgeable about medicine; he was not just someone looking to put a few needles into someone’s face in exchange for a few dollars. He was very creative and really had a true vision for what a younger face should look like.”

“He was a good friend. Many of his patients became his personal friends,” Dr Geronemus added, noting that even colleagues who were considered competitors liked him.

Clinical Practices in Manhattan and Coral Gables

Dr Brandt was born on June 26, 1949, in Newark, New Jersey, to Irving and Esther Brandt and grew up there. He is survived by his brother, Paul.

He graduated with a Bachelor of Arts degree from Rutgers University in New Brunswick, New Jersey, in 1971 and earned a medical degree from Hahnemann Medical College (now known as Drexel University College of Medicine) in Philadelphia, Pennsylvania, in 1975.

Dr Brandt completed an internship at New York University in New York City from 1975 to 1976, a residency in internal medicine at New York University from 1976 to 1978, and a residency in dermatology at the University of Miami in Florida from 1978 to 1981, according to his curriculum vitae. The information in his curriculum vitae conflicts with media reports that say he completed medical residencies at New York University and Memorial Sloan Kettering Cancer Center in Manhattan, with residencies in nephrology and oncology.

Dr Brandt went into private practice in Coral Gables in 1982 and in New York City in 1996. He was the founder and chairman of the board for Cosmetic Dermatology Inc in Miami from 1990 until his death. It was there that he created the Dr Brandt skincare line, which has been sold in more than 40 countries. “He was very creative and thoughtful about what he was doing with [his product line],” Dr Geronemus noted.

He was a clinical voluntary associate professor in the Department of Dermatology at the University of Miami in Florida from 1999 until May 2001.

Esteemed Researcher, Author

He founded and was the principal investigator for the Dermatology Research Institute LLC in Coral Gables from 2006 until his death. “He had a clinical research program in Miami, [and] we did some drug studies in New York as well,” Dr Geronemus explained. “He was involved with the clinical development of many of the products that he used, so he understood them quite well. He understood their limitations, he understood their strengths, he understood which products should be used where, and would always look for any method possible for improving the outcome of his patients.”

“A lot of it was based on his own research, with the knowledge that he gained helping these companies develop their products or doing the phase 1, 2, and 3 clinical trials for the [US Food and Drug Administration],” he added.

Along with the multiple studies in which he was the principal investigator, Dr Brandt was also a sought-after presenter at scores of dermatology conferences around the world.

He was a board-certified member of the American Board of Internal Medicine and the American Board of Dermatology. He was a member of the International Society for Dermatologic Surgery, International Society of Cosmetic Laser Surgeons, American Medical Association, American Society for Dermatologic Surgery, Dermatology Foundation Leaders Society, and Florida Medical Association, among others.

Dr Brandt wrote two books about skin aging and maintaining a youthful appearance: 10 Minutes/10 Years: Your Definitive Guide to a Beautiful and Youthful Appearance and Age-less: The Definitive Guide to Botox, Collagen, Lasers, Peels, and Other Solutions for Flawless Skin.

“He had some novel ideas, concepts, and techniques in terms of the use of botulinum toxin and filler substances,” Dr Geronemus said. “[M]any physicians in the country and around the world have adopted them into their daily practice.”

Dr Brandt claimed he tested every product he used on himself before using them on his patients.

The rise of the ‘Botox boob job’

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  • The ‘Botox boob job’ involves having Botox injected into pectoral muscles
  • Relaxing effect forces the shoulder and chest muscles to take the strain
  • As a result, breasts look perkier, higher and up to a cup size larger
  • Dr Neetu Nirdosh says it is becoming increasingly popular with celebrities
  • Treatment costs £1,000 and lasts for six months but avoids scarring 

Bust-boosting surgery has never been more popular, with more than 11,000 boob job operations taking place in the UK alone each year.

But not everyone wants to go under the knife, including some of the A-list clients who visit Harley Street medic Dr Neetu Nirdosh.

Instead of scalpels and implants, they are opting for a new treatment which has been dubbed ‘the Botox boob job’ and uses injectables to plump up the cleavage.

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New look: The 'Botox boob job' is said to boost the breasts by up to a cup size but only lasts for six months

New look: The ‘Botox boob job’ is said to boost the breasts by up to a cup size but only lasts for six months

‘The Breastox- Botox is fast becoming the must have pre-red carpet procedure for my celebrity clients,’ explains Dr Nirdosh. 

The £1,000 treatment involves injecting Botox into the pectoral muscles which temporarily relaxes them, leaving the shoulder and surrounding chest muscles to take the strain.

As a result, breasts are lifted and look higher and firmer, although given Botox wears off, the effect lasts for a maximum of six months.

‘There’s no downtime, no reported side effects, no scars and it is virtually painless,’ adds Dr Nirdosh.

‘It takes less than 30 minutes and is the ideal treatment for women suffering from post-pregnancy droopy boobs, ageing, sagging breasts or a wrinkly bust line as a result of sun damage.

Popular: Botox is the most popular injectable in use in the UK and accounts for 45,464 treatments a year

Popular: Botox is the most popular injectable in use in the UK and accounts for 45,464 treatments a year

Risky: Breast enhancement isn't without its risks as the recent PIP implant scandal demonstrated

Risky: Breast enhancement isn’t without its risks as the recent PIP implant scandal demonstrated

‘It is also good if you want a bit of extra support so you can go braless as many of my red carpet clients do.’

Traditional breast enhancement involves having a cut made either beneath the breasts or in the armpits and inserting a silicone implant between the breast tissue and the chest muscle.

Operations cost between £3,500 and £5,000 and, according to the NHS, complications can include infection, scarring and loss of sensation in the nipple.

Nevertheless, according to figures produced by the British Association of Aesthetic Surgeons [BAAPS], they remain one of the most popular cosmetic surgeries.

But thanks to scandals such as the PIP implant saga, which saw women fitted with enhancements made with industrial, rather than medical, grade silicone, many are turning to ‘safer’ injectables such as Botox.

Although Macrolane, a filler marketed as a ‘lunchtime boob jab’ was withdrawn from sale two years ago following claims that 25 per cent of patients suffered complications after the treatment, others have proved considerably less problematic.

Among them is Botox, which, according to the International Society of Aesthetic Plastic Surgeons [ISAPS], is the most popular non-surgical cosmetic treatment in the world.

In total, say ISAPS, 45,464 Botox injections were carried out by qualified practitioners on British women last year.

 

Botox ‘stunts emotional growth’

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By Smitha MundasadHealth reporter, BBC News

Picture of an injection given to the forehead
Botox is the most well-known version of this drug and is made using a toxic protein

Giving young people Botox treatment may restrict their emotional growth, experts warn.

Writing in the Journal of Aesthetic Nursing, clinicians say there is a growing trend for under-25s to seek the wrinkle-smoothing injections.

But the research suggests “frozen faces” could stop young people from learning how to express emotions fully.

A leading body of UK plastic surgeons says injecting teenagers for cosmetic reasons is “morally wrong”.

Botox and other versions of the toxin work by temporarily paralysing muscles in the upper face to reduce wrinkling when people frown.

Mimicking to learn

Nurse practitioner Helen Collier, who carried out the research, says reality TV shows and celebrity culture are driving young people to idealise the “inexpressive frozen face.”

But she points to a well-known psychological theory, the facial feedback hypothesis, that suggests adolescents learn how best to relate to people by mimicking their facial expressions.

She says: “As a human being our ability to demonstrate a wide range of emotions is very dependent on facial expressions.

“Emotions such as empathy and sympathy help us to survive and grow into confident and communicative adults.”

But she warns that a “growing generation of blank-faced” young people could be harming their ability to correctly convey their feelings.

“If you wipe those expressions out, this might stunt their emotional and social development,” she says.

The research calls for practitioners to use assessment tools to decide whether there are clear clinical reasons for Botox treatment.

Several assessment scales exist that take into account how thick the skin is, how sun-damaged it appears, and the depth of any wrinkles, but experts warn that some Botox clinics are putting financial gain first.

Natural emotions

Ms Collier calls on therapists to spend time helping young people boost their confidence rather than reaching for injections.

She adds: “Though most of the effects of the toxin are temporary, research suggests the muscles don’t fully recover from injections.

“We really need to understand the consequences of starting treatments too soon.”

Dr Michael Lewis, a researcher in psychology at Cardiff University, says: “The expressions we make on our face affect the emotions we feel.

“We smile because we are happy, but smiling also makes us happy.

“Treatment with drugs like Botox prevents the patient from being able to make a particular expression and can therefore have an effect on our learning to feel emotions naturally.”

Rajiv Grover, president of the British Association of Aesthetic Plastic Surgeons, says: “Injecting teenagers with Botox for cosmetic purposes is morally wrong and something that no ethical practitioner would do.

“This can only exacerbate body image issues at a vulnerable time.”

Ms Collier’s research will be presented at the Clinical Cosmetic and Reconstructive Expo in October.

Botox may have cancer fighting role

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Botox injection

Botox injections – beloved by those seeking a wrinkle-free face – may help fight cancer, animal tests suggest.

The study, published in Science Translational Medicine, showed nerves help stomach cancers grow.

Research on mice found that using the toxin to kill nerves could halt the growth of stomach tumours and make them more vulnerable to chemotherapy.

Cancer Research UK said it was early days and it was unclear whether the injections could help save lives.

Botox is usually used in the fight against the signs of ageing, not cancer.

The toxin disrupts nerve function to relax muscles and even out wrinkles, but a growing body of work suggests nerves can also help fuel cancer growth.

Stomach cancer

Scientists Columbia University Medical Centre, in New York, and the Norwegian University of Science and Technology in Trondheim investigated the role of the vagus nerve – which runs from the brain to the digestive system – in stomach cancer.

Either cutting the nerve or using the toxin Botox slowed the growth of tumours or made them more responsive to chemotherapy.

One of the scientists, Dr Timothy Wang, told the BBC: “If you just cut nerves is it going to cure cancer? Probably not.

“At least in early phase, if you [disrupt the nerve] the tumour becomes much more responsive to chemotherapy, so we don’t see this as a single cure, but making current and future treatments more effective.”

Stomach cancer
Stomach cancer can be fuelled by nerves

Some trials have started in people who are having surgery to remove a stomach cancer. There has also been research suggesting nerves may have a role in prostate cancer too.

However, Dr Wang acknowledged that there was a long way to go before this could be considered a treatment.

“With everything new in cancer, even if it looks great, when you start to roll it out to patients it always seems cancer is smarter than we are.

“Tumours have the ability to out-evolve any single agent, knocking one leg of a stool is probably not going to topple it.

“But I think this has a lot of potential and in a decade or two I can see these pathways being targeted.”

Eleanor Barrie, senior science communications manager at Cancer Research UK, said: “Over the last few years, some evidence has emerged that certain stomach cancers might depend on signals from the nervous system to grow.

“This interesting study adds to that evidence, and shows how probing the inner workings of cancer can spark ideas for innovative new treatments. But the research is at an early stage and it’s not yet clear if this particular approach could help to save patients’ lives.”

‘Needle risk’ over beauty treatments.

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A health watchdog is concerned that people having beauty treatments like Botox could be at risk of infection from dirty needles.

The National Institute for Health and Care Excellence says growing numbers of people are injecting tanning agents, dermal fillers and Botox at home and in salons, and some are lax about hygiene.

Sharing needles can spread blood-borne diseases like HIV and hepatitis C.

Nice is updating its advice for England and Wales accordingly.

The guidelines, which are out for public consultation, aim to encourage people to use sterile needle and syringe programmes to stem the spread of infections.

Sharps bins

Most blood-borne diseases occur among people who inject drugs like heroin and anabolic steroids.

But NICE says people seeking out cosmetic fixes are also at risk.

“Start Quote

The dangers of sharing needles in cosmetic injectables are so great that any practitioner who does this should be considered guilty of a criminal offence and nothing less”

President of BAAPS Rajiv Grover

A spokeswoman said: “We are seeing an increasing issue with drugs that are used for vanity purposes.”

This includes the anti-wrinkle treatment Botox, dermal fillers and tanning agents.

Prof Mike Kelly, Director of the NICE Centre for Public Health Excellence, said: “Since we last published our guidance on needle and syringe programmes in 2009, we’ve seen an increase in the use of performance-and-image-enhancing drugs such as anabolic steroids, Botox, tanning agents and the use of dermal fillers like collagen.

“We’ve also heard anecdotal evidence that more teenagers are injecting these performance-and-image-enhancing drugs too.

“We’re updating our guidance – and our public consultation on the draft update is an important part of this process – to make sure all of these groups of people are considered in the planning and delivery of needle and syringe programmes.”

One of the recommendations proposed in the new guidelines is that local councils consider providing sharps boxes for people to dispose of used needles and syringes.

Rajiv Grover, consultant plastic surgeon and president of the British Association of Aesthetic Plastic Surgeons (BAAPS), said: “Due to the lack of regulation in the cosmetic sector it is impossible to know how many patients could be at risk of blood borne diseases from needle sharing with either Botox or fillers.

“These should be considered medical procedures and BAAPS has campaigned for over a decade to have this field of non-surgical cosmetic treatments tightly regulated. The dangers of sharing needles in cosmetic injectables are so great that any practitioner who does this should be considered guilty of a criminal offence and nothing less.”

Allergan, a healthcare company that provides Botox, said that Botox is a prescription-only medicine which should only be administered by a trained and qualified medical healthcare professional.

“These treatments should be carried out by appropriately trained and qualified medical practitioners, who have high levels of expertise in full-face anatomy and can provide sufficient aftercare and redress for the patient in the event of an adverse event,” said a spokesman.

Doctors and pharma in China.

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Doctor—patient relationships in China are in crisis. Doctors have been injured or even killed by patients at work. One of the major drivers might be the unhealthy and unethical relations between many doctors and some drug companies.

china

On July 8, GlaxoSmithKline (GSK) said that they were investigating allegations that its staff had improperly used cash and other incentives to encourage the prescription of onabotulinumtoxin A (Botox) in China. The company added that “inquiries to date have found no evidence of bribery or corruption in relation to our sales and marketing of therapeutic Botox in China.”

The Lancet has no evidence to suggest that the allegations against GSK in China are true. However, some observers claim that bribing doctors to boost drug prescriptions by some drug companies is an open secret, and that this alleged practice has compromised the public’s trust in doctors. The varieties of unethical relationships that exist between some doctors and some of the drug companies in China are said to range from cash kickbacks, lavish gifts or entertainment, ghost writing services, sponsored supplements in journals, and all-expenses-paid trips. There is real concern that doctors’ prescriptions are therefore not based solely on patient need and clinical evidence, but may be biased by commercial interests.

The perceived unethical association between physicians and industry in China is worrying, because it inevitably harms patients as well as doctors. It damages the doctor—patient relationship and, ultimately, China’s whole health system. The GSK China allegations, although unproven, have clearly rung an alarm bell for China’s regulatory authorities to ensure the drug industry promotes products in a responsible, ethical, and professional way. Chinese doctors should rely on evidence-based clinical guidelines to inform their practice, and are in urgent need of guidance on their collaborations with the drug industry in various areas such as patient care, professional education, and research. Furthermore, training for doctors in China on managing their relationships ethically with the drug industry and other organisations should start at medical school and be part of continuing professional education.

Source: Lancet