Participatory design and needs assessment for a pressure-sensitive pen and mobile application (SensoGrip) for children with handwriting problems

PURPOSE

Problems with handwriting are a common referral to occupational therapy in children and are often associated with inadequate pen grip and tip pressure. Technologies providing immediate feedback on applied forces are currently not available. Therefore, the aim was to identify user's perspectives on the optimal functionality of a pressure-sensitive pen with an integrated feedback system.

METHODS

To ensure that the product meets the requirements of the users, user needs of paediatric occupational therapists, elementary or special education teachers and children were collected in two focus groups and a children's workshops before starting the technical development process. Focus group transcripts were analyzed and rephrased as user stories to identify user-centred requirements. In a second step, user stories were merged and ranked regarding importance and feasibility.

RESULTS

120 user story requirements were generated from the focus groups and children's workshops, indicating requirements regarding design and functionality for the pen and mobile application. Visual feedback, appropriate size and weight, customizability, ease of settings and usability of the pen were pivotal.

CONCLUSIONS

This study comprehensively researched the requirements for a device that may facilitate children in adjusting their handwriting pressure and can guide further research and evaluation.

Evaluating the Experiences of Occupational Therapists and Children Using the SensoGrip Pressure-Sensitive Pen in a Handwriting Intervention: Multimethods Study

BACKGROUND

The acquisition of handwriting skills is essential for a child's academic success, self-confidence, and general school performance. Nevertheless, an estimated 5% to 27% of children face handwriting challenges, where the ability to modulate pressure on the pencil and lead on the paper is a key motor component.

OBJECTIVE

We aimed to investigate the experience with and usability of the SensoGrip system, a pressure-measuring pen system with personalized real-time feedback about pressure modulation, in a clinical setting with children and occupational therapists (OTs).

METHODS

A multimethods study was conducted, incorporating qualitative interviews and questionnaires with children, user diaries, focus group discussions, and a usability questionnaire with OTs, along with a questionnaire for parents.

RESULTS

The study involved OTs (n=8), children with handwriting difficulties (n=16), and their parents (n=16), each of whom used the SensoGrip system in up to 5 therapy sessions. OTs reported that the SensoGrip system helped to focus the child's awareness on handwriting pressure and to measure it objectively. The system received high acceptance and usability ratings from the OTs-usefulness: median score of 4 out of 7; ease of use and ease of learning: median score of 6 out of 7; and satisfaction: median score of 6 out of 7. Participants appreciated that it fosters pressure awareness and motivation to draw and write.

CONCLUSIONS

The SensoGrip pressure-sensing system with real-time feedback is a promising tool for pediatric occupational therapy. It supports children with handwriting difficulties to adjust their pressure application during the task. In the future, controlled quantitative trials are warranted to further examine the system's impact.

International Survey to Evaluate Current Options for Subcutaneous Injection of Methotrexate (MTX) and a New Button-Free MTX Autoinjector

Purpose

Prefilled syringes (PFS) and various types of pens are available for subcutaneous injection of methotrexate (MTX) in patients with rheumatoid arthritis or moderate to severe psoriasis. A new MTX pen with modernized button-free autoinjection technology was developed as a successor to a button-activated pen (metoject®/metex® PEN). To assess the needs of users and the relevance of features of the new MTX autoinjector an international online survey was performed.

Methods

A structured questionnaire was distributed to physicians, nurses and patients in Germany, France, and the United Kingdom. Participants received illustrations and information about features of the new MTX autoinjector.

Results

In total, 189 rheumatologists, 111 dermatologists, 90 nurses, and 180 patients answered the questions. Specific reasons for a preference for the use of MTX pens over PFS could predominantly be assigned to the categories "dosing/administration" and "ease of use". The first impression of the new MTX autoinjector was positive in 82% of physicians, 87% of nurses, and 76% of patients, respectively. The four most important features of the new MTX autoinjector were 2-step autoinjector mechanism (receiving a mean 14.1 to 18.1 chips of a total of 100 chips), small injection volume (9.7 to 11.7 chips), 10 different doses for dose flexibility (8.0 to 13.2 chips), and short injection time below 5 seconds (8.5 to 11.1 chips).

Conclusion

Arguments for the use of MTX pens as opposed to PFS predominantly refer to dosing/administration and ease of use. The new button-free MTX autoinjector combines a number of advantageous features identified by the international survey.

Antimicrobial resistance of Escherichia coli from dairy farms participating in an antimicrobial stewardship educational program for farm employees

Antimicrobial use in food-producing animals is under increasing scrutiny due to the potential effect on the selection of antimicrobial-resistant bacteria that may be transmitted to humans by direct contact, with the food chain, or the environment. Novel data monitoring commensal Escherichia coli from dairy farms is essential for understanding antimicrobial resistance (AMR) patterns and their association with herd health management practices. The objectives of this study were to: (1) compare the prevalence of antimicrobial resistance in the E. coli isolates from the hospital, fresh, and mid-lactation pens from 18 conventional dairy farms participating in an educational training program in antimicrobial stewardship practices in California and Ohio, and (2) to characterize the prevalence of antimicrobial resistance of commensal E. coli isolated from pooled fecal pat samples before and 3 mo after participating in the educational training program. Pooled fecal pat samples were collected from the hospital pen, the fresh pen (1 to 5 DIM), and the mid-lactation pens (90 to 150 DIM) on conventional dairies in CA (n = 9) and OH (n = 9). Fecal samples were collected as part of a larger study using a quasi-experimental design that assigned farms to the training intervention group (TG; 6 per state) or the control group (CG; 3 per state). For the TG, farm worker(s) identified as having the task of diagnosis and treatment of adult cows on the farm participated in a training program on antimicrobial stewardship practices. Pooled fecal samples (n = 7) were collected at enrollment and 3 mo after completing the intervention on each of the participating farms (n = 18), followed by culture for E. coli isolation and antimicrobial sensitivity testing using the broth microdilution methodology. Logistic regression models were used to evaluate the association between E. coli antimicrobial resistance patterns with the training intervention and farm-level factors. No effect was observed in the prevalence of resistant isolates between the control and intervention farms after the training was delivered. Isolates from the hospital pens were 2.48 (95% CI: 1.06-6.22, P = 0.03) and 5.61 (95% CI: 1.94-16.91, P < 0.001) times, more likely to be resistant to streptomycin and chloramphenicol, respectively, than isolates from the mid-lactation pens. Our findings indicate there was a higher prevalence of AMR in E. coli associated with the hospital pen within the farm, while the training program for 3 mo did not affect the prevalence of AMR in E. coli on the farms participating in the program. Further research efforts should be conducted to identify factors driving AMR at the pen level, as well as approaches that could be used to reduce the risk of disseminating AMR from sick pens to animals being housed and to other pens on the farm.

Behavior of Cows in the Lying Area When the Exit Gates in the Pens Are Opened: How Many Cows Are Forced to Get Up to Go to the Milking Parlor?

Equipping a farm with a milking parlor requires moving groups of cows from their pens to the part of the barn where milking takes place. The task of moving cows, carried out two or three times each day, shows links to the lying area of the barn. When the cows are taken from the pen to the milking parlor, some of them may be lying down, and this lying down must be interrupted. The forced standing up of cows can be considered in terms of their welfare. The aim of the study was to examine the number of cows lying in the stalls at the time of opening the exit gates in the pens in order to take the cows to the milking parlor. The study covered four pens, each with 12 cows. The behavior of the cows in the pens before morning and afternoon milking was recorded over 26 days. In the analysis, the dependent variable was the number of lying cows, and the independent variables were the time of milking and the level of sand in the lying stalls. The results of the study showed the significance of differences in the number of lying cows for stalls with a low and high level of sand, both in the case of morning and afternoon milking. Differences in the number of lying cows were also found when comparing the time before morning and afternoon milking. To compare the tendency of individual cows to lie down before going to milking, an index of forced standing up was proposed. The research conducted showed differences in the behavior of cows before leaving the pen to the milking parlor. The stage to reduce the forced standing up of cows is to equip the farm with an automatic milking system (AMS) instead of using a milking parlor. In barns with AMS, cows have full freedom to get up and approach the milking stall. The results of the observations are thus an additional argument confirming the benefits of using an automatic milking system, considered in terms of the welfare of dairy cows, regarding their lying down and getting up.

Enclosing a pen in a postal questionnaire follow-up to increase response rate: a study within a trial

Background

Poor response rates to follow-up questionnaires can adversely affect the progress of a randomised controlled trial and the validity of its results. This embedded 'study within a trial' aimed to investigate the impact of including a pen with the postal 3-month questionnaire completed by the trial participants on the response rates to this questionnaire.

Methods

This study was a two-armed randomised controlled trial nested in the Gentle Years Yoga (GYY) trial. Participants in the intervention group of the GYY trial were allocated 1:1 using simple randomisation to either receive a pen (intervention) or no pen with their 3-month questionnaire (control). The primary outcome was the proportion of participants sent a 3-month questionnaire who returned it. Secondary outcomes were time taken to return the questionnaire, proportion of participants sent a reminder to return the questionnaire, and completeness of the questionnaire. Binary outcomes were analysed using logistic regression, time to return by Cox Proportional Hazards regression and number of items completed by linear regression.

Results

There were 111 participants randomised to the pen group and 118 to the no pen group who were sent a 3-month questionnaire. There was no evidence of a difference in return rates between the two groups (pen 107 (96.4%), no pen 117 (99.2%); OR 0.23, 95% CI 0.02 to 2.19, p=0.20). Furthermore, there was no evidence of a difference between the two groups in terms of time to return the questionnaire (HR 0.90, 95% CI 0.69 to 1.18, p=0.47), the proportion of participants sent a reminder (OR 0.85, 95% CI 0.48 to 1.53, p=0.60) nor the number of items completed (mean difference 0.51, 95% CI -0.04 to 1.06, p=0.07).

Conclusion

The inclusion of a pen with the postal 3-month follow-up questionnaire did not have a statistically significant effect on response rate.

Extraction of foreign body from the urinary bladder using nephroscope: A case report of endoscopy treatment

Transurethral foreign bodies (FBs) in the urinary tract are rare findings in a clinical setting. The most common cases are reported for FBs in the urinary bladder. The present report similarly aimed to examine a whole pen as a FB with a discussion about symptoms and complexities. Here, we significantly reported the management of pen extraction from the bladder of a female patient using nephroscope and proposed success with possible recommendations for treatment in future operations.

Enclosing a pen in a postal questionnaire follow-up to increase response rate: a study within a trial [version 1; peer review: 2 approved]

Background

Poor response rates to follow-up questionnaires can adversely affect the progress of a randomised controlled trial and the validity of its results. This embedded 'study within a trial' aimed to investigate the impact of including a pen with the postal 3-month questionnaire completed by the trial participants on the response rates to this questionnaire.

Methods

This study was a two-armed randomised controlled trial nested in the Gentle Years Yoga (GYY) trial. Participants in the intervention group of the GYY trial were allocated 1:1 using simple randomisation to either receive a pen (intervention) or no pen with their 3-month questionnaire (control). The primary outcome was the proportion of participants sent a 3-month questionnaire who returned it. Secondary outcomes were time taken to return the questionnaire, proportion of participants sent a reminder to return the questionnaire, and completeness of the questionnaire. Binary outcomes were analysed using logistic regression, time to return by Cox Proportional hazards regression and number of items completed by linear regression.

Results

There were 111 participants randomised to the pen group and 118 to the no pen group who were sent a 3-month questionnaire. There was no evidence of a difference in return rates between the two groups (pen 107 (96.4%), no pen 117 (99.2%); OR 0.23, 95% CI 0.02 to 2.19, p=0.20). Furthermore, there was no evidence of a difference between the two groups in terms of time to return the questionnaire (HR 0.90, 95% CI 0.69 to 1.18, p=0.47), the proportion of participants sent a reminder (OR 0.85, 95% CI 0.48 to 1.53, p=0.60) nor the number of items completed (mean difference 0.51, 95% CI-0.04 to 1.06, p=0.07).

Conclusion

The inclusion of a pen with the postal 3-month follow-up questionnaire did not have a statistically significant effect on response rate.

Evaluating Use of the Octreotide Acetate Pen Injector in a Summative Human Factors Validation Study

OBJECTIVE

Subcutaneous injections of octreotide acetate require chronic administration by healthcare providers (HCPs). We aimed to validate the safe and effective use of the octreotide acetate pen injector, its labelling, and instructions for use (IFU) by patients, caregivers, and HCPs and mitigation of use-related risks.

METHODS

This summative human factors validation study enrolled adults with neuroendocrine tumors and related diarrhea or flushing, adult caregivers, and HCPs. Prior to simulated use, participants self-familiarized as they desired. Each participant was assigned 1 injection site for administration into an injection pad. The first of 2 unaided injections assessed first use and required priming; the second assessed routine use and dose change. Participants gave subjective feedback after each injection and completed knowledge probes and reading comprehension questions after the second injection.

RESULTS

The study enrolled 45 participants (15/group). Forty-two participants completed the first injection successfully by administering the dose correctly. Three participants did not successfully dose; 3 failed to prime the pen and 1 also failed to dial the correct dose. Unrelated to dosing, 2 participants failed to remove the needle after injection. Forty-four participants completed the second injection-1 participant failed to dial the correct dose. No other errors were observed. Overall success rates on knowledge probes and reading comprehension questions were 99.1% and 99.6%, respectively. All participants found the IFU easy to follow and understand.

CONCLUSION

The octreotide acetate pen injector, labelling, and IFU enabled intended users to administer subcutaneous octreotide safely and effectively. The residual risks of use are low and acceptable.

The Review of Insulin Pens-Past, Present, and Look to the Future

Currently, there are about 150-200 million diabetic patients treated with insulin globally. The year 2021 is special because the 100th anniversary of the insulin discovery is being celebrated. It is a good occasion to sum up the insulin pen technology invention and improvement which are nowadays the leading mode of an insulin delivery. Even though so many years have passed, insulin is still administered subcutaneously, that is why devices to deliver it are of great importance. Insulin pens have evolved only through the last decades (the reusable, durable pens, and the disposable, prefilled pens) and modern smart insulin pens have been developed in the last few years, and both types of the devices compared to traditional syringes and vials are more convenient, discrete in use, have better dosing accuracy, and improve adherence. In this review, we will focus on the history of insulin pens and their improvement over the previous decades.

Inpatient Insulin Pen Implementation, Waste, and Potential Cost Savings: A Community Hospital Experience

BACKGROUND

Insulin pen injectors ("pens") are intended to facilitate a patient's self-administration of insulin and can be used in hospitalized patients as a learning opportunity. Unnecessary or duplicate dispensation of insulin pens is associated with increased healthcare costs.

METHODS

Inpatient dispensation of insulin pens in a 240-bed community hospital between July 2018 and July 2019 was analyzed. We calculated the percentage of insulin pens unnecessarily dispensed for patients who had the same type of insulin pen assigned. The estimated cost of insulin pen waste was calculated. A pharmacist-led task force group implemented hospital-wide awareness and collaborated with hospital leadership to define goals and interventions.

RESULTS

9516 insulin pens were dispensed to 3121 patients. Of the pens dispensed, 6451 (68%) were insulin aspart and 3065 (32%) were glargine. Among patients on insulin aspart, an average of 2.2 aspart pens was dispensed per patient, but only an estimated 1.2 pens/patient were deemed necessary. Similarly, for inpatients prescribed glargine, an average of 2.1 pens/patient was dispensed, but only 1.3 pens/patient were necessary. A number of gaps were identified and interventions were undertaken to reduce insulin pen waste, which resulted in a significant decrease in both aspart (p = 0.0002) and glargine (p = 0.0005) pens/patient over time. Reductions in pen waste resulted in an estimated cost savings of $66 261 per year.

CONCLUSIONS

In a community hospital setting, identification of causes leading to unnecessary insulin dispensation and implementation of hospital-wide staff education led to change in insulin pen dispensation practice. These changes translated into considerable cost savings and facilitated diabetes self-management education.

Enclosing a pen to improve response rate to postal questionnaire: an embedded randomised controlled trial

Background: Poor response to questionnaires collecting outcome data in randomised controlled trials (RCTs) can affect the validity of trial results. The aim of this study within a trial (SWAT) was to evaluate the effectiveness of including a pen with a follow-up postal questionnaire on response rate. Methods: A two-armed RCT was embedded within SSHeW (Stopping Slips among Healthcare Workers), a trial of slip-resistant footwear to reduce slips in NHS staff.  Participants were randomised 1:1 to receive a pen or no pen with their follow-up questionnaire. The primary outcome was the proportion of participants who returned the questionnaire. Secondary outcomes were: time to response, completeness of response, and whether a postal reminder notice was required. Data were analysed using logistic regression, linear regression and Cox proportional hazards regression. Results: Overall, 1466 SSHEW trial participants were randomised into the SWAT. In total, 13 withdrew from the host trial before they were due to be sent their follow-up questionnaire, 728 participants received a pen with their questionnaire, and 725 did not receive a pen.  A questionnaire was returned from 67.7% of the pen group and 64.7% of the group who did not receive a pen. There was no significant difference in return rates between the two groups (OR 1.15, 95% CI 0.92 to 1.43, p=0.22), nor level of completeness of the questionnaires (AMD -0.01, 95% CI 0.06 to 0.05, p=0.77).  There was weak evidence of a reduction in the proportion of participants requiring a reminder and in time to response in the pen group. Conclusion: Inclusion of a pen with the follow-up postal questionnaire sent to participants in the SSHeW trial did not statistically significantly increase the response rate. These results add to the body of evidence around improving response rates in trials. Trial registration: ISRCTN 33051393 (for SSHEW). Registered on 14/03/2017.

A 2x2 randomised factorial SWAT of the use of a pen and small, financial incentive to improve recruitment in a randomised controlled trial of yoga for older adults with multimorbidity

Background: Monetary and other incentives may increase recruitment to randomised controlled trials. Methods: 2x2 factorial 'study within a trial' of including a pen and/or £5 (GBP) in cash with a postal recruitment pack to increase the number of participants randomised into the host trial ('Gentle Years Yoga') for older adults with multimorbidity. Secondary outcomes: return, and time to return, of screening form, and the cost per additional participant randomised. Binary data were analysed using logistic regression and time to return using Cox proportional hazards regression.  Results: 818 potential host trial participants were included. Between those sent a pen (n=409) and not sent a pen (n=409), there was no evidence of a difference in the proportion of participants randomised (15 (3.7%) versus 11 (2.7%); OR 1.38, 95% CI 0.63-3.04), in returning a screening form (66 (16.1%) versus 61 (14.9%); OR 1.10, 95% CI 0.75-1.61) nor in time to return the screening form (HR 1.09, 95% CI 0.77-1.55). Between those sent £5 (n=409) and not sent £5 (n=409), there was no evidence of increased randomisation (14 (3.4%) versus 12 (2.9%); OR 1.18, 95% CI 0.54-2.57), but more screening forms were returned (77 (18.8%) versus 50 (12.2%); OR 1.67, 95% CI 1.13-2.45) and there was decreased time to return screening form (HR 1.56, 95% CI 1.09-2.22). No significant interaction between the interventions was observed. The cost per additional participant randomised was £32 and £1000 for the pen and £5, respectively. Conclusion: A small, monetary incentive did not result in more participants being randomised into the host trial but did encourage increased and faster response to the recruitment invitation. Since it is relatively costly, we do not recommend this intervention for use to increase recruitment in this population. Pens were cheaper but did not provide evidence of benefit.

Penetrating Orbital Injuries: A Review

Penetrating injuries to the orbit represent a small but very complicated portion of head injuries. Because of the close proximity to many vital structures, any penetrating orbital injury requires a multidisciplinary follow-up. Cases of penetrating injuries have flooded the literature, but no one has presented a systematic approach to the complications associated with these types of injuries. Herein, we present the complications associated with each orbital entry mode: superior, inferior, medial, lateral rims of the orbit, and extraorbital entry.

Patient and Physician Perspectives on Mode of Administration of the PCSK9 Monoclonal Antibody Alirocumab, an Injectable Medication to Lower LDL-C Levels

PURPOSE

Clinical trials of the PCSK9 inhibitor alirocumab, an every 2 week injectable monoclonal antibody, have shown significant reductions in LDL-cholesterol. However, many patients requiring lipid-lowering therapy are not experienced with self-injected medication. This study assessed patient and physician perceptions of 2 alirocumab delivery devices.

METHODS

400 participants (200 physicians, 200 patients) were included from 6 countries. Physicians (99 primary care physicians [PCPs]; 101 specialists) had mean practice experience of 17.8 years and an average of 797 hypercholesterolemic patients. Participating patients had LDL-C levels above their goal and at least one of the following: familial hypercholesterolemia, statin intolerance, high cardiovascular risk, and/or diabetes. Mean patient age was 58.5 years, 51% were female, and 25.5% had injectable medication experience. Following device instruction and demonstration, participants tested either a pre-filled pen or pre-filled syringe, using both 75 and 150 mg doses of single-blinded placebo into a prosthetic pad. Data were collected by self-administered questionnaire.

FINDINGS

Participant acceptance of both devices was positive, with 83-100% agreeing with ease-of-use statements. After testing, physicians estimated that 66% (pen) and 58% (syringe) of their patients would be willing to self-inject using the device (relative increases from pre-testing of 22% and 16%, respectively; both P<0.05). Specialist estimates were higher than PCP estimates: for the pen, 60% versus 47% (pre-testing), respectively, and 72% versus 61% (post-testing); for the syringe, 57% versus 43% (pre-testing), 63% versus 54% (post-testing; all P<0.05, specialist vs PCP). After testing, 72% (pen) and 63% (syringe) of patient-participants were very willing to self-inject (relative increases from pre-testing of 26% [P<0.05] and 11%, respectively); 96% (pen) and 93% (syringe) were either very willing or somewhat willing to self-inject. The proportion of patients aged <60 years who were very willing to self-inject with either device was numerically (but not statistically) higher compared with those ≥60 years. Initially, patients with injectable medication experience were generally more willing to use the pen than injection-naive patients; after testing there was no difference between groups. No significant differences were observed in responses to the 2 different doses.

IMPLICATIONS

Responses from physicians and patients to pre-filled pen and syringe devices were positive. Devices were considered easy to operate, with most patients willing to use and accept self-injection. Patient willingness to self-inject increased after demonstration and testing. Results suggest that, in clinical practice, alirocumab administration by either pre-filled pen or syringe would not deter most physicians from prescribing or most patients from self-administering.

Mixing Pens and the Future of Diabetes Drugs

With the availability of a smaller mixing pen, mass marketing of less stable medications is possible. Bidureon is one such medication, and the properties of its pen are discussed along with the prospects for future mixing pens.

Pen-on-paper approach toward the design of universal surface enhanced Raman scattering substrates

The translation of a technology from the laboratory into the real world should meet the demand of economic viability and operational simplicity. Inspired by recent advances in conductive ink pens for electronic devices on paper, we present a "pen-on-paper" approach for making surface enhanced Raman scattering (SERS) substrates. Through this approach, no professional training is required to create SERS arrays on paper using an ordinary fountain pen filled with plasmonic inks comprising metal nanoparticles of arbitrary shape and size. We demonstrate the use of plasmonic inks made of gold nanospheres, silver nanospheres and gold nanorods, to write SERS arrays that can be used with various excitation wavelengths. The strong SERS activity of these features allowed us to reach detection limits down to 10 attomoles of dye molecules in a sample volume of 10 μL, depending on the excitation wavelength, dye molecule and type of nanoparticles. Furthermore, such simple substrates were applied to pesticide detection down to 20 ppb. This universal approach offers portable, cost effective fabrication of efficient SERS substrates at the point of care. This approach should bring SERS closer to the real world through ink cartridges to be fixed to a pen to create plasmonic sensors at will.

Does Device Make Any Difference? A Real-world Retrospective Study of Insulin Treatment Among Elderly Patients With Type 2 Diabetes

We compared real-world clinical and economic outcomes for insulin glargine treatment administered by disposable pen and traditional vial-and-syringe injections among elderly patients with type 2 diabetes mellitus (T2DM). Using a large database of US retirees, this retrospective longitudinal study examined 1-year follow-up outcomes in patients with T2DM aged 65 years or older who were either insulin naïve and initiated insulin glargine via disposable pen (pen initiators [PI]) or vial (vial initiators [VI]) or were already insulin glargine users but either continued with a vial (vial continuers [VC]) or switched to a disposable pen (pen switchers [PS]). There were 7856 propensity-score-matched patients, including 2930 each in the PI and VI cohorts, and 998 each in the VC and PS cohorts. Compared with vial-and-syringe users, the disposable pen users had significantly greater treatment persistence (P < .0001 for both comparisons), duration of persistence (P < .0001 for both), and adherence (P < .01 for both) and lower insulin daily average consumption (P < .05 for both). Compared with the VI cohort, the PI cohort had significantly fewer hypoglycemia-related events (P = .0164). Total health care costs were comparable for the respective matched cohorts. In elderly patients with T2DM receiving insulin glargine therapy, initiating or switching to a disposable pen was associated with better treatment persistence and adherence than initiating or continuing with vial-and-syringe, without increased total health care costs. Among insulin-naïve patients, initiating insulin glargine by disposable pen was also associated with significantly reduced risk of hypoglycemia compared with vial-and-syringe patients.

Usage and perceptions of pen injectors for diabetes management: a survey of type 2 diabetes patients in the United States

BACKGROUND

This study was conducted to investigate type 2 diabetes mellitus (T2DM) patient perceptions of their pen injectors and determine which features were deemed most important to overall satisfaction.

METHODS

Frost & Sullivan conducted a Web-based survey of T2DM patients in the United States in November 2010. Survey participants were initially screened prior to full participation. A total of 1002 adult T2DM patients who were using a pen injector on a regular basis to administer their diabetes medication(s) were surveyed. The survey consisted of 24 questions focused on awareness and current usage of pen injectors by type and brand, specific features of pen injectors, and patients' preferences for and satisfaction with pen injectors.

RESULTS

The majority of surveyed patients were using prefilled pen injectors as compared with durable pens. The LANTUS SoloSTAR (sanofi-aventis) was reported to be the most commonly used pen. The LANTUS SoloSTAR was also ranked highly for overall satisfaction and likelihood of continued usage. Regardless of brand, most surveyed patients reported that they were likely to continue using their current pen. In general, the single most important feature for user satisfaction was an easy push-button injection.

CONCLUSIONS

Ease of self-administration is of highest priority to users of pen injectors. Important features facilitating ease of use, such as an easily depressed push-button injection, are likely to minimize the burden on T2DM patients, thereby improving compliance and clinical outcomes.

What can we learn from patient-reported outcomes of insulin pen devices?

Although a variety of effective treatment options are available for patients with type 1 or type 2 diabetes, many patients in the United States have difficulty reaching their glycemic goals. Patient adherence to insulin therapy, which often involves self-administered subcutaneous injections of insulin using either a vial and syringe or an insulin pen device, is often poor. Various factors associated with the type of injection device have been shown to influence the rate of patient adherence to insulin therapy. This article reviews patient-reported outcome (PRO) evidence from pediatric and adult studies that compared insulin pen devices with vial and syringe use. In a majority of these cases, patients preferred the pen devices over vial and syringe, stating advantages such as ease of use, convenience, greater confidence in their ability to properly administer the drug, and a greater perceived social acceptance. The pens were considered less painful than syringes and were associated with less needle fear. In addition, PRO evidence has directed pen technology design, leading to development of more advanced insulin pen devices. By appreciating the correlation between adherence to insulin regimens and a patient's device preference, clinicians can make improved treatment recommendations to facilitate achievement and maintenance of glycemic targets.

Trend analyses of insulin delivery systems in the United States

BACKGROUND

Despite potential advantages in insulin pen delivery systems (IPDSs), the percentage of patients using an IPDS is relatively low in the United States.

OBJECTIVE

Our aim was to investigate the trend of initiating IPDSs among patients with type 2 diabetes mellitus (T2DM) who newly initiated insulin therapy.

METHODS

A retrospective analysis was conducted using a U.S. database from January 1, 2004, to December 31, 2008. Patients with T2DM who initiated a new insulin type and delivery system were included. The Cochran-Armitage test was used to assess the significance of the trend of initiating an insulin delivery system, including vial/syringe, IPDS overall, reusable pen delivery systems (RPDSs), and prefilled pen delivery systems (PPDSs). Different types of insulin (e.g., basal analog, prandial analog) were examined separately.

RESULTS

Patients initiating an IPDS increased from 10.6% in 2004 to 48.5% in 2008 (p < .001), most notably in basal analog and prandial analog insulin therapies. Although the percentage of patients using a PPDS increased by 36.2 percentage points (from 9.2% in 2004 to 45.4% in 2008; p < .001), use of a RPDS increased only by 1.7 percentage points (from 1.4% in 2004 to 3.1% in 2008; p < .001).

CONCLUSION

There was an overall increase in the use of IPDSs in the United States among patients with T2DM who newly initiated insulin from July 1, 2004, to December 31, 2008. This increase was driven by the use of PPDSs for basal analog and prandial analog insulin therapies. Despite the increasing use of IPDS over time, approximately 50% of patients still initiated insulin using a vial/syringe in 2008.

Analysis and perspective: A randomized, open-label, comparative crossover handling trial between two durable pens in patients with type 1 or 2 diabetes mellitus

Insulin pen therapy is superior to vial and syringe with regard to more accurate insulin delivery, patient preference, adherence, and favorable health economics. In this issue of Journal of Diabetes Science and Technology, Sommavilla and Pietranera compare two generations of NovoPen, showing significant improvements in selecting and injecting the insulin dose as well as superior overall satisfaction with the newer versus older generation insulin pen among both experienced pen users and insulin-naïve patients. There are other potentially useful features that might be implemented and better-studied in future pen devices. These include insulin dose tracking, insulin error mitigation, and insulin dosing advice. Caring more effectively for the multitude of people impacted by the diabetes epidemic requires a new approach that will require "smarter," more "connected" devices.

Developments in administration of growth hormone treatment: focus on Norditropin® Flexpro®

Recombinant human growth hormone is used for the treatment of growth failure in children and metabolic dysfunction in adults with growth hormone deficiency. However, conventional growth hormone therapy requires daily subcutaneous injections that may affect treatment adherence, and subsequently efficacy outcomes. To enhance potential treatment adherence, improved ease of use of growth hormone delivery devices and long-acting growth hormone formulations are now being developed. Flexpro(®), approved by the US Food and Drug Administration in March 2010, is the most recent pen device developed by Novo Nordisk A/S to deliver Norditropin(®). It is a multidose, premixed, preloaded, disposable pen device that requires relatively less force to inject and does not require refrigeration after initial use. Dose adjustments can be optimized by small dose increments of the pen delivery device at 0.025 mg, 0.05 mg and 0.1 mg. In addition, for patients with needle anxiety, NovoFine(®) needles, some of the shortest and thinnest available, and Autocover(®), which hides the needle during injections, can be used with the Flexpro pen device. This article reviews the Norditropin Flexpro pen device in the context of other growth hormone delivery devices, sustained-release growth hormone formulations in development, and future prospects.

'PEN' appendicitis

We report a three-year-old boy who ingested the tip of a pen and presented with signs of appendicitis. Plain abdominal radiographs showed the foreign body in the right iliac fossa. Surgical exploration revealed perforated appendix and the foreign body in its lumen. Appendectomy resulted in satisfactory recovery.

Analysis: including visually impaired participants in validation design studies of diabetes technology

In an article in this issue of Journal of Diabetes Science and Technology, Sherwyn Schwartz, M.D., presents a study to validate the design of the ClikSTAR® insulin pen from sanofi-aventis and demonstrates that the device can be used correctly by participants with diabetes. Concern with this article lies with the selection of participants, which was meant to reflect the intended audience for the insulin pen device but does not address the inclusion of visually impaired individuals, who comprise over 20% of the adult diabetes population. Visually impaired individuals need to be included as part of the intended audience for insulin administration technology, and manufacturers of these devices need to design their products for safe use by all people, including those who are visually impaired. The study demonstrated successful use of the ClikSTAR insulin pen in a population that did not include subjects with severe visual impairment. We believe that future validation studies for insulin administration technology should also include samples of visually impaired users and that visually impaired patients will embrace the use of insulin pens designed with their needs in mind.

Plant enemy-derived elicitors increase the foliar tannin concentration of Onobrychis viciifolia without a trade-off to growth

BACKGROUND AND AIMS

Molecular experiments suggest that the regulation of the biosynthesis of condensed tannin (CT) is sensitive to the presence of plant enemies. The enemy-specific response of CT concentrations to simulated attacks by pathogenic fungi, bacteria or herbivores was studied in Onobrychis viciifolia grown at four levels of nutrient availability. It was hypothesized that CT concentrations increase in response to an attack, and that constitutive and induced levels of CT are higher at low than at high nutrient availability. Investment in CT was also predicted to be negatively related to plant growth.

METHODS

Recently discovered substances by which plants recognize their opponents (i.e. elicitors) were used to simulate attacks to Onobrychis viciifolia grown at 0.0027, 0.075, 0.67 or 2 mm phosphorus in the nutrient solution.

KEY RESULTS

Relative growth rate and final biomass (P < 0.001) were highest at 0.67 mm of phosphorus. CT concentrations decreased with increasing phosphorus availability, from 94.9 to 69.0 mg g(-1) leaf dry weight (P < 0.001). Compared with unscathed plants, sterile mere mechanical wounding reduced tannin concentrations from 83.8 to 69.3 mg g(-1) leaf dry weight (P < 0.01). Local CT concentrations were higher when wounded leaves were additionally treated with fungal (+15.9 %), bacterial (+19.6 %) or insect (+31.0 %) elicitors (each elicitor; P < 0.05); however, only the insect elicitor (saliva of the lepidopteron Spodoptera littoralis) induced CT concentrations higher than those of unscathed leaves.

CONCLUSIONS

CT concentrations were inducible in the vicinity of the wound but the level of induction was unrelated to the nutrient status of the plant. There was no evidence of a growth-defence trade-off. The inverse relationship between CT concentrations and nutrient availability appears to reflect passive growth dilution at high nutrient availability, rather than surplus CT production at low nutrient availability.

Insulin pen-the "iPod" for insulin delivery (why pen wins over syringe)

Diabetes affects most aspects of everyday life and places considerable responsibility on the patient; therefore, without patient acceptance of what we offer, the therapy is unlikely to be adhered to especially when that therapy happens to be insulin injection. In 2008, almost every physician/health care provider carries new and sleek cell phones (because the newer ones are well designed and function better). Why these same providers continue to prescribe insulin via syringes in 2008 is something that I cannot fathom. Previously, some insurance companies only paid for vials and there was no other choice, but today almost all insurance pay for pens and so the "insurance reason" is no longer tenable. Since Banting and Best discovered insulin in 1921, scientists have continued to improve the types of insulin (making them mimic physiology more closely in order to minimize hypoglycemia and improve glycemic control as seen with the latest analog insulins). In the same manner, the delivery process of insulin has also continued to evolve to make it easier and more acceptable to patients. Studies have shown that patients prefer device use over traditional vials/syringes. Pen devices used to inject insulin lead to better compliance, are quicker to inject, dosing is much more accurate, and, surprisingly, are more cost effective. I challenge my colleagues to take full responsibility for what their patients use. If a provider believes in pen devices, most of his/her patients will use them. The products your patients use is a direct reflection of what you practice. Educating providers to change their beliefs and practices is key to moving American diabetic patients from syringes to pen devices.