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Laohawiriyakamol T, Boonsri P, Phutphithak K, Niyomkarn T, Klabklay P, Chuaychoosakoon C. Appropriate intradeltoid muscle needle penetration depth in vaccine administration: an MRI study in Thailand. Front Immunol 2023; 14:1302891. [PMID: 38162663 PMCID: PMC10757374 DOI: 10.3389/fimmu.2023.1302891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/27/2023] [Indexed: 01/03/2024] Open
Abstract
Objective The objective of this study was to evaluate the appropriate vaccination needle penetration depth into the deltoid muscle to avoid injection-site complications from an inappropriate injection depth and/or injection site in the Thai population. Methods This was a retrospective study using axial proton density-weighted images of MRI shoulders at the level of 2 fingerbreadths below the acromion process to measure the combined thickness of the skin, subcutaneous fat pad and deltoid muscle to evaluate the percentage of injections into the deltoid muscle with various needle penetration depths. Results There were 509 MRI shoulder images of 222 males and 287 females (265 right shoulders and 244 left shoulders). The average body mass index and age were 24.54 ± 3.54 kg/m2 and 64.81 ± 10.20 years, respectively. Using a needle penetration depth of 12.7 mm (0.5 inches) achieved 100% of injections into the deltoid muscle. Conclusion We recommend advancing the entire length of a 0.5-inch needle perpendicular to the skin at 2 fingerbreadths below the acromion process for adult intradeltoid vaccinations. This approach ensures optimal vaccine delivery and minimizes the risk of injection-related injuries.
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Shapiro JR, Seddu K, Park HS, Lee JS, Creisher PS, Yin A, Shea P, Kuo H, Li H, Abrams E, Leng SX, Morgan R, Klein SL. The intersection of biological sex and gender in adverse events following seasonal influenza vaccination in older adults. Immun Ageing 2023; 20:43. [PMID: 37644610 PMCID: PMC10463383 DOI: 10.1186/s12979-023-00367-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 07/22/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Women/females report more adverse events (AE) following immunization than men/males for many vaccines, including the influenza and COVID-19 vaccines. This discrepancy is often dismissed as a reporting bias, yet the relative contributions of biological sex and gender are poorly understood. We investigated the roles of sex and gender in the rate of AE following administration of the high-dose seasonal influenza vaccine to older adults (≥ 75 years) using an AE questionnaire administered 5-8 days post-vaccination. Participant sex (male or female) was determined by self-report and a gender score questionnaire was used to assign participants to one of four gender categories (feminine, masculine, androgynous, or undifferentiated). Sex steroid hormones and inflammatory cytokines were measured in plasma samples collected prior to vaccination to generate hypotheses as to the biological mechanism underpinning the AE reported. RESULTS A total of 423 vaccines were administered to 173 participants over four influenza seasons (2019-22) and gender data were available for 339 of these vaccinations (2020-22). At least one AE was reported following 105 vaccinations (25%), by 23 males and 82 females. The majority of AE occurred at the site of injection, were mild, and transient. The odds of experiencing an AE were 3-fold greater in females than males and decreased with age to a greater extent in females than males. The effects of gender, however, were not statistically significant, supporting a central role of biological sex in the occurrence of AE. In males, estradiol was significantly associated with IL-6 and with the probability of experiencing an AE. Both associations were absent in females, suggesting a sex-specific effect of estradiol on the occurrence of AE that supports the finding of a biological sex difference. CONCLUSIONS These data support a larger role for biological sex than for gender in the occurrence of AE following influenza vaccination in older adults and provide an initial investigation of hormonal mechanisms that may mediate this sex difference. This study highlights the complexities of measuring gender and the importance of assessing AE separately for males and females to better understand how vaccination strategies can be tailored to different subsets of the population.
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Affiliation(s)
- Janna R Shapiro
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Kumba Seddu
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Han-Sol Park
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - John S Lee
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Patrick S Creisher
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Anna Yin
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Patrick Shea
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Helen Kuo
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Huifen Li
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Engle Abrams
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sean X Leng
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rosemary Morgan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sabra L Klein
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Kowatari R, Sasaki H, Murata K, Sato K, Sagawa K, Kudo M, Minakawa M. Establishment of prediction equations for subcutaneous tissue thickness in two representative intramuscular deltoid injections. Vaccine X 2023; 14:100316. [PMID: 37275271 PMCID: PMC10239006 DOI: 10.1016/j.jvacx.2023.100316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 05/17/2023] [Accepted: 05/18/2023] [Indexed: 06/07/2023] Open
Abstract
This study clarifies the predicted subcutaneous shoulder depth and investigates the safety of the conventional (three-finger breadth method) and new (axillary method) intramuscular injection methods. The anatomical features of 245 volunteers who received the COVID-19 vaccination via the conventional method were investigated at the injection site (T point) and the hypothetical injection site using the new method (A point) via ultrasonography. The body mass index (BMI) and subcutaneous thickness at the T point (men: r = 0.75; women: r = 0.45) and the A point (men: r = 0.81; women: r = 0.55) were positively correlated. The upper arm circumference and subcutaneous thickness at the T point (r = 0.51) and the A point (r = 0.58) were correlated in women. Formulas to predict subcutaneous thickness using BMI and upper arm circumference were established: predicted subcutaneous thickness at the A point = 0.62 × BMI - 7.7 mm (R2 = 0.66) in men and 0.658 × BMI - 5.5 mm (R2 = 0.31) in women. This study demonstrates safe intramuscular injection sites and their depth.
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Affiliation(s)
- Ryosuke Kowatari
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University School of Medicine, Japan
| | - Hanae Sasaki
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University School of Medicine, Japan
| | - Kenyu Murata
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University School of Medicine, Japan
| | - Ken Sato
- Hirosaki University Health Administration Center, Japan
| | - Koichi Sagawa
- Hirosaki University Graduate School of Science and Technology, Japan
| | - Masako Kudo
- Hirosaki University Hospital Nursing Department, Japan
| | - Masahito Minakawa
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University School of Medicine, Japan
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Hemingway S, Lui S, White J. Considering skin-to-muscle depth for successful intramuscular injections in an increasingly obese population. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2023; 32:628-635. [PMID: 37410678 DOI: 10.12968/bjon.2023.32.13.628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
BACKGROUND Intramuscular (IM) injection practice is an essential nursing skill. Current practice relies on clinical judgement to determine needle length (unless specified in the medicine's product licence). Obesity is increasing in the global population, but guidelines have largely ignored how to select needle length to meet individual patient need. AIM The aim of this review was to systematically review the skin-to-muscle depth required to achieve injection into muscle in adults. The objectives were to identify any implications of obesity status when selecting an appropriate needle length and site in clinical practice. Search and review methodology: Studies of subjects above the age of 18 years using observational or experimental designs where the distance from the skin to muscle had been measured at any IM injection site, and obesity status was reported, were included in the search strategy. The primary outcome of interest was the distance from skin surface to muscle penetration. FINDINGS 14 studies were identified that investigated the dorsogluteal, ventrogluteal, deltoid and vastus lateralis sites, all used cross-sectional observational designs. Ten used ultrasound, three used computed tomography (CT) and one used magnetic resonance imaging. Obesity status was reported as BMI or hip-to-waist ratio. In all studies there was a correlation between obesity status and the distance from skin surface to muscle. In females this exceeded 37 mm at both gluteal sites, independent of obesity status. CONCLUSIONS There should be an assessment of obesity status before selecting needle length for IM injections in both genders. Needles longer than the standard 37 mm are recommended for all females, whatever their obesity status, for any gluteal site. Injections into gluteal sites should be avoided in females who are obese. Deltoid injections are more likely to achieve muscle penetration in both genders, and in patients who are overweight or obese. Further research is required.
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Affiliation(s)
| | - Steve Lui
- Senior Lecturer, University of Huddersfield
| | - Jacqueline White
- Professor of Nursing and Head of School of Nursing and Midwifery, Faculty of Health Sciences, University of Hull
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Mardourian M, Hao KA, Wiggins W, Arias J, King JJ, Wright TW, Wright JO. Optimizing needle length and site choice for adult immunization. Vaccine 2023:S0264-410X(23)00697-7. [PMID: 37365058 DOI: 10.1016/j.vaccine.2023.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 05/01/2023] [Accepted: 06/06/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND Current recommendations for needle length and vaccination site for intramuscular deltoid vaccinations are backed by minimal data. AIM To determine the ideal needle length and vaccination site for intramuscular deltoid vaccine administration. METHODS 120 shoulder CT scans were evaluated and grouped by patient weight and sex as recommended by the United States CDC: Group 1, <60 kg, Group 2, 60-70 kg, Group 3, females 70-90 kg and males 70-118 kg, and Group 4, females > 90 kg and males > 118 kg. For each group, distance from skin to deltoid fascia and deltoid muscle width were measured at 2, 4, and 6 cm distal to the posterolateral corner of the acromion for 5 unique trajectories. Needle lengths of 0.625″, 1.0″, and 1.5″ were simulated at each site to determine inoculation location relative to the deltoid. RESULTS For Group 1, a 0.625″ needle in the mid-lateral (ML) trajectory 4 cm distal to the posterolateral corner provided a perfect rate of successful inoculations (100 %). For Groups 2-3, a 1″ needle in the posterolateral (PL) trajectory 4 cm distal provided high rates (>80 %) of successful intramuscular inoculations with low rates of overpenetration (<15 %) while minimizing risk to the axillary nerve. For Group 4, a 1.5″ needle using the same strategy provided the highest rate of successful inoculations (96 %) and minimal overpenetration (4 %). Overpenetration was associated with more anterior and superior injection sites (P < 0.001 for both) for all needle lengths. CONCLUSIONS The overall ideal injection site to maximize successful intramuscular vaccine administration, minimize overpenetration, and avoid axillary nerve injury is 4 cm distal to and in line with the posterolateral corner of the acromion, a site more posterior and inferior than current CDC recommendations. We caution against use of a 1.5″ needle for patients < 118 kg due to high predicted rates of overpenetration.
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Affiliation(s)
| | - Kevin A Hao
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Whitman Wiggins
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Jonathan Arias
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Joseph J King
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Thomas W Wright
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Jonathan O Wright
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL, USA.
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Bchini R, Goutte N. [Evidence-based practice and nursing: intramuscular injection in psychiatry]. Soins Psychiatr 2023; 44:21-26. [PMID: 37328226 DOI: 10.1016/j.spsy.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Intramuscular injection is a frequent technical procedure in psychiatry. In France, nurses who perform this care do not have official guidelines for good practice. The advanced practice nurse is a field actor who can promote evidence-based practice to improve the quality of care for the benefit of the patient.
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Affiliation(s)
- Rayan Bchini
- Groupement hospitalier de territoire Psy Sud Paris, Groupe hospitalier Paul-Guiraud, 54 avenue de la République, BP 20065, 94806 Villejuif cedex, France; Inserm UMR 1018 CESP UPS UVSQ, équipe Moods, Hôpital Paul-Brousse, Bâtiment 15-16, 16 avenue Paul-Vaillant-Couturier, 94807 Villejuif cedex, France; Université Paris Cité 2 rue Valette, 75005 Paris, France.
| | - Nathalie Goutte
- Inserm UMR 1193, Hôpital Paul-Brousse, Groupe hospitalier Paris Sud, 12-14 avenue Paul-Vaillant-Couturier, 94807 Villejuif cedex, France
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7
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Gulnar E, Ordu Y, Biyik Bayram S, Çalışkan N. Gluteal muscle and subcutaneous tissue thicknesses in adults: a systematic review and meta-analysis. J Res Nurs 2023; 28:181-196. [PMID: 37332320 PMCID: PMC10272691 DOI: 10.1177/17449871231155769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023] Open
Abstract
Background Nurses often administer intramuscular injections at the gluteal site. This study aimed to determine gluteal muscle and subcutaneous tissue thicknesses in adults. Methods Systematic review and meta-analysis. The databases Turkish Medline, Ulakbim, National Thesis Center, Cochrane, Web of Science, Science Direct, PubMed, CINAHL Plus with Full text (EBSCO host), OVID and SCOPUS were screened using the keywords 'intramuscular injection', 'subcutaneous tissue thickness', 'muscle tissue thickness' and 'needle length' between April and May 2021. The studies were evaluated with ultrasound. This study was reported according to the PRISMA recommendations. Results Six studies met the eligibility criteria. The total sample size was 734 (women: 432, men: 302). The V method revealed that the ventrogluteal site had a muscle and subcutaneous tissue thickness of 38.071 ± 2.119 and 19.927 ± 2.493 mm, respectively. The geometric method revealed that the ventrogluteal site had a muscle and subcutaneous tissue thickness of 35.989 ± 4.190 and 19.661 ± 3.992 mm, respectively. The geometric method also revealed that the dorsogluteal site had a thickness of 42.560 ± 8.840 mm. According to the V method, females had thicker subcutaneous tissue at the ventrogluteal site than males (Q = 5.37, df = 1, p = 0.0204). Body mass index did not affect the subcutaneous tissue thicknesses at the ventrogluteal site. Conclusion The results show that gluteal muscle, subcutaneous and total tissue thicknesses vary across injection sites.
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Affiliation(s)
- Emel Gulnar
- Associate Professor, RN, Department of Nursing, Faculty of Health Sciences, Kırıkkale University, Kırıkkale, Turkey
| | - Yadigar Ordu
- Lecturer, RN, Eldivan Health Services Vocational School, Cankiri Karatekin University, Cankiri, Turkey
| | - Sule Biyik Bayram
- Assistant Professor, RN, Department of Nursing, Faculty of Health Sciences, Karadeniz Technical University, Trabzon, Turkey
| | - Nurcan Çalışkan
- Professor, RN, Faculty of Nursing, Gazi University, Ankara, Turkey
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8
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When should a longer needle be used for intramuscular injection in obese patients? A combined analysis of New Zealand data. Vaccine 2023; 41:2690-2695. [PMID: 36935287 DOI: 10.1016/j.vaccine.2023.03.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/14/2023] [Accepted: 03/08/2023] [Indexed: 03/19/2023]
Abstract
AIM To estimate thresholds for Body Mass Index (BMI) and arm circumference above which a longer needle is needed to ensure intramuscular (IM) delivery of a vaccine in the deltoid muscle at the site recommended by New Zealand (NZ) immunization guidelines. METHODS A combined analysis of two studies, including 442 adults, with measurements of arm circumference, BMI and skin to deltoid muscle distance (SDMD) at the NZ immunization guideline-recommended IM injection site. Receiver Operator Characteristic curves identified arm circumference and BMI cut-points that gave 100% sensitivity for SDMD thresholds. These thresholds were: SDMD of 20 mm, accounting for a minimal penetration of 5 mm into muscle with the standard needle; and 25 mm, which is the length of a standard needle for IM injection, representing the depth this can reach. RESULTS Cut-point values for arm circumference, at which a longer needle would be required, were higher for males than females: 35 cm versus 30 cm for the 20 mm cut-point, and 40 cm versus 36.7 cm for the 25 mm cut-point respectively. The BMI cut-points were also higher for male than females: 24.6 kg/m2 versus 23.7 kg/m2 for the 20 mm cut-point, and 38.2 kg/m2 vs 31.6 kg/m2 for the 25 mm cut-point respectively. CONCLUSION Arm circumference and BMI cut-points provide practical measures from which to choose a needle length that increases the chance of successful IM vaccination. Based on our data, an arm circumference of 35 cm for men and 30 cm for women should prompt selection of a longer needle to ensure intramuscular injection at the deltoid site. Thresholds for the different skin to deltoid sites proposed internationally should be determined to enable successful IM vaccination in clinical practice beyond NZ.
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9
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Shapiro JR, Seddu K, Park HS, Lee JS, Creisher PS, Yin A, Shea P, Kuo H, Li H, Abrams E, Leng SX, Morgan R, Klein SL. The intersection of biological sex and gender in adverse events following seasonal influenza vaccination in older adults. RESEARCH SQUARE 2023:rs.3.rs-2557775. [PMID: 36798418 PMCID: PMC9934749 DOI: 10.21203/rs.3.rs-2557775/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Background Women/females report more adverse events (AE) following immunization than men/males for many vaccines, including the influenza and COVID-19 vaccines. This discrepancy is often dismissed as a reporting bias, yet the relative contributions of biological sex and gender are poorly understood. We investigated the roles of sex and gender in the rate of AE following administration of the high-dose seasonal influenza vaccine to older adults (≥ 75 years) using an AE questionnaire administered 5-8 days post-vaccination. Participant sex (male or female) was determined by self-report and a gender score questionnaire was used to assign participants to one of four gender categories (feminine, masculine, androgynous, or undifferentiated). Sex steroid hormones and inflammatory cytokines were measured in plasma samples collected prior to vaccination to elucidate a possible biological mechanism for the AE reported. Results A total of 423 vaccines were administered to 173 participants over four influenza seasons (2019-22) and gender data were available for 339 of these vaccinations (2020-22). At least one AE was reported following 105 vaccinations (25%), by 23 males and 82 females. The majority of AE occurred at the site of injection, were mild, and transient. The odds of experiencing an AE were 3-fold greater in females than males and decreased with age to a greater extent in females than males. The effects of gender, however, were not statistically significant, supporting a central role of biological sex in the occurrence of AE. In males, estradiol was significantly associated with IL-6 and with the probability of experiencing an AE. Both associations were absent in females, suggesting a sex-specific effect of estradiol on the occurrence of AE that supports the finding of a biological sex difference. Conclusions These data support a larger role for biological sex than for gender in the occurrence of AE following influenza vaccination in older adults and provide an initial investigation of hormonal mechanisms that may mediate this sex difference. This study highlights the complexities of measuring gender and the importance of assessing AE separately for males and females to better understand how vaccination strategies can be tailored to different subsets of the population.
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Affiliation(s)
| | - Kumba Seddu
- Johns Hopkins Bloomberg School of Public Health
| | | | - John S Lee
- Johns Hopkins Bloomberg School of Public Health
| | | | - Anna Yin
- Johns Hopkins Bloomberg School of Public Health
| | | | - Helen Kuo
- Johns Hopkins Bloomberg School of Public Health
| | - Huifen Li
- Johns Hopkins University School of Medicine
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Kearns C, Houghton C, Dickinson E, Hatter L, Bruce P, Krishnamoorthy S, Weatherall M, Hills T, Doppen M, Ali Mirjalili S, Beasley R. What variables should inform needle length choice for deltoid intramuscular injection? A systematic review. BMJ Open 2023; 13:e063530. [PMID: 36669836 PMCID: PMC9872490 DOI: 10.1136/bmjopen-2022-063530] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 01/05/2023] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES (1) Assess the distribution of skin-to-deltoid-muscle distance (SDMD) at the deltoid intramuscular (IM) injection site; (2) its relationship with demographic and anthropometric variables and (3) Consider the findings in relation to clinical guidance on IM injection, such as COVID-19 vaccines. DESIGN Systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. DATA SOURCES MEDLINE, EMBASE, ClinicalTrials.gov, Cochrane Library, CINAHL and SCOPUS between June and July 2021 with no publication date limit. ELIGIBILITY CRITERIA Studies reporting measurements of the SDMD in living adults aged 16 years and older, at the deltoid IM injection site, published in English were considered. DATA EXTRACTION AND SYNTHESIS Two independent reviewers performed each stage of screening, data extraction and quality assessments using the Joanna Briggs Institute Critical Appraisal Checklist for analytical cross sectional studies. RESULTS 16 105 papers were identified, of which 11 studies were suitable for review, representing 1414 participants. Heterogeneity in the definition of the deltoid IM injection site, locations measured and methods of measurement precluded meta-analysis. Evidence from ultrasound SDMD measurements demonstrated some patients in all but 'underweight' body mass index (BMI) categories, may require needles longer than 25 mm for successful IM injection. Calliper measurements overestimated SDMD compared with ultrasound. Female sex, higher BMI categories and greater weight in women were associated with greater SDMD. CONCLUSIONS The reviewed evidence was insufficient to inform definitive needle length 'cut points' for IM injection based on demographic or anthropomorphic variables. Contemporary clinical guidance currently based on this evidence, including the site of injection and choice of needle length, may result in subcutaneous administration in a small proportion of recipients, particularly if obese or of female sex. PROSPERO REGISTRATION NUMBER CRD42021264625.
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Affiliation(s)
- Ciléin Kearns
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Claire Houghton
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Emily Dickinson
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Capital and Coast District Health Board, Wellington, New Zealand
| | - Lee Hatter
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Pepa Bruce
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Srinidhi Krishnamoorthy
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Capital and Coast District Health Board, Wellington, New Zealand
| | | | - Thomas Hills
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Auckland District Health Board, Auckland, New Zealand
| | - Marjan Doppen
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | | | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand
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11
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Kang BH, Lee DW, Kang S, Yoon JS. Risk assessment of dorsal scapular nerve injury in the medial scapular area associated with upper extremity position: An ultrasonographic study. Muscle Nerve 2023; 67:39-44. [PMID: 36354084 DOI: 10.1002/mus.27750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 11/01/2022] [Accepted: 11/06/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION/AIMS Injuries to the dorsal scapular nerve (DSN) in the interscapular region are relatively uncommon. Physicians may therefore underestimate the risk of damage to the DSN during procedures. The aim of this study was to identify the topographic position of the DSN in the interscapular region and to identify injection positions for the upper extremities that minimize the risk of damage to the DSN during procedures. METHODS The positional relationships between the DSN and scapula were quantified by ultrasonography in 46 healthy volunteers. The distances between the medial scapular line and DSN and the DSN depths from the surface in Zones 1 (the superior angle), 2 (the scapular spine), and 3 (between the scapular spine and inferior angle) were measured in the anatomical and contralateral shoulder touch positions (positions 1 and 2, respectively). RESULTS The DSN was located further away from the medial border of the scapula and closer to the skin in position 2 than in position 1. The horizontal distance of the DSN in Zone 2 differed significantly between the two positions (0.85 ± 0.38 vs 1.23 ± 0.38, P < .001). The results suggest a safe area as just medial to the medial scapular border in Zone 2 in position 2. The safety margin should be considered at least 1.5 cm medial to the medial border of the scapula in Zone 3 in position 1. DISCUSSION Performing invasive procedures in the interscapular region, appropriate individualized positioning may reduce the risk of DSN injury.
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Affiliation(s)
- Byung Heon Kang
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, Korea
| | - Dae Wook Lee
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, Korea
| | - Seok Kang
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, Korea
| | - Joon Shik Yoon
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, Korea
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12
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COVID-19 vaccination and the skin to deltoid MUSCLE distance in adults with diabetes. Vaccine X 2022; 13:100248. [PMID: 36536872 PMCID: PMC9753456 DOI: 10.1016/j.jvacx.2022.100248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 10/02/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Objectives To estimate the proportion of adult diabetics with a skin to deltoid muscle distance (SDMD) of > 25 mm, representing a distance greater than the standard needle length used for intramuscular COVID-19 vaccination, and to assess whether anthropometric measurements predict ultrasound SDMD measurements. Design Non-interventional cross-sectional study. Setting Single site, non-clinical setting, Wellington, New Zealand. Participants One hundred participants (50 females) aged at least 18 years diagnosis with diabetes. All participants completed the study. Main outcome measures The proportions of participants with a SDMD > 25 mm and a SDMD > 20 mm (indicating that the needle would not have penetrated at least 5 mm into the deltoid, which is considered necessary to ensure deposition of vaccine into muscle); the relationship between anthropometric measurements (body weight, body height, body mass index (BMI), skinfold thickness, arm circumference) and SDMD measured by ultrasound. Results The proportion (95 %CI) of participants with a SDMD > 25 mm was 6/100; 6 % (2.2 to 12.6), and the proportion with a SDMD > 20 mm was 11 % (5.6 to 18.8), of which 9/11 had a BMI ≥ 30 kg/m2 and 9/11 were female. The strongest relationships between anthropometric measurements and SDMD were with arm circumference (r = 0.76, P < 0.001) and BMI (r = 0.73, P < 0.001). Arm circumference and BMI were the best predictors of SDMD measurements with AUC for ROC curves of 0.99 and 0.94 above the 25 mm cut point, 0.97 and 0.89 above the 20 mm cut point respectively. Conclusions The standard needle length of 25 mm is likely to be insufficient to ensure deposition of COVID-19 vaccine within the deltoid muscle in a small but important proportion of obese adults with diabetes. Arm circumference and BMI are simple measurements that could identify those that need a long needle to ensure successful intramuscular vaccine administration. Funding Ruth Maud Ring Spencer Estate; Health Research Council of New Zealand (Independent Research Organisation).
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13
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Cook IF. Localized lipoatrophy and inadvertent subcutaneous administration of a COVID-19 vaccine. Hum Vaccin Immunother 2022; 18:2042136. [PMID: 35258436 PMCID: PMC9196709 DOI: 10.1080/21645515.2022.2042136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 60-year-old woman presented with a depressed lesion at the site of her first COVID-19 (Astra Zeneca) vaccine injection. The lesion was diagnosed as a case of injection related localized lipoatrophy as markers of autoimmune disease were negative and biopsy differentiated it from localized involutional lipoatrophy. This case of localized lipoatrophy was likely due to inadvertent subcutaneous injection of the COVID-19 vaccine with a 16 mm long needle.
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Affiliation(s)
- Ian F Cook
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
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14
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Bass JR, Poland GA. Shoulder injury related to vaccine administration (SIRVA) after COVID-19 vaccination. Vaccine 2022; 40:4964-4971. [PMID: 35817645 PMCID: PMC9174179 DOI: 10.1016/j.vaccine.2022.06.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 05/13/2022] [Accepted: 06/02/2022] [Indexed: 01/16/2023]
Abstract
OBJECTIVE The global fight against COVID-19 has required mass vaccination clinics as well as mass recruitment of personnel, including many who may not regularly administer intramuscular deltoid immunizations, potentially increasing the incidence of improper intramuscular injection. Shoulder injury related to vaccine administration (SIRVA) is a well-described, preventable injury resulting from improper injection into anatomic structures adjacent to the deltoid muscle leading to mechanical and chemical trauma augmented by an inflammatory immune response to the vaccine and/or adjuvants. SIRVA is best described in the setting of influenza vaccination, and little is known about it as it pertains to COVID-19 vaccination. This study aims to describe SIRVA in the current pandemic, increase clinician awareness, and offer considerations for prevention. METHODS To identify clinical characteristics of patients with post-COVID-19-vaccination shoulder injuries, we performed a systematic review of the cases of vaccination-related shoulder injuries reported in the literature and conducted a review of the public Vaccine Adverse Event Reporting System (VAERS). RESULTS We identified 305 cases of SIRVA in the VAERS database and 28 cases of SIRVA in the setting of COVID-19 vaccination from the literature (n = 333). Patients had a mean age of 51.8 years and a median of 51.5 (range: 19-90) years. Of these, 76.3% were female and 23.7% male. Most patients sought medical evaluation with 54 of the 305 VAERS cases reporting utilizing emergency services. Of patients with imaging-confirmed SIRVA (n = 95), the most common diagnoses were adhesive capsulitis and bursitis, and the most common symptoms were pain (97.7%) and limited range of motion (68.1%). Most patients reported requiring treatment with the majority receiving physical therapy (56.3%), followed by cortisone injection (34.4%). Other modalities used were non-steroidal anti-inflammatory drugs, oral steroids, and surgery. Only 5 patients from this group reported recovery while 60 stated they had not yet recovered. Of those, 23.3% reported disability. CONCLUSION SIRVA should be regarded as an under-reported, significant cause of post-vaccination morbidity. In the setting of COVID-19 mass vaccination, clinicians must be aware of signs and symptoms of SIRVA as well as appropriate diagnostic modalities and treatment options. Additionally, standardization and proper education regarding injection technique and appropriate needle length is imperative to reducing harm.
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Affiliation(s)
| | - Gregory A Poland
- Mayo Clinic Vaccine Research Group, Mayo Clinic, Rochester, MN, United States.
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15
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Hills T, Paterson A, Woodward R, Middleton F, Carlton LH, McGregor R, Barfoot S, Ramiah C, Whitcombe AL, Zimbron VM, Mahuika D, Brown J, Palmer-Neels K, Manning B, Jani D, Reeves B, Whitta GT, Morpeth S, Beasley R, Weatherall M, Jordan A, McIntyre P, Moreland NJ, Mirjalili SA. The effect of needle length and skin to deltoid muscle distance in adults receiving an mRNA COVID-19 vaccine. Vaccine 2022; 40:4827-4834. [PMID: 35792021 PMCID: PMC9239984 DOI: 10.1016/j.vaccine.2022.06.070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/22/2022] [Accepted: 06/23/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND The mRNA COVID vaccines are only licensed for intramuscular injection but it is unclear whether successful intramuscular administration is required for immunogenicity. METHODS In this observational study, eligible adults receiving their first ComirnatyTM/BNT162b2 dose had their skin to deltoid muscle distance (SDMD) measured by ultrasound. The relationship between SDMD and height, weight, body mass index, and arm circumference was assessed. Three needle length groups were identified: 'clearly sufficient' (needle exceeding SDMD by >5 mm), 'probably sufficient' (needle exceeding SDMD by ≤ 5 mm), and 'insufficient' (needle length ≤ SDMD). Baseline and follow-up finger prick blood samples were collected and the primary outcome variable was mean spike antibody levels in the three needle length groups. RESULTS Participants (n = 402) had a mean age of 34.7 years, BMI 29.1 kg/m2, arm circumference 37.5 cm, and SDMD 13.3 mm. The SDMD was >25 mm in 23/402 (5.7%) and >20 mm in 61/402 (15.2%) participants. Both arm circumference (≥40 cm) and BMI (≥33 kg/m2) were able to identify those with a SDMD of >25 mm, the length of a standard injection needle, with a sensitivity of 100% and specificities of 71.2 and 79.9%, respectively. Of 249/402 (62%) participants with paired blood samples, there was no significant difference in spike antibody titres between needle length groups. The mean (SD) spike BAU/mL was 464.5 (677.1) in 'clearly sufficient needle length' (n = 217) compared with 506.4 (265.1) in 'probably sufficient' (n = 21, p = 0.09), and 489.4 (452.3) in 'insufficient needle length' (n = 11, p = 0.65). CONCLUSIONS A 25 mm needle length is likely to be inadequate to ensure vaccine deposition within the deltoid muscle in a small proportion of adults. Vaccine-induced spike antibody titres were comparable in those vaccinated with a needle of sufficient versus insufficient length suggesting deltoid muscle deposition may not be required for an adequate antibody response to mRNA vaccines.
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Affiliation(s)
- Thomas Hills
- Medical Research Institute of New Zealand, New Zealand; Auckland District Health Board, New Zealand
| | - Aimee Paterson
- School of Medical Sciences, The University of Auckland, New Zealand
| | - Rebecca Woodward
- Auckland Radiology Group Auckland Radiology Group, Auckland, New Zealand
| | | | - Lauren H Carlton
- School of Medical Sciences, The University of Auckland, New Zealand
| | - Reuben McGregor
- School of Medical Sciences, The University of Auckland, New Zealand
| | | | - Ciara Ramiah
- School of Medical Sciences, The University of Auckland, New Zealand
| | | | - Victor M Zimbron
- School of Medical Sciences, The University of Auckland, New Zealand
| | - David Mahuika
- School of Medical Sciences, The University of Auckland, New Zealand
| | - Joshua Brown
- School of Medical Sciences, The University of Auckland, New Zealand
| | | | - Brittany Manning
- School of Medical Sciences, The University of Auckland, New Zealand
| | - Devanshi Jani
- School of Medical Sciences, The University of Auckland, New Zealand
| | - Brooke Reeves
- School of Medical Sciences, The University of Auckland, New Zealand
| | - Georgia T Whitta
- School of Medical Sciences, The University of Auckland, New Zealand
| | | | | | - Mark Weatherall
- Capital and Coast District Health Board, New Zealand; University of Otago Wellington, New Zealand
| | | | | | - Nicole J Moreland
- School of Medical Sciences, The University of Auckland, New Zealand.
| | - S Ali Mirjalili
- School of Medical Sciences, The University of Auckland, New Zealand.
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16
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Nakayama T, Sekino H, Aihara H, Kino M. Appropriate Needle Length Determined by Ultrasonic Echography for Intramuscular Injection in Japanese Elderly over 50 Years. Healthcare (Basel) 2022; 10:800. [PMID: 35627937 PMCID: PMC9140583 DOI: 10.3390/healthcare10050800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/30/2022] [Accepted: 04/19/2022] [Indexed: 11/29/2022] Open
Abstract
Adjuvanted vaccines are administered through intramuscular injection. To perform appropriate injection using an appropriate needle in different age groups or different daily living activities, we investigated the depth from the skin surface to muscle fascia and bone in the deltoid muscle area in 156 elderly aged ≥ 50 years by ultrasonic echography. Subjects consisted of 50 healthy elderly aged 50−64 years, 50 subjects aged 65−74 years, and 56 subjects aged ≥ 75 years (20 outpatients, 18 who needed nursing care, and 18 bedridden in a nursing home). The mean depth ± 1.0 SD from the skin surface to muscle fascia was 7.52 ± 2.13 mm for subjects aged ≥ 75 years, being shorter than 9.16 ± 3.02 mm in those aged 50−64years (p < 0.01). The depth from the skin surface to bone was 22.54 ± 3.85 mm for subjects aged ≥ 75 years and 25.41 ± 4.24 mm for those aged 65−74 years, significantly shorter than those aged 50−64 years (p < 0.01), depending on the reduced muscle volume. The subcutaneous volume length was greater in females (8.29 ± 2.63 mm) than in males (5.62 ± 2.80 mm) aged 50−64 years (p < 0.01). A similar result was obtained in those aged 65−74 years, but there was no difference in the muscle volume length. Our study found that a five-eighths of an inch (16 mm) needle was an appropriate length for average-sized elderly aged ≥ 50 years, but it should be longer for those with large body sizes.
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Affiliation(s)
- Tetsuo Nakayama
- Laboratory of Viral Infection, Ömura Satoshi Memorial Institute, Kitasato University, Minato-ku, Shirokane 5-9-1, Tokyo 108-8641, Japan
| | - Hisakuni Sekino
- Sekino Hospital, Toshima-ku, Ikebukuro 3-28-3, Tokyo 171-0014, Japan;
| | - Hirokazu Aihara
- Shiki-Kashiwamachi Clinic, Kashiwa-cho 1-6-74, Shiki 353-0007, Japan;
| | - Minoru Kino
- Department of Pediatrics, Osaka Asahi Children’s Hospital, Asahi-ku, Shinmori 4-13-17, Osaka 535-0022, Japan;
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17
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Aldosary AH. Prolonged shoulder dysfunction after coronavirus disease vaccination: A case of shoulder injury related to vaccine administration. SAGE Open Med Case Rep 2022; 10:2050313X221089494. [PMID: 35433003 PMCID: PMC9008811 DOI: 10.1177/2050313x221089494] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/07/2022] [Indexed: 12/03/2022] Open
Abstract
Shoulder pain is a common symptom after intramuscular vaccination. However, only
a few cases of shoulder joint injury have been reported after coronavirus
disease 2019 vaccination. A 52-year-old woman experienced clinically significant
pain in the left shoulder joint after receiving the first dose of a coronavirus
disease 2019 vaccine. She neglected the shoulder pain, hoping that it would
spontaneously improve without medical attention. However, the pain continued
with obvious limitations in shoulder movement and function. After 8 months, she
presented to the outpatient clinic with a frozen left shoulder. Such rare
consequences of vaccinations, known as shoulder injury related to vaccine
administration, can be prevented by using an appropriate needle gauge and length
according to the patient’s sex and weight with the correct injection site away
from shoulder structures.
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Affiliation(s)
- Ahmad Hamad Aldosary
- Department of Family and Community Medicine, Unaizah College of Medicine and Medical Sciences, Qassim University, Unaizah, Saudi Arabia
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18
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Sebro R. Statistical estimation of deltoid subcutaneous fat pad thickness: implications for needle length for vaccination. Sci Rep 2022; 12:1069. [PMID: 35058499 PMCID: PMC8776900 DOI: 10.1038/s41598-022-05020-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/17/2021] [Indexed: 11/09/2022] Open
Abstract
Current US Centers for Disease Control and Prevention intramuscular injection needle length guidelines for injection fo the deltoid muscle are based on weight and gender. The aims of this study are (1) to evaluate whether other biometric data (age, gender, height, weight and body mass index (BMI)) are better predictors of the thickness of the deltoid subcutaneous fat pad (DSFP) than weight and gender and (2) to evaluate the performance of the CDC weight-based needle length guidelines. This was a retrospective single center cohort study of 386 patients who underwent surveillance PET/CT between 01/01/2020 and 04/01/2021. Patient age, gender, height, weight, BMI and CT measurements of the DSFP were evaluated. DSFP was positively correlated with weight and BMI in men (r = 0.67, P < 0.001; r = 0.74, P < 0.001) and women (r = 0.69, P < 0.001; r = 0.75, P < 0.001) respectively. DSFP was negatively correlated with age in women (r = - 0.19, P = 0.013). Age and BMI were better predictors of DSFP than weight. The best model to predict the DSFP is: [Formula: see text] A 1-inch needle is expected to reach the deltoid in 85.3% of women less than 200 pounds, and 98.6% of men less than 260 pounds. This rate differed between genders (P < 0.001, odds ratio (OR) 0.08, 95% CI (0.02, 0.29)). A 1.5-inch needle is expected to reach the deltoid in 76.7% of women greater than 200 pounds, and 75.0% of men greater than 260 pounds. Current CDC deltoid intramuscular injection needle length guidelines result in women and obese individuals being more likely to receive subcutaneous injections. Age and BMI based guidelines for needle length selection are more accurate.
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Affiliation(s)
- Ronnie Sebro
- Department of Radiology, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA. .,Center for Augmented Intelligence, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA.
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19
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Des Roches A, Graham F, Begin P, Paradis L, Gold M. Evaluation of Adverse Reactions to Vaccines. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3584-3597. [PMID: 34627533 DOI: 10.1016/j.jaip.2021.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/05/2021] [Accepted: 08/08/2021] [Indexed: 02/05/2023]
Abstract
The development and widespread use of vaccination over the past centuries has been the single most impactful intervention in public health, by effectively preventing morbidity and mortality from infectious diseases. Vaccination is generally well tolerated in the vast majority of the population, and the benefits of vaccination largely outweigh the risk of severe adverse events in the majority of patients. Vaccine hesitancy can be a significant concern and lead to infectious disease outbreaks. All health care providers play an important role in maintaining public confidence in vaccines because their attitude and knowledge is often critical in facilitating acceptance of a vaccine. The purpose of this review is to first, provide an understanding of the basic concepts that are relevant to vaccine pharmacovigilance, and secondly, to provide an overview and discuss management of both immune and nonimmune adverse events after vaccination.
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Affiliation(s)
- Anne Des Roches
- Department of Pediatrics, Service of Allergy and Clinical Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada.
| | - François Graham
- Department of Pediatrics, Service of Allergy and Clinical Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada; Department of Medicine, Service of Allergy and Clinical Immunology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Philippe Begin
- Department of Pediatrics, Service of Allergy and Clinical Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada; Department of Medicine, Service of Allergy and Clinical Immunology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Louis Paradis
- Department of Pediatrics, Service of Allergy and Clinical Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada; Department of Medicine, Service of Allergy and Clinical Immunology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Michael Gold
- Discipline of Pediatrics, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
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20
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Shoulder Injury Related to Vaccine Administration. J Am Acad Orthop Surg 2021; 29:732-739. [PMID: 34185028 DOI: 10.5435/jaaos-d-21-00021] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 06/03/2021] [Indexed: 02/01/2023] Open
Abstract
Shoulder injury related to vaccine administration (SIRVA) is a rare yet increasingly recognized complication of immunization. Although a medicolegal term rather than a true diagnosis, SIRVA was introduced in 2010 by the Vaccine Injury Compensation Program after an increase in claims filed for vaccine-related shoulder injury. Patients typically present with severe pain and limited range of motion within 48 hours of vaccination and may experience notable functional limitations. Although the underlying pathophysiology is incompletely understood, the existing literature suggests that SIRVA results from the inflammatory response produced when the vaccine is injected into tissues containing a preexisting antibody. Current treatment modalities include physical therapy, corticosteroid injections, and antiinflammatory medications. In some cases, surgery may be required to treat underlying pathology, such as rotator cuff or biceps tendinopathy. Although the available literature indicates modest improvement in patients with SIRVA undergoing treatment, current data are limited to case series. Larger, high-quality studies are needed to determine the natural history and optimal treatment of this increasingly prevalent condition.
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21
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Cook IF. Minimizing shoulder injury related to vaccine administration. Hum Vaccin Immunother 2021; 18:1-2. [PMID: 34310254 PMCID: PMC8920141 DOI: 10.1080/21645515.2021.1938495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Ian F Cook
- School of Public Health and Medicine, University of Newcastle, Callaghan, Australia
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22
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Cagle PJ. Shoulder Injury after Vaccination: A Systematic Review. Rev Bras Ortop 2020; 56:299-306. [PMID: 34239193 PMCID: PMC8249056 DOI: 10.1055/s-0040-1719086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 09/16/2020] [Indexed: 10/27/2022] Open
Abstract
Adverse reactions to vaccine injections are usually mild and incredibly rare in nature, but multiple cases of shoulder events including bursitis, generalized pain or decreased range of motion have been reported following routine vaccine administrations. These events are known as Shoulder Injury Related to Vaccine Administration or SIRVA. A systematic review of literature was performed to identify all published accounts of SIRVA. Twenty-seven papers reporting one or more accounts of SIRVA were identified. The most common vaccination involved was the Influenza vaccine. The most common symptoms were pain that began in 48 hours or less and loss of shoulder range of motion. The most common treatment modalities were physical therapy, corticosteroid injections and anti-inflammatory medication; but in some patients, surgery was required. Regardless of intervention, the vast majority of outcomes demonstrated improved pain and functional except in the occasions of nerve injury. The etiology of SIRVA injuries has multiple possibilities including needle length, mechanical injury from needle overpenetration and the possibility of an immune inflammatory response from the vaccine components, but a unique definitive test or quantifiably result does not yet exist.
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Affiliation(s)
- Paul J Cagle
- Departamento de Cirurgia Ortopédica, Icahn School of Medicine at Mount Sinai, Nova York, Nova York, Estados Unidos
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23
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Serafin A, Malinowski M, Prażmowska-Wilanowska A. Blood volume and pain perception during finger prick capillary blood sampling: are all safety lancets equal? Postgrad Med 2020; 132:288-295. [PMID: 32027205 DOI: 10.1080/00325481.2020.1717160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES This study aimed to assess various types of safety lancets in terms of blood volume and pain perception during capillary blood sampling, a routine finger-puncture procedure for obtaining a small amount of human blood for running various screening and diagnostic tests. METHODS Data were collected from 100 adult healthy volunteers following finger-puncture procedure. Four different types of safety lancets were tested (Acti-Lance, Prolance, Medlance Plus, and MediSafe Solo). Each type has its own versions, giving 16 different safety lancets in total. RESULTS A significant difference in the mean capillary blood volume was found between blade and needle equipped safety lancets. MediSafe Solo type lancet had no blade version, and hence its use was associated with the lowest mean collected capillary blood volume (42.4 μL). Acti-Lance and Medlance Plus type lancets had one blade version and the mean collected capillary blood volume was 82.2 and 99.0 μL, respectively. Prolance type lancet had two blade versions, and its use was associated with the highest mean capillary blood volume (118.3 μL). The level of pain intensity was evaluated as low by the majority of patients for all lancets. Medlance Plus was the least painful and Acti-Lance was the most painful type of safety lancet. On a 0-to-10 scale of pain, 75% of punctures were assessed by the participants at a level not exceeding 3 points. CONCLUSIONS This study suggests that although all investigated safety lancets achieve adequate performance regarding the necessary capillary blood volume to run a diagnostic of test, lancets equipped with blades differ significantly from those equipped with needles in terms of the mean obtained capillary blood volume. Further, although all devices produced relatively low levels of pain, the amount of pain caused by blade versions of safety lancets has been found to be higher than that of needle versions. CLINICALTRIALS.GOV ID NCT04001348. (https://clinicaltrials.gov/ct2/show/NCT04001348?term=NCT04001348&draw=2&rank=1).
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Affiliation(s)
- A Serafin
- Regulatory Affairs Department, HTL-Strefa S.A , Ozorków, Poland
| | - M Malinowski
- Regulatory Affairs Department, HTL-Strefa S.A , Ozorków, Poland
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24
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Hesse EM, Atanasoff S, Hibbs BF, Adegoke OJ, Ng C, Marquez P, Osborn M, Su JR, Moro PL, Shimabukuro T, Nair N. Shoulder Injury Related to Vaccine Administration (SIRVA): Petitioner claims to the National Vaccine Injury Compensation Program, 2010-2016. Vaccine 2020; 38:1076-1083. [PMID: 31771864 PMCID: PMC9169064 DOI: 10.1016/j.vaccine.2019.11.032] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 11/12/2019] [Accepted: 11/14/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Since 2010, petitioner claims of shoulder injury related to vaccine administration (SIRVA) to the National Vaccine Injury Compensation Program (VICP) have been increasing. OBJECTIVE To conduct a scientific review of clinical characteristics of SIRVA petitions to the VICP. METHODS We queried the VICP's Injury Compensation System database for medical reports of alleged SIRVA and SIRVA-like injuries. Medical reports are summaries of petitioner claims and supporting documentation along with a VICP clinician reviewer diagnosis and assessment of criteria for concession. We conducted a descriptive analysis of SIRVA petitioner claims recommended by the VICP for concession as SIRVA injuries. RESULTS We identified 476 petitioner claims recommended for concession. Claims per year increased from two in 2011, the first full year in the analytic period, to 227 in 2016. Median age was 51 years, 82.8% were women, and median body mass index was 25.1 (range 17.0-48.9). Four hundred cases (84.0%) involved influenza vaccine. Pharmacy or store (n = 168; 35.3%) was the most common place of vaccination followed by doctor's office (n = 147; 30.9%). Fewer than half of cases reported a suspected administration error; 172 (36.1%) reported 'injection too high' on the arm. Shoulder pain, rotator cuff problems, and bursitis were common initial diagnoses. Most (80.0%) cases received physical or occupational therapy, 60.1% had at least one steroid injection, and 32.6% had surgery. Most (71.9%) healthcare providers who gave opinions on causality considered the injury was caused by vaccination. A minority (24.3%) of cases indicated that symptoms had resolved by the last visit available in medical records. CONCLUSIONS Most conceded claims for SIRVA were in women and involved influenza vaccines. Injection too high on the arm could be a factor due to the risk of injecting into underlying non-muscular tissues. Healthcare providers should be aware of proper injection technique and anatomical landmarks when administering vaccines.
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Affiliation(s)
- Elisabeth M Hesse
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, 1600 Clifton Rd, MS V24-5, Atlanta, GA 30329, United States; Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, 1600 Clifton Rd, MSV18-4, Atlanta, GA 30329, United States.
| | - Sarah Atanasoff
- National Vaccine Injury Compensation Program, Health Resources and Services Administration, U.S. Department of Health and Human Services, 5600 Fishers Lane, Rockville, MD 20857, United States
| | - Beth F Hibbs
- Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, 1600 Clifton Rd, MSV18-4, Atlanta, GA 30329, United States
| | - Oluwasegun J Adegoke
- Public Health Informatics Fellowship Program, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, United States; Global Immunizations Division, Center for Global Health, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, 1600 Clifton Rd, MS H24-2, Atlanta, GA 30329, United States
| | - Carmen Ng
- Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, 1600 Clifton Rd, MSV18-4, Atlanta, GA 30329, United States
| | - Paige Marquez
- Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, 1600 Clifton Rd, MSV18-4, Atlanta, GA 30329, United States
| | - Mark Osborn
- National Vaccine Injury Compensation Program, Health Resources and Services Administration, U.S. Department of Health and Human Services, 5600 Fishers Lane, Rockville, MD 20857, United States
| | - John R Su
- Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, 1600 Clifton Rd, MSV18-4, Atlanta, GA 30329, United States
| | - Pedro L Moro
- Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, 1600 Clifton Rd, MSV18-4, Atlanta, GA 30329, United States
| | - Tom Shimabukuro
- Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, 1600 Clifton Rd, MSV18-4, Atlanta, GA 30329, United States
| | - Narayan Nair
- National Vaccine Injury Compensation Program, Health Resources and Services Administration, U.S. Department of Health and Human Services, 5600 Fishers Lane, Rockville, MD 20857, United States
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Reports of atypical shoulder pain and dysfunction following inactivated influenza vaccine, Vaccine Adverse Event Reporting System (VAERS), 2010-2017. Vaccine 2019; 38:1137-1143. [PMID: 31784231 DOI: 10.1016/j.vaccine.2019.11.023] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 11/07/2019] [Accepted: 11/11/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Vaccines administered into or too close to underlying joint structures have the potential to cause shoulder injuries. Limited data exist on the epidemiology of such events. OBJECTIVE To describe case reports of atypical shoulder pain and dysfunction following injection of inactivated influenza vaccine (IIV). METHODS We searched the Vaccine Adverse Event Reporting System (VAERS) database from July 2010 to June 2017 for reports of atypical shoulder pain and dysfunction following IIV. When identifying reports, we made no assumptions about true incident injury or causality with respect to vaccination. Pain had to begin <48 h after vaccination and signs and symptoms had to continue for >7 days to differentiate from self-limited local reactions. We conducted descriptive analysis. RESULTS We identified 1220 reports that met our case definition (2.0% of all IIV reports, range 1.5%-2.5% across influenza seasons). Median age was 52 years (range 16-94) and most patients (82.6%) were female. Shoulder pain (44.1%), injected limb mobility decreased (40.8%), joint range of motion decreased (21.2%), rotator cuff syndrome (9.2%), and bursitis (9.0%) were frequently reported. In 86.6% of reports, signs and symptoms had not resolved by the time of report submission. In reports that included descriptions suggesting contributing factors (n = 266), vaccination given "too high" on the arm was cited in 81.2%. Nearly half (n = 605, 49.6%) of reports described a healthcare provider evaluation. Treatments included non-narcotic analgesics, physical therapy, and corticosteroid injection. Vaccinations were most commonly administered in a pharmacy or retail store (41.0%) or doctor's office or hospital (31.6%). CONCLUSIONS Reports of atypical shoulder pain and dysfunction following IIV were uncommon, considering the amount of IIV use, and stable across influenza seasons. While specific etiology of cases is unknown, improperly administered vaccine, which is preventable, might be a factor. Prevention strategies include education, training, and adherence to best practices for vaccine administration.
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Ganokroj P, Matrakool L, Limsuwarn P, Sissaynarane T, Yimvassana C, Laoratanavoraphong S, Ratanawarinchai J. A Prospective Randomized Study Comparing the Effectiveness of Midlateral and Posterior Subacromial Steroid Injections. Orthopedics 2019; 42:e44-e50. [PMID: 30427054 DOI: 10.3928/01477447-20181109-03] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 07/18/2018] [Indexed: 02/03/2023]
Abstract
The authors sought to compare the accuracy and effectiveness of the mid-lateral and posterior routes of subacromial injection. They conducted a prospective randomized study involving 50 shoulders scheduled to receive subacromial injection via the midlateral or posterior route. After injection, a blinded musculoskeletal radiologist interpreted the radiographs. Age, sex, body mass index, side of shoulder involved, circumference of the proximal humerus, and acromial type were assessed. The accuracy rates of the injections, modified University of California Los Angeles shoulder scores, and visual analog scale pain scores were compared. The accuracy rate of the midlateral route was significantly higher than that of the posterior route (92% vs 68%; P<.034). Although there were significantly improved modified University of California Los Angeles shoulder and visual analog scale pain scores in both groups after injection, differences in functional outcomes were not statistically significant (P>.05). Univariate analysis showed no correlation between accuracy and age, sex, body mass index, or circumference of the proximal humerus. However, injection route had some influence on accuracy, with a crude odds ratio of 5.41 (95% confidence interval, 1.017-28.791; P=.048) for the midlateral route. Midlateral was the preferred route for subacromial injection. [Orthopedics. 2019; 42(1):e44-e50.].
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Beirne PV, Hennessy S, Cadogan SL, Shiely F, Fitzgerald T, MacLeod F, Cochrane Pain, Palliative and Supportive Care Group. Needle size for vaccination procedures in children and adolescents. Cochrane Database Syst Rev 2018; 8:CD010720. [PMID: 30091147 PMCID: PMC6513245 DOI: 10.1002/14651858.cd010720.pub3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND This is an update of a Cochrane Review first published in 2015. The conclusions have not changed.Hypodermic needles of different sizes (gauges and lengths) can be used for vaccination procedures. The gauge (G) refers to the outside diameter of the needle tubing. The higher the gauge number, the smaller the diameter of the needle (e.g. a 23 G needle is 0.6 mm in diameter, whereas a 25 G needle is 0.5 mm in diameter). Many vaccines are recommended for injection into muscle (intramuscularly), although some are delivered subcutaneously (under the skin) and intradermally (into skin). Choosing an appropriate length and gauge of a needle may be important to ensure that a vaccine is delivered to the appropriate site and produces the maximum immune response while causing the least possible harm. Guidelines conflict regarding the sizes of needles that should be used for vaccinating children and adolescents. OBJECTIVES To assess the effects of using needles of different sizes for administering vaccines to children and adolescents on vaccine immunogenicity (the ability of the vaccine to elicit an immune response), procedural pain, and other reactogenicity events (adverse events following vaccine administration). SEARCH METHODS We updated our searches of CENTRAL, MEDLINE, Embase, and CINAHL to October 2017. We also searched proceedings of vaccine conferences and two trials registers. SELECTION CRITERIA Randomised controlled trials evaluating the effects of using hypodermic needles of any gauge or length to administer any type of vaccine to people aged from birth to 24 years. DATA COLLECTION AND ANALYSIS Three review authors independently extracted trial data and assessed the risk of bias. We contacted trial authors for additional information. We rated the quality of evidence using the GRADE system. MAIN RESULTS We included five trials involving 1350 participants in the original review. The updated review identified no new trials. The evidence from two small trials (one trial including infants and one including adolescents) was insufficient to allow any definitive statements to be made about the effects of the needles evaluated in the trials on vaccine immunogenicity and reactogenicity.The remaining three trials (1135 participants) contributed data to comparisons between 25 G 25 mm, 23 G 25 mm, and 25 G 16 mm needles. These trials included infants predominantly aged from two to six months undergoing intramuscular vaccination in the anterolateral thigh using the World Health Organization (WHO) injection technique (skin stretched flat, needle inserted at a 90° angle and up to the needle hub in healthy infants). The vaccines administered were combination vaccines containing diphtheria, tetanus, and whole-cell pertussis antigens (DTwP). In some trials, the vaccines also contained Haemophilus influenzae type b (DTwP-Hib) and hepatitis B (DTwP-Hib-Hep B) antigen components.Primary outcomesIncidence of vaccine-preventable diseases: No trials reported this outcome.Procedural pain and crying: Using a wider gauge 23 G 25 mm needle may slightly reduce procedural pain (low-quality evidence) and probably leads to a slight reduction in the duration of crying time immediately after vaccination (moderate-quality evidence) compared with a narrower gauge 25 G 25 mm needle (one trial, 320 participants). The effects are probably not large enough to be clinically relevant.Secondary outcomesImmune response: There is probably little or no difference in immune response, defined in terms of the proportion of seroprotected infants, between use of 25 G 25 mm, 23 G 25 mm, or 25 G 16 mm needles to administer a series of three doses of a DTwP-Hib vaccine at ages two, three, and four months (moderate-quality evidence, one trial, numbers of participants in analyses range from 309 to 402. The immune response to the pertussis antigen was not measured).Severe and non-severe local reactions: 25 mm needles (either 25 G or 23 G) probably lead to fewer severe and non-severe local reactions after DTwP-Hib vaccination compared with 25 G 16 mm needles (moderate-quality evidence, one trial, 447 to 458 participants in analyses). We estimate that one fewer infant will experience a severe local reaction (extensive redness and swelling) after the first vaccine dose for every 25 infants vaccinated with the longer rather than the shorter needle (number needed to treat for an additional beneficial outcome (NNTB) with a 25 G 25 mm needle: 25 (95% confidence interval (CI) 15 to 100); NNTB with a 23 G 25 mm needle: 25 (95% CI 17 to 100)). We estimate that one fewer infant will experience a non-severe local reaction (any redness, swelling, tenderness, or hardness (composite outcome)) at 24 hours after the first vaccine dose for every 5 or 6 infants vaccinated with a 25 mm rather than a 16 mm needle (NNTB with a 25 G 25 mm needle: 5 (95% CI 4 to 10); NNTB with a 23 G 25 mm needle: 6 (95% CI 4 to 13)). The results are similar after the second and third vaccine doses.Using a narrow gauge 25 G 25 mm needle may produce a small reduction in the incidence of local reactions after each dose of a DTwP vaccine compared with a wider gauge 23 G 25 mm needle, but the effect estimates are imprecise (low-quality evidence, two trials, 100 to 459 participants in analyses).Systemic reactions: The comparative effects of 23 G 25 mm, 25 G 25 mm, and 25 G 16 mm needles on the incidence of postvaccination fever and other systemic events such as drowsiness, loss of appetite, and vomiting are uncertain due to the very low quality of the evidence. AUTHORS' CONCLUSIONS Using 25 mm needles (either 23 G or 25 G) for intramuscular vaccination procedures in the anterolateral thigh of infants using the WHO injection technique probably reduces the occurrence of local reactions while achieving a comparable immune response to 25 G 16 mm needles. These findings are applicable to healthy infants aged two to six months receiving combination DTwP vaccines with a reactogenic whole-cell pertussis antigen component. These vaccines are predominantly used in low- and middle-income countries. The applicability of the findings to vaccines with acellular pertussis components and other vaccines with different reactogenicity profiles is uncertain.
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Affiliation(s)
- Paul V Beirne
- University College CorkDepartment of Epidemiology and Public Health4th Floor, Western Gateway Building, Western RoadCorkIreland
| | - Sarah Hennessy
- University College CorkDepartment of Epidemiology and Public Health4th Floor, Western Gateway Building, Western RoadCorkIreland
| | - Sharon L Cadogan
- School of Public Health, Imperial College LondonDepartment of Epidemiology and BiostatisticsSt. Mary's Campus, Norfolk PlaceLondonUKW2 1PG
| | - Frances Shiely
- University College CorkDepartment of Epidemiology and Public Health4th Floor, Western Gateway Building, Western RoadCorkIreland
| | - Tony Fitzgerald
- University College CorkDepartment of Epidemiology and Public Health4th Floor, Western Gateway Building, Western RoadCorkIreland
| | - Fiona MacLeod
- University College CorkDepartment of Epidemiology and Public Health4th Floor, Western Gateway Building, Western RoadCorkIreland
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Soliman E, Ranjan S, Xu T, Gee C, Harker A, Barrera A, Geddes J. A narrative review of the success of intramuscular gluteal injections and its impact in psychiatry. Biodes Manuf 2018; 1:161-170. [PMID: 30546922 PMCID: PMC6267269 DOI: 10.1007/s42242-018-0018-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 07/12/2018] [Indexed: 12/01/2022]
Abstract
There are 12 billion injections given worldwide every year. For many injections, the intramuscular route is favoured over the subcutaneous route due to the increased vascularity of muscle tissue and the corresponding increase in the bioavailability of drugs when administered intramuscularly. This paper is a review of the variables that affect the success of intramuscular injections and the implications that these success rates have in psychiatry and general medicine. Studies have shown that the success rates of intended intramuscular injections vary between 32 and 52%, with the rest potentially resulting in inadvertent subcutaneous drug deposition. These rates are found to be even lower for certain at-risk populations, such as obese patients and those on antipsychotic medications. The variables associated with an increased risk of injection failure include female sex, obesity, site of injection, and subcutaneous fat depth. New guidelines and methods are needed in order to address this challenge and ensure that patients receive optimum care. Looking forward, the best way to improve the delivery of intramuscular injections worldwide is to develop uniform algorithms or innovative medical devices to confirm or guarantee successful delivery at the bedside.
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Affiliation(s)
- Erfan Soliman
- 1Department of Engineering Sciences, Institute of Biomedical Engineering, Old Road Campus Research Building, University of Oxford, Oxford, OX3 7DQ UK
| | - Sarujan Ranjan
- 1Department of Engineering Sciences, Institute of Biomedical Engineering, Old Road Campus Research Building, University of Oxford, Oxford, OX3 7DQ UK
| | - Tianyou Xu
- 1Department of Engineering Sciences, Institute of Biomedical Engineering, Old Road Campus Research Building, University of Oxford, Oxford, OX3 7DQ UK
| | - Carol Gee
- 2Warneford Hospital, Oxford Health NHS Foundation Trust, Warneford Ln, Oxford, OX3 7JX UK
| | - Aidan Harker
- 2Warneford Hospital, Oxford Health NHS Foundation Trust, Warneford Ln, Oxford, OX3 7JX UK
| | - Alvaro Barrera
- 2Warneford Hospital, Oxford Health NHS Foundation Trust, Warneford Ln, Oxford, OX3 7JX UK
| | - John Geddes
- 3Department of Psychiatry, University of Oxford, Warneford Hospital, Warneford Ln, Oxford, OX3 7JX UK
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Kim KH, Kim GY, Lim SG, Park BK, Kim DH. A More Precise Electromyographic Needle Approach for Examination of the Rhomboid Major. PM R 2018; 10:1380-1384. [PMID: 29783066 DOI: 10.1016/j.pmrj.2018.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/23/2018] [Accepted: 05/12/2018] [Indexed: 01/29/2023]
Abstract
BACKGROUND Safe and accurate needle access to the rhomboid major (RM) during electromyography is challenging due to the overlying trapezius muscle and the risk of pneumothorax. OBJECTIVE To investigate the RM anatomy associated with the trapezius using ultrasonography and to determine a safe and accurate needle insertion point for needle electromyography of the RM. DESIGN Descriptive study. SETTING Department of physical medicine and rehabilitation of a tertiary clinic center. PARTICIPANTS Participants between 23 and 71 years of age without any diseases (N = 25; 13 men, 12 women; 50 scapulae) were included. INTERVENTIONS Ultrasonography of the RM and trapezius muscles around the scapula. MAIN OUTCOME MEASURES The point at which the lateral margin of the trapezius crosses the medial border of the scapula (point A) was determined. The probe was positioned at the level of the midpoint (point M) between point A and the inferior angle of the scapula. The horizontal distance from the point at which the RM was the thickest (point X) to point M was measured. At point X, the depth of the RM, RM thickness, and the depth of the pleura were measured. RESULTS The mean age and body mass index were 37.4 ± 12.0 years and 22.3 ± 2.1 kg/m2, respectively. Point M was located at a mean distance of 3.9 ± 0.6 cm proximal to the inferior angle of the scapula. The mean distance between point X and point M was 1.0 ± 0.2 cm. At point X, the RM was at a mean depth of 9.7 ± 3.1 mm from the skin and had a mean thickness of 9.9 ± 1.8 mm. The pleura was observed at a mean depth of 28.4 ± 3.8 mm from the skin. CONCLUSION Needle electromyographic examination of the RM can be performed easily and safely through the lower part of the RM that is not covered by the trapezius. LEVEL OF EVIDENCE not applicable.
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Affiliation(s)
- Ki Hoon Kim
- Department of Physical Medicine & Rehabilitation, Korea University Ansan Hospital, Gyeonggi-do, Republic of Korea(∗)
| | - Goo Young Kim
- Department of Physical Medicine & Rehabilitation, Korea University Ansan Hospital, Gyeonggi-do, Republic of Korea(†)
| | - Seong Gyu Lim
- Department of Physical Medicine & Rehabilitation, Korea University Ansan Hospital, Gyeonggi-do, Republic of Korea(‡)
| | - Byung Kyu Park
- Department of Physical Medicine & Rehabilitation, Korea University Ansan Hospital, Gyeonggi-do, Republic of Korea(§)
| | - Dong Hwee Kim
- Department of Physical Medicine and Rehabilitation, Korea University Ansan Hospital, 123 Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do, Republic of Korea, 15355(¶).
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Giarratano A, Green SE, Nicolau DP. Review of antimicrobial use and considerations in the elderly population. Clin Interv Aging 2018; 13:657-667. [PMID: 29713150 PMCID: PMC5909780 DOI: 10.2147/cia.s133640] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Pharmacologic management of infections in elderly patients presents multiple challenges to health care professionals due to variable pharmacokinetics, pharmacodynamics, and immune function. Age is a well-established risk factor for infection, but furthermore is a risk factor for prolonged length of hospital stay, increased incidence of complications, and significant and sustained decline in baseline functional status. In 2014, 46.2 million Americans were aged ≥65 years, accounting for 14.5% of the total population. By 2033, for the first time, the population of persons aged ≥65 years is projected to outnumber the people <18 years of age. According to the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, 154 million prescriptions for antimicrobials were estimated to have been written in doctors’ offices and emergency departments during a 1-year time period. In 2014, 266.1 million courses of antimicrobials were dispensed to outpatients by US community pharmacies. A study that evaluated 2007–2009 Medicare Part D data found that patients aged ≥65 years used more antimicrobials, at 1.10 per person per year, compared to 0.88 antimicrobials used per person per year in patients aged 0–64 years. With the abundance of antimicrobial prescriptions and the current growth in the number and proportion of older adults in the US, it is essential that health care providers understand appropriate antimicrobial pharmacotherapy in the elderly patient. This review focuses on the use and implications of antimicrobial agents in the elderly population.
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Affiliation(s)
| | | | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
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31
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Larkin TA, Ashcroft E, Elgellaie A, Hickey BA. Ventrogluteal versus dorsogluteal site selection: A cross-sectional study of muscle and subcutaneous fat thicknesses and an algorithm incorporating demographic and anthropometric data to predict injection outcome. Int J Nurs Stud 2017; 71:1-7. [DOI: 10.1016/j.ijnurstu.2017.02.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 01/30/2017] [Accepted: 02/19/2017] [Indexed: 02/03/2023]
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Salmon JH, Geoffroy M, Eschard JP, Ohl X. Bone erosion and subacromial bursitis caused by diphtheria-tetanus-poliomyelitis vaccine. Vaccine 2015; 33:6152-5. [PMID: 26458794 DOI: 10.1016/j.vaccine.2015.09.090] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 09/26/2015] [Accepted: 09/28/2015] [Indexed: 10/22/2022]
Abstract
Revaxis(®) is a vaccine against diphtheria, tetanus and poliomyelitis (dT-IPV). This vaccine should not be administered by the intradermal or intravenous route. Poor injection techniques and related consequences are rare. We report a case of bursitis associated with reactive glenohumeral effusion complicated by bone erosion occurring after injection of the dT-IPV vaccine. A 26 year old patient was admitted for painful left shoulder causing functional impairment. Control magnetic resonance imaging showed bone oedema on the upper outer part of the humeral head, with a slight cortical irregularity, indicating that the vaccine was injected in contact with the bone at this location, causing erosion. Outcome was favourable after intra-articular corticosteroids. Reports of articular or periarticular injury after vaccination are extremely rare, in view of the substantial number of vaccines administered every year. The potential complications of vaccination are well known to general practitioners but under-reported in the literature.
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Affiliation(s)
- J H Salmon
- Rheumatology Department, Maison Blanche Hospital, Reims University Hospitals, Reims F-51092, France; University of Reims Champagne-Ardenne, Faculty of Medicine, EA 3797, Reims F-51095, France.
| | - M Geoffroy
- Rheumatology Department, Maison Blanche Hospital, Reims University Hospitals, Reims F-51092, France
| | - J P Eschard
- Rheumatology Department, Maison Blanche Hospital, Reims University Hospitals, Reims F-51092, France
| | - X Ohl
- Orthopedics and Traumatology Department, Maison Blanche Hospital, Reims University Hospitals, Reims F-51092, France
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Zaybak A, İsmailoğlu EG, İsmailoğlu E. Examination of Subcutaneous Tissue Thickness in the Thigh Site for Intramuscular Injection in Obese Individuals. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:1657-1662. [PMID: 26269301 DOI: 10.7863/ultra.15.14.09005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 12/16/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVES The aim of the study was to investigate the thickness of subcutaneous (SC) tissue in the dorsogluteal and thigh sites in obese adults and its suitability for intramuscular injection using a standard-length needle. METHODS The sample for this prospective study consisted of 54 obese adults who presented to the ultrasound unit of the radiology clinic of a university hospital in the province of İzmir, Turkey, between June 2012 and August 2013. The study received Institutional Review Board approval, and informed written consent was obtained from all participants. The thickness of the SC tissue in the dorsogluteal and thigh sites was measured by sonography. The sonographic measurements were performed by a radiology specialist. RESULTS The mean thicknesses of the SC tissue were 61.70 ± 15.73 mm in the dorsogluteal site, 27.05 ± 8.52 mm in the rectus femoris site, and 23.23 ± 8.44 mm in vastus lateralis site. The SC tissue was thicker in the dorsogluteal than the thigh site (P < .001). CONCLUSIONS A standard needle used in intramuscular injections to the thigh site would be effective in reaching the muscle in the rectus femoris and vastus lateralis sites in all men and in 77.8% of women, although it is not usually adequate for gluteal injection.
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Affiliation(s)
- Ayten Zaybak
- Department of Fundamentals of Nursing, Faculty of Nursing (A.Z., E.G.İ.), and Department of Radiology, Faculty of Medicine (E.İ.), Ege University, İzmir, Turkey
| | - Elif Günay İsmailoğlu
- Department of Fundamentals of Nursing, Faculty of Nursing (A.Z., E.G.İ.), and Department of Radiology, Faculty of Medicine (E.İ.), Ege University, İzmir, Turkey.
| | - Eren İsmailoğlu
- Department of Fundamentals of Nursing, Faculty of Nursing (A.Z., E.G.İ.), and Department of Radiology, Faculty of Medicine (E.İ.), Ege University, İzmir, Turkey
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Beirne PV, Hennessy S, Cadogan SL, Shiely F, Fitzgerald T, MacLeod F. Needle size for vaccination procedures in children and adolescents. Cochrane Database Syst Rev 2015:CD010720. [PMID: 26086647 DOI: 10.1002/14651858.cd010720.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Hypodermic needles of different sizes (gauges and lengths) can be used for vaccination procedures. The gauge (G) refers to the outside diameter of the needle tubing. The higher the gauge number, the smaller diameter of the needle (eg a 25 G needle is 0.5 mm in diameter and is narrower than a 23 G needle (0.6 mm)). Many vaccines are recommended for injection into muscle (intramuscularly), although some are delivered subcutaneously (under the skin) and intradermally (into skin). Choosing an appropriate length and gauge of a needle may be important to ensure that a vaccine is delivered to the appropriate site and produces the maximum immune response while causing the least possible harm. There are some conflicting guidelines regarding the lengths and gauges of needles that should be used for vaccination procedures in children and adolescents. OBJECTIVES To assess the effects of using needles of different lengths and gauges for administering vaccines to children and adolescents on vaccine immunogenicity (the ability of the vaccine to elicit an immune response), procedural pain, and other reactogenicity events (adverse events following vaccine administration). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2014, Issue 10), MEDLINE and MEDLINE in Progress via Ovid (1947 to November 2014), EMBASE via Ovid (1974 to November 2014), and CINAHL via EBSCOhost (1982 to November 2014). We also searched reference lists of articles and textbooks, the proceedings of vaccine conferences, and three clinical trial registers. SELECTION CRITERIA Randomised controlled trials evaluating the effects of using hypodermic needles of any gauge or length to administer any type of vaccine to people aged from birth to 24 years. DATA COLLECTION AND ANALYSIS Three review authors independently extracted trial data and assessed the risk of bias. We contacted trial authors for additional information. We rated the quality of evidence using the GRADE system. MAIN RESULTS We included five trials involving 1350 participants. Data for the primary review outcomes were either absent (for the incidence of vaccine-preventable diseases) or limited (for procedural pain and crying). The available evidence was compromised by the use of surrogate immunogenicity outcomes, incomplete blinding of outcome assessors, and imprecision for some outcomes. The evidence from two small trials was insufficient to allow any confident statements to be made about the effects of the needles evaluated in the trials on vaccine immunogenicity and reactogenicity.The remaining three trials (1135 participants) contributed data to comparisons between 25 G 25 mm, 23 G 25 mm, and 25 G 16 mm needles. These trials involved infants predominantly aged two to six months undergoing intramuscular vaccination in the anterolateral thigh using the World Health Organization (WHO) injection technique (skin stretched flat, needle inserted at a 90° angle and up to the needle hub in healthy infants). The vaccines administered were combination vaccines containing diphtheria, tetanus, and whole-cell pertussis antigens (DTwP). In some trials, the vaccines also contained Haemophilus influenzae type b (DTwP-Hib) and hepatitis B (DTwP-Hib-HepB) antigen components.We found moderate quality evidence from one trial that there is probably little or no difference in immune response, defined in terms of the proportion of seroprotected infants, between using 25 G 25 mm, 23 G 25 mm, or 25 G 16 mm needles to administer a series of three doses of a DTwP-Hib vaccine at ages two, three, and four months (numbers of participants in analyses range from 309 to 402. Immune response to pertussis antigen not measured).25 mm needles (either 23 G or 25 G) probably lead to fewer severe local reactions (extensive redness and swelling) and fewer non-severe local reactions (any redness, swelling, tenderness or hardness (composite outcome)) after DTwP-Hib vaccination compared with 25 G 16 mm needles. We estimate that one fewer infant will experience a severe local reaction after the first vaccine dose for every 25 infants vaccinated with the longer rather than the shorter needle (number needed to treat (NNT) 25 (95% confidence interval (CI) 15 to 100)). We estimate that one fewer infant will experience a non-severe local reaction at 24 hours after the first, second, and third vaccine doses for every five to eight infants vaccinated with the longer rather than the shorter needle (NNTs range from 5 (95% CI 4 to 10) to 8 (95% CI 5 to 34)) (moderate quality evidence, one trial for first and second doses, two trials for third dose, numbers of participants in analyses range from 413 to 528).Using a wider gauge needle (23 G 25 mm) may slightly reduce procedural pain (low quality evidence) and probably leads to a slight reduction in the duration of crying time immediately after vaccination (moderate quality evidence) compared with a narrower gauge (25 G 25 mm) needle (one trial, 320 participants). The effects are probably not large enough to be of any clinical relevance. The 25 G 25 mm needle may produce a small reduction in the incidence of local reactions after each dose of a DTwP vaccine compared with the 23 G 25 mm needle, but the effect estimates are imprecise (low quality evidence, two trials, numbers of participants in analyses range from 100 to 459).The comparative effects of 23 G 25 mm, 25 G 25 mm, and 25 G 16 mm needles on the incidence of post-vaccination fever, persistent inconsolable crying, and other systemic events such as drowsiness, loss of appetite, and vomiting are uncertain due to the very low quality of the evidence. AUTHORS' CONCLUSIONS Using 25 mm needles (either 23 G or 25 G) for intramuscular vaccination procedures in the anterolateral thigh of infants using the WHO injection technique probably reduces the occurrence of local reactions while achieving a comparable immune response to 25 G 16 mm needles. These findings are applicable to healthy infants aged two to six months receiving combination DTwP vaccines with a reactogenic whole-cell pertussis antigen component. These vaccines are predominantly used in developing countries. The applicability of the findings to vaccines with acellular pertussis components and other vaccines with different reactogenicity profiles is uncertain.
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Affiliation(s)
- Paul V Beirne
- Department of Epidemiology and Public Health, University College Cork, 4th Floor, Western Gateway Building, Western Road, Cork, Ireland
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Cook IF. Best vaccination practice and medically attended injection site events following deltoid intramuscular injection. Hum Vaccin Immunother 2015; 11:1184-91. [PMID: 25868476 PMCID: PMC4514326 DOI: 10.1080/21645515.2015.1017694] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 01/25/2015] [Accepted: 02/06/2015] [Indexed: 11/10/2022] Open
Abstract
Analysis of medically attended injection site events data provides a vehicle to appreciate the inadequacies of vaccination practice for deltoid intramuscular injection and to develop best practice procedures. These data can be divided into 3 groups; nerve palsies, musculoskeletal injuries and cutaneous reactions and reflect inappropriate site of injection, needle over or under penetration, local sepsis and vascular complications. The aim of this review is to formulate best vaccination practice procedures for deltoid intramuscular injection of vaccines through the collation and analysis of medically attended injection site events.
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Affiliation(s)
- Ian F Cook
- University of Newcastle; Newcastle, New South Wales, Australia
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Shankar N, Saxena D, Lokkur PP, Kumar NM, William NC, Vijaykumar N. Influence of skin-to-muscle and muscle-to-bone thickness on depth of needle penetration in adults at the deltoid intramuscular injection site. Med J Armed Forces India 2014; 70:338-43. [PMID: 25382907 DOI: 10.1016/j.mjafi.2014.08.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 08/05/2014] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND THE OBJECTIVES OF THE STUDY WERE TO ESTIMATE THE FOLLOWING IN ADULTS OF INDIAN ORIGIN: a) Gender and side differences in the skin-to-muscle (SM) and muscle-to-bone thickness (MB) at the deltoid intramuscular injection site; b) Correlation of SM thickness with the BMI, age and gender; c) The prevalence of under and over-penetration assuming a standard needle length of 25 mm and following prescribed guidelines for IM injection. METHODS The SM, MB and skin-to-bone (SB) thicknesses were bilaterally estimated in two hundred adult Indian subjects (100 male and 100 female) using an ultrasound probe at a pre-determined point on the upper arms of the subjects. The BMI of each subject was calculated. The unpaired sample 't' test and paired 't' test were used to analyse differences between groups. Pearson's correlation coefficient was used in correlation analysis and suitable linear regression equations were generated. RESULTS Females had a significantly higher SM thickness and lower MB thickness. The SM thickness was significantly greater on the left side, while the SB and MB thickness were significantly greater on the right. Multiple linear regression equations for both the dominant and non-dominant arms had good model fit properties. Under-penetration would have occurred in 2 (1%) subjects while over-penetration would have occurred in 50% of the subjects. CONCLUSION Over-penetration of deltoid IM injections is likely to be more prevalent as compared to under-penetration. Therefore, the technique of IM injection needs to be modified based on the body type of the individual patient.
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Affiliation(s)
- Nachiket Shankar
- Associate Professor, Department of Anatomy, St. John's Medical College, Bangalore 560034, Karnataka, India
| | - Deepali Saxena
- Assistant Professor, Department of Radiology, St. John's Medical College Hospital, Bangalore, Karnataka, India
| | - Pooja P Lokkur
- Intern, St. John's Medical College Hospital, Bangalore, Karnataka, India
| | - Nikhil M Kumar
- Intern, St. John's Medical College Hospital, Bangalore, Karnataka, India
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Herzog C. Influence of parenteral administration routes and additional factors on vaccine safety and immunogenicity: a review of recent literature. Expert Rev Vaccines 2014; 13:399-415. [DOI: 10.1586/14760584.2014.883285] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Palma S, Strohfus P. Are IM injections IM in obese and overweight females? A study in injection technique. Appl Nurs Res 2013; 26:e1-4. [PMID: 24156877 DOI: 10.1016/j.apnr.2013.09.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 09/19/2013] [Accepted: 09/20/2013] [Indexed: 10/26/2022]
Abstract
If given incorrectly, intramuscular injections may result in poor absorption of drug, reduced drug effectiveness, or irritation to surrounding tissues. In this study, IM injection techniques were observed and documented for needle length, injection site, needle insertion, and stretching or bunching of the skin during injection in a population of adult females. The patients' weights and BMIs were recorded to determine the amount of subcutaneous fat at the injection site. In 22 patients of varied weights, 90% of injections were given within current Advisory Committee on Immunization Practice (ACIP) guidelines in normal and underweight patients, and 17% were given within ACIP guidelines in overweight and obese patients. The study concluded that the needle length used is often too short in overweight and obese individuals.
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Affiliation(s)
- Sara Palma
- 1351 E Mona Lisa Dr, Meridian 83642, ID, USA.
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Beirne PV, Shiely F, Hennessy S, Fitzgerald T, MacLeod F. Needle size for vaccination procedures in children and adolescents. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2013. [DOI: 10.1002/14651858.cd010720] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Marshall HS, Clarke MF, Evans S, Piotto L, Gent RJ. Randomized trial using ultrasound to assess intramuscular vaccination at a 60° or 90° needle angle. Vaccine 2013; 31:2647-52. [PMID: 23566948 DOI: 10.1016/j.vaccine.2013.03.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Revised: 03/05/2013] [Accepted: 03/20/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Globally, recommendations differ on the ideal angle of needle insertion to ensure vaccinate deposition in muscle for optimal safety and immunogenicity. This study aimed to compare the level of vaccinate deposition during vaccination, using two different needle angles (60° and 90°), in young children, adolescents and adults. METHODS In this randomized cross-over study, two doses of a licensed hepatitis vaccine, were administered to study participants, at a 60° or 90° angle using a fixed template. Ultrasonography was performed with a Philips iu22 ultrasound system. Real time clips and hard copies of images were recorded showing the injection and level of deposition of the vaccinate. Reactogenicity at the site of administration was assessed by participants/parents. RESULTS Nineteen participants were enrolled including children, adolescents and adults. Of the total 38 injections performed, 29 (76%) were confirmed by ultrasound as intramuscular (IM), 3 (8%) as not IM, and 6 (16%) unknown. For vaccinations visualised and administered at 60°, 87% (13/15) were intramuscular vs 94.1% (16/17) for those administered at 90°. A body mass index (BMI)≤25 was associated with a higher likelihood of IM injection compared to BMI>25 (p=0.038). There were no differences in reactogenicity for either 60° or 90° angle of administration. CONCLUSION For the majority of vaccinees, a 60-90° angle of vaccine administration is appropriate for IM deposition of vaccinate. The likelihood of intramuscular deposition is reduced for individuals with a BMI>25. The increasing rates of obesity globally highlight the importance of tailoring vaccination procedures accordingly.
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Affiliation(s)
- Helen Siobhan Marshall
- Vaccinology and Immunology Research Trials Unit, Women's and Children's Hospital, 72 King William Road, North Adelaide, South Australia, Australia.
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Choi DW, Sohng KY, Kim BS. [Prediction of optimal gluteal intramuscular needle length by skinfold thickness measurements in Korean adults]. J Korean Acad Nurs 2011; 40:844-51. [PMID: 21336018 DOI: 10.4040/jkan.2010.40.6.844] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
PURPOSE This study was conducted to assess optimal needle length for gluteal intramuscular injections (IM) via simple skinfold thickness (SFT). METHODS For this study, 190 healthy adults were recruited and grouped into eight groups according to gender and body mass index (BMI) (kg/m²). The Korean Society for the Study of Obesity criteria defines a BMI under 20 as underweight, 20.1-22.9 as normal, 23-24.9 as overweight and over 25 as obese. For each participant, the SFT of dorsoguteal (DG) and ventrogluteal (VG) sites were measured using a caliper. Subcutaneous tissue thickness was acquired through ultrasonic images. RESULTS For men in the overweight and obese groups at the DG site, for the obese group at the VG site, and for women in the normal weight, overweight and obese groups at both sites, the mean subcutaneous tissue thickness exceeded 1.84 cm, the minimal length for a 1 inch needle used for IM. At the DG site, optimal intramuscular needle length (OINL) was 1.4 times in women and 1.0 times in men compared to SFT. At the VG site, OINL was 1.3 times in women and 0.9 times in men compared to SFT. CONCLUSION The results of this study suggest that SFT is a reliable index to determine optimal needle length with minimal effort prior to IM.
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Yang CSH, Chen HC, Liang CC, Yu TY, Hung D, Tseng TC, Tsai WC. Sonographic measurements of the thickness of the soft tissues of the interscapular region in a population of normal young adults. JOURNAL OF CLINICAL ULTRASOUND : JCU 2011; 39:78-82. [PMID: 21213332 DOI: 10.1002/jcu.20775] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2009] [Accepted: 10/05/2010] [Indexed: 05/30/2023]
Abstract
BACKGROUND To use sonography (US) to measure the interscapular soft-tissue thickness and to determine any correlation with anthropometric indices. METHODS Fifty-five healthy young adults (21 men and 34 women) with a mean age of 22.1 ± 3.0 years (range, 18-35) were enrolled. High-resolution US was used to measure the bilateral soft-tissue thickness near the medial border of the scapula. Anthropometric indices, including body weight, height, and circumferences of chest, waist, and hip, were also measured. RESULTS On the right side, mean values ± standard deviation for the thickness of the trapezius, rhomboid, and posterior serratus muscles in millimeters were 4.9 ± 1.0, 6.3 ± 2.3, and 3.5 ± 1.4, respectively, for men and 3.4 ± 0.8, 3.8 ± 1.7, and 2.2 ± 1.5, respectively, for women. The thickness of each muscle was significantly greater in men than in women (p < 0.05). For both genders, no significant differences in the soft-tissue thicknesses were found between both sides. Based on the anthropometric indices, body weight was the only significant contributor to the soft-tissue thickness. CONCLUSIONS US is a practical tool for measuring soft-tissue thickness in the interscapular region. Body weight and soft-tissue thickness are closely associated.
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Affiliation(s)
- Clement Shih-Hsien Yang
- Department of Physical Medicine and Rehabilitation, Buddhist Tzu Chi General Hospital, Hualien, Taiwan; College of Medicine, Tzu Chi University, Hualien, Taiwan
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Shep D, Ojha A, Patel S, Nivsarkar M, Jaiswal V, Padh H. Pharmacokinetic profile of an intradeltoid diclofenac injection in obese Indian volunteers. J Pain Res 2010; 3:235-40. [PMID: 21311716 PMCID: PMC3033031 DOI: 10.2147/jpr.s13894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND A new propylene glycol-free and reduced-volume formulation of diclofenac sodium 75 mg/mL designed for intradeltoid administration has been found to be bioequivalent to a reference formulation of diclofenac sodium 75 mg/3 mL given via the intragluteal route in normal healthy volunteers. Standard needles may not reach the gluteus maximus muscle in many cases, especially in the obese. The objective of this study was to determine the pharmacokinetic parameters of the new formulation and compare the bioavailability of intradeltoid diclofenac sodium 75 mg/mL with that of the intragluteal 75 mg/3 mL reference formulation in obese volunteers. METHODS A comparative, two-way, single-dose, bioavailability study was carried out in 10 obese (body mass index > 25) male Indian volunteers after a washout period of seven days. Blood samples were collected until six hours following drug administration and analyzed using a prevalidated high-pressure liquid chromatography method. RESULTS The mean maximum plasma concentration and time to reach maximum plasma concentration for the test formulation were 1.30 μg/mL and 0.50 hours, respectively, versus 0.93 μg/ mL and 1.08 hours for the reference formulation. The mean areas under the curve from 0 to last measurable time point (AUC(0-t)) for the test and reference formulations were 2.71 μg·h/mL and 2.73 μg·h/mL, respectively. The mean AUCs from 0 to infinity (AUC(0-∞)) for the test and reference formulations were 3.71 μg·h/mL and 3.75 μg·h/mL, respectively. CONCLUSION The results suggest that the test formulation of diclofenac sodium 75 mg/mL has an AUC(0-t) and AUC(0-∞) comparable with the reference intragluteal formulation of diclofenac sodium 75 mg/3 mL, but with an earlier time to reach maximum plasma concentration and a trend towards a higher maximum plasma concentration. This could be attributed to faster absorption from the deltoid region than from the gluteal region. The test formulation could be helpful in the management of pain in obese or overweight patients and those with dense subcutaneous fat in the gluteal area.
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Affiliation(s)
- Dhaneshwar Shep
- Medical Services, Troikaa Pharmaceuticals Ltd, Ahmedabad, India
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Atanasoff S, Ryan T, Lightfoot R, Johann-Liang R. Shoulder injury related to vaccine administration (SIRVA). Vaccine 2010; 28:8049-52. [PMID: 20955829 DOI: 10.1016/j.vaccine.2010.10.005] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Revised: 10/01/2010] [Accepted: 10/03/2010] [Indexed: 10/18/2022]
Abstract
Shoulder pain is a common transient side-effect of vaccination. Infrequently, patients can develop prolonged shoulder pain and dysfunction following vaccination. A series of 13 cases are described in which persistent shoulder dysfunction and pain developed following immunization. Common clinical characteristics include absence of a history of prior shoulder dysfunction, previous exposure to vaccine administered, rapid onset of pain, and limited range of motion. The proposed mechanism of injury is the unintentional injection of antigenic material into synovial tissues resulting in an immune-mediated inflammatory reaction. Careful consideration should be given to appropriate injection technique when administering intramuscular vaccinations to reduce the risk of shoulder injury.
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Affiliation(s)
- S Atanasoff
- U.S. Department of Health and Human Services, Health Resources and Services Administration, National Vaccine Injury Compensation Program, USA.
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Koster MP, Stellato N, Kohn N, Rubin LG. Needle length for immunization of early adolescents as determined by ultrasound. Pediatrics 2009; 124:667-72. [PMID: 19651584 DOI: 10.1542/peds.2008-1127] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To determine the appropriate needle length for intramuscular injection of vaccines to early adolescents by measuring muscle depth at the deltoid injection site. METHODS Students from Nassau County, New York, and patients attending an adolescent clinic were invited to participate. Height, weight, and arm circumference were measured. BMI percentiles were obtained. Depths of muscle and bone underlying the deltoid injection site were measured by using ultrasonography while the deltoid area was bunched or flattened. A sufficiently long needle length was defined as greater than or equal to the skin-to-muscle depth plus 5 mm (based on measurement, no needle used). Too long was considered greater than or equal to skin-to-bone depth. RESULTS The age range of the 141 subjects was 11 to 15 years. Fifty-five percent were female. Twenty-six percent weighed <40 kg, and 20% were between 60 and 108 kg. The mean and median BMI percentiles were 58th and 62th, respectively, with 6% of the subjects at <10th percentile and 28% of subjects at >85th percentile. Using the bunch technique, we found that a 25-mm (1-in) needle is acceptable in 86% of subjects; in the subgroup of >or=60 kg, it is acceptable in 100% of subjects. A 16-mm (-in) needle is acceptable in 88%; in the subgroup of <60 kg, it is acceptable in 98% of subjects. Using the flatten technique, a 25-mm needle is acceptable in 39%; in the subgroup of >or=60 kg, it is acceptable in 93% of subjects. A 16-mm needle is acceptable in 92%; in the subgroup of <60 kg, it is acceptable in 96% of subjects. CONCLUSIONS For intramuscular immunization of early adolescents, a 16-mm needle is appropriate for those weighing <60 kg, and a 25-mm needle is appropriate for those weighing 60 to 70 kg, using either technique.
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Affiliation(s)
- Michael Philip Koster
- Department of Pediatrics, Schneider Children's Hospital of the North Shore-Long Island Jewish Health System, New Hyde Park, New York, USA.
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Leddy MA, Schulkin J, Power ML. Consequences of high incarceration rate and high obesity prevalence on the prison system. JOURNAL OF CORRECTIONAL HEALTH CARE 2009; 15:318-27. [PMID: 19633334 DOI: 10.1177/1078345809340426] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Incarceration and obesity rates have both increased in the United States. An implication is that there will be more obese inmates, which likely will raise the prevalence of obesity-related diseases, affecting the cost and performance of correctional health care. Other issues include increased costs of transport, restraint, and housing. There is surprisingly little published information on inmate obesity prevalence. The few published research studies suggest obesity prevalence in prisons reflects that of their region. Cardiovascular-related prisoner deaths appear to be associated with state-level obesity, though other risk factors are likely involved. Weight gain while incarcerated is common, and the prevalence of diabetes is increasing. The data suggest that preventive care is not a priority in prisons. Evidence from Japan suggests restricted diets and enforced activity can improve inmate health.
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Affiliation(s)
- Meaghan A Leddy
- American College of Obstetricians and Gynecologists, Washington, DC 20016, USA.
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A Prospective Baseline Versus On-Treatment Study Assessing Patient Perceptions of Using a Smaller Needle When Injecting Intramuscular Interferon Beta-1a (Avonex). J Neurosci Nurs 2008; 40:350-5. [DOI: 10.1097/01376517-200812000-00007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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48
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Intradermal vaccine delivery: will new delivery systems transform vaccine administration? Vaccine 2008; 26:3197-208. [PMID: 18486285 DOI: 10.1016/j.vaccine.2008.03.095] [Citation(s) in RCA: 220] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2008] [Revised: 03/17/2008] [Accepted: 03/24/2008] [Indexed: 11/23/2022]
Abstract
There has been a recent resurgence of interest in intradermal vaccine delivery. The physiological advantages of intradermal vaccine delivery have been known for some time, but the difficulties associated with performing an intradermal injection have historically limited its use. New delivery systems currently in development facilitate convenient intradermal vaccination, unlocking the potential advantages of this delivery route, and potentially transforming vaccine delivery.
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Kang MN, Rizio L, Prybicien M, Middlemas DA, Blacksin MF. The accuracy of subacromial corticosteroid injections: a comparison of multiple methods. J Shoulder Elbow Surg 2008; 17:61S-66S. [PMID: 18201659 DOI: 10.1016/j.jse.2007.07.010] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2006] [Revised: 06/27/2007] [Accepted: 07/13/2007] [Indexed: 02/01/2023]
Abstract
Corticosteroids are commonly used in the treatment of the impingement syndrome. Efficacy, as well as accurate placement, have been questioned. The purpose of this prospective, randomized study is to assess the accuracy of subacromial injections and to correlate accuracy with short term clinical outcome at 3 months. Sixty shoulders, which were diagnosed with impingement syndrome, were randomized to receive a subacromial injection of corticosteroids, local anesthetic, and contrast dye from 1 of 3 locations: anterolateral, lateral, or posterior. Accuracy was confirmed by 3 radiographic views of the shoulder, while clinical ratings were assessed by the UCLA shoulder score and a 10-point visual pain analog scale during the initial, post-injection, and 3-month visits. The overall accuracy was 70%, with no difference among the 3 portals. Accuracy was not related to body mass index. Furthermore, accurate injections did not significantly improve the UCLA score, pain scale, or patient satisfaction at 3 months. In contrast, accurate injections produced a positive Neer's impingement test more often (35/39 vs 9/16; P = .009). Overall, there was an improvement in the UCLA score (26.2-32.2; P < .001) and a decrease in the pain scale (7.2-3.43; P < .001) at 3-month follow-up. In conclusion, the accuracy of injection was 70%. Clinical improvement did not correlate with accuracy; however, accuracy did reliably produce a positive impingement test. This multimodal treatment plan did produce significant improvement in shoulder function and pain level in the short term.
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Affiliation(s)
- Michael N Kang
- Insall-Scott-Kelly Institute for Orthopedics and Sports Medicine, New York, NY 10021, USA.
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50
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Abstract
Older adults disproportionately sustain morbidity and mortality due to vaccine-preventable illnesses. Despite this observation, adult immunization rates continue to lag behind national goals. Reduced vaccine efficacy in older adults leading to apathy regarding the need for vaccine administration, unrealistic expectations for disease prevention rather than reduced illness severity, and system issues that make vaccine administration and tracking difficult all contribute to this problem. In this review, the biologic and system-based causes for vaccine failure in aged adults are reviewed, issues of efficacy and cost-effectiveness in older adults are summarized for influenza and pneumococcal vaccine, and ways to improve vaccine effectiveness in older adults, now and in the future, are outlined.
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Affiliation(s)
- Kevin High
- Section on Infectious Diseases, Wake Forest University Health Sciences, 100 Medical Center Boulevard, Winston Salem, NC 27157-1042, USA.
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