Shenkang injection for the treatment of acute kidney injury: a systematic review and meta-analysis

OBJECTIVE

Shenkang injection (SKI) has been widely used in China for many years for the treatment of kidney disease. The objective of this systematic review was to assess the efficacy of Shenkang injection for the treatment of acute kidney injury (AKI).

METHODS

A search was conducted across seven databases, encompassing data from the inception of each database through October 8th, 2023. Randomized controlled trials comparing SKI-treated AKI patients with control subjects were extracted. The main outcome measure was serum creatinine (SCr) levels. Secondary outcomes included blood urea nitrogen (BUN), serum cystatin C (CysC), 24-h urine protein (24 h-Upro) levels, APACHE II score and adverse reactions.

RESULTS

This meta-analysis included eleven studies, and the analysis indicated that, compared with the control group, SKI significantly decreased SCr [WMD = -23.31, 95% CI (-28.06, -18.57); p < 0.001]; BUN [WMD = -2.07, 95% CI (-2.56, -1.57); p < 0.001]; CysC [WMD = -0.55, 95% CI (-0.78, -0.32), p < 0.001]; 24-h urine protein [WMD = -0.43, 95% CI (-0.53, -0.34), p < 0.001]; and the APACHE II score [WMD = -3.07, 95% CI (-3.67, -2.48), p < 0.001]. There was no difference in adverse reactions between the SKI group and the control group [RR = 1.32, 95% CI (0.66, 2.63), p = 0.431].

CONCLUSION

The use of SKI in AKI patients may reduce SCr, BUN, CysC, 24-h Upro levels, and APACHE II scores in AKI patients. The incidence of adverse reactions did not differ from that in the control group. Additional rigorous clinical trials will be necessary in the future to thoroughly evaluate and establish the effectiveness of SKI in the treatment of AKI.

Backflow reduction in local injection therapy with gelatin formulations

The local injection of therapeutic drugs, including cells, oncolytic viruses and nucleic acids, into different organs is an administrative route used to achieve high drug exposure at the site of action. However, after local injection, material backflow and side effect reactions can occur. Hence, this study was carried out to investigate the effect of gelatin on backflow reduction in local injection. Gelatin particles (GPs) and hydrolyzed gelatin (HG) were injected into tissue models, including versatile training tissue (VTT), versatile training tissue tumor-in type (VTT-T), and broiler chicken muscles (BCM), using needle gauges between 23 G and 33 G. The backflow material fluid was collected with filter paper, and the backflow fluid rate was determined. The backflow rate was significantly reduced with 35 μm GPs (p value < .0001) at different concentrations up to 5% and with 75 μm GPs (p value < .01) up to 2% in the tissue models. The reduction in backflow with HG of different molecular weights showed that lower-molecular-weight HG required a higher-concentration dose (5% to 30%) and that higher-molecular-weight HG required a lower-concentration dose (7% to 8%). The backflow rate was significantly reduced with the gelatin-based formulation, in regard to the injection volumes, which varied from 10 μL to 100 μL with VTT or VTT-T and from 10 μL to 200 μL with BCM. The 35 μm GPs were injectable with needles of small gauges, which included 33 G, and the 75 μm GPs and HG were injectable with 27 G needles. The backflow rate was dependent on an optimal viscosity of the gelatin solutions. An optimal concentration of GPs or HG can prevent material backflow in local injection, and further studies with active drugs are necessary to investigate the applicability in tumor and organ injections.

Chitosan-nanoclay embolic material for catheter-directed arterial embolization

Minimally invasive transcatheter embolization is a common nonsurgical procedure in interventional radiology. It is used for the deliberate occlusion of blood vessels for the treatment of disease or injured vasculature, including vascular malformation and malignant/benign tumors. Here, we introduce a gel embolic agent comprising chitosan nanofibers and nanoclay with excellent catheter injectability and tunable mechanical properties for embolization. The properties of the gel were optimized by varying the ratio between each individual component and also adjusting the total solid content. The rheological studies confirm the shear thinning property and gel nature of the developed gel as well as their recoverability. Injection force was measured to record the force required to pass the embolic gel through a clinically relevant catheter, evaluating for practicality of hand-injection. Theoretical predicted injection force was calculated to reduce the development time and to enhance the physician's experience. The stability of occlusion was also tested in vitro by monitoring the pressure required to displace the gel. The engineered gels exhibited sterility, hemocompatibility and cell biocompatibility, highlighting their potential for transcatheter embolization.

Gastric peroral endoscopic myotomy versus botulinum toxin injection for the treatment of refractory gastroparesis: results of a double-blind randomized controlled study

INTRODUCTION

Gastric peroral endoscopic myotomy (G-POEM) is a promising technique for treating refractory gastroparesis. We present the first double-blind randomized study comparing the clinical efficacy of G-POEM versus pyloric botulinum toxin injection (BTI).

METHODS

This randomized study, conducted in two expert centers, enrolled patients with refractory gastroparesis, medically managed for >6 months and confirmed by gastric emptying scintigraphy (GES), into two groups, G-POEM versus BTI, with follow-up of 1 year. The primary end point was the 3-month clinical efficacy, defined as a >1-point decrease in the mean Gastroparesis Cardinal Symptom Index (GCSI) score. Secondary end points were: 1-year efficacy, GES evolution, adverse events, and quality of life.

RESULTS

40 patients (22 women; mean age 48.1 [SD 17.4]), with mean symptom duration of 5.8 (SD 5.7) years, were randomized. Etiologies included idiopathic (n=18), diabetes (n=11), postoperative (n=6), and mixed (n=4). G-POEM showed a higher 3-month clinical success than BTI (65% vs. 40%, respectively; P=0.10), along with non-significantly higher 1-year clinical success (60% vs. 40%, respectively) on intention-to-treat analysis. The GCSI decreased in both groups at 3 months and 1 year. Only three minor adverse events occurred in the G-POEM group. The GES improvement rate was 72% in the G-POEM group versus 50% in the BTI group (non-significant).

CONCLUSION

G-POEM seems to have a higher clinically relevant success rate than BTI, but this was not statistically demonstrated. This study confirms the interest in treatments targeting the pylorus, either mechanically or chemically, for managing refractory gastroparesis.

Shuxuening Injection Inhibits Apoptosis and Reduces Myocardial Ischemia-Reperfusion Injury in Rats through PI3K/AKT Pathway

OBJECTIVE

To investigate the main components and potential mechanism of Shuxuening Injection (SXNI) in the treatment of myocardial ischemia-reperfusion injury (MIRI) through network pharmacology and in vivo research.

METHODS

The Traditional Chinese Medicine Systems Pharmacology (TCMSP) and PharmMapper databases were used to extract and evaluate the effective components of Ginkgo biloba leaves, the main component of SXNI. The Online Mendelian Inheritance in Man (OMIM) and GeneCards databases were searched for disease targets and obtain the drug target and disease target intersections. The active ingredient-target network was built using Cytoscape 3.9.1 software. The STRING database, Metascape online platform, and R language were used to obtain the key targets and signaling pathways of the anti-MIRI effects of SXNI. In order to verify the therapeutic effect of different concentrations of SXNI on MIRI in rats, 60 rats were first divided into 5 groups according to random number table method: the sham operation group, the model group, SXNI low-dose (3.68 mg/kg), medium-dose (7.35 mg/kg), and high-dose (14.7 mg/kg) groups, with 12 rats in each group. Then, another 60 rats were randomly divided into 5 groups: the sham operation group, the model group, SXNI group (14.7 mg/kg), SXNI+LY294002 group, and LY294002 group, with 12 rats in each group. The drug was then administered intraperitoneally at body weight for 14 days. The main biological processes were validated using in vivo testing. Evans blue/triphenyltetrazolium chloride (TTC) double staining, hematoxylin-eosin (HE) staining, terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay, enzyme-linked immunosorbent assay (ELISA), and Western blot analysis were used to investigate the efficacy and mechanism of SXNI in MIRI rats.

RESULTS

Eleven core targets and 30 Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways were selected. Among these, the phosphoinositide 3-kinase (PI3K)/ protein kinase B (AKT) pathway was closely related to SXNI treatment of MIRI. In vivo experiments showed that SXNI reduced the myocardial infarction area in the model group, improved rat heart pathological damage, and reduced the cardiomyocyte apoptosis rate (all P<0.01). After SXNI treatment, the p-PI3K/PI3K and p-AKT/AKT ratios as well as B-cell lymphoma-2 (Bcl-2) protein expression in cardiomyocytes were increased, while the Bax and cleaved caspase 3 protein expression levels were decreased (all P<0.05). LY294002 partially reversed the protective effect of SXNI on MIRI.

CONCLUSION

SXNI protects against MIRI by activating the PI3K/AKT signaling pathway.

A New Injection Method of Nerve Block Combined with Local Infiltration Anesthesia for Relieving Pain of Horizontal Neck Lines Injection

SUMMARY

Filler injection is an effective method for the treatment of horizontal neck lines, but injection pain presents a burden for many patients. Topical anesthesia and local refrigeration are common methods to relieve the pain of injection, each of which has disadvantages. The transverse cervical nerve is the main innervating nerve for pain sensation in the anterior skin of the neck. The authors performed nerve block anesthesia and local infiltration anesthesia on one side of horizontal neck lines and applied topical anesthesia cream on the other side of the neck in 100 patients. The pain level with nerve block anesthesia and local infiltration anesthesia was reduced by 81% compared with the pain level with topical anesthesia. This treatment did not affect surgeon judgment on neck line shape and shortened treatment time. This new method can be used to relieve the pain of neck line injection.

Predictors and Variation in Steroid Injection Use for Carpal Tunnel Syndrome from a Multicenter Quality Collaborative

BACKGROUND

Steroid injections are commonly used as first-line treatment for carpal tunnel syndrome (CTS); however, research has shown that their benefit is generally short term, and many patients go on to receive carpal tunnel release (CTR). The purpose of this study was to determine the variation in steroid injection use by hand surgeons.

METHODS

The authors analyzed data from a nine-center hand surgery quality collaborative. Data from 1586 patients (2381 hands) were included if they underwent elective CTR at one of the sites. Mixed effects logistic regression models were used to examine the association of receipt of steroid injection and association of receipt of more than one steroid injection among patient-level covariates.

RESULTS

Steroid injection use significantly varied by practice, ranging from 12% to 53% of patients. The odds of receiving a steroid injection were 1.4 times higher for women ( P < 0.01), 1.6 times higher for patients with chronic pain syndrome ( P < 0.01), 0.5 times lower for patients with moderate electromyography (EMG) classification, and 0.4 times lower for patients with severe EMG classification (both P < 0.01). Patients with high scores on the Six-Item CTS Scale ( P = 0.02) and patients with moderate ( P = 0.04) or severe EMG ( P = 0.05) classification had lower odds of receiving multiple steroid injections. Complete symptomatic improvement after steroid injection was significantly reported by patients with a high Six-Item CTS Scale score ( P = 0.03) and patients with severe EMG classification ( P = 0.02).

CONCLUSIONS

The authors found wide patient-level and practice-level variation in the use of steroid injections before CTR. These findings underscore the need for improved data and standard practice guidelines regarding which patients benefit from steroid injection.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Design of a Reciprocal Injection Device for Stability Studies of Parenteral Biological Drug Products

Formulation screening, essential for assessing the impact of physical, chemical, and mechanical stresses on protein stability, plays a critical role in biologics drug product development. This research introduces a Reciprocal Injection Device (RID) designed to accelerate formulation screening by probing protein stability under intensified stress conditions within prefilled syringes. This versatile device is designed to accommodate a broad spectrum of injection parameters and diverse syringe dimensions. A commercial drug product was employed as a model monoclonal antibody formulation. Our findings effectively highlight the efficacy of the RID in assessing concentration-dependent protein stability. This device exhibits significant potential to amplify the influences of interfacial interactions, such as those with buffer salts, excipients, air, metals, and silicone oils, commonly found in combination drug products, and to evaluate the protein stability under varied stresses.

Willingness and preferences for long-acting injectable PrEP among US men who have sex with men: a discrete choice experiment

INTRODUCTION

Cabotegravir long-acting injectable HIV pre-exposure prophylaxis (LA-PrEP) was shown to be safe and effective in multiple clinical trials. Increasing uptake and persistence among populations with elevated risk for HIV acquisition, especially among men who have sex with men (MSM), is critical to HIV prevention.

OBJECTIVE

This analysis aims to understand potential users' preferences for LA-PrEP, with audience segmentation.

DESIGN

Willingness to use and preferences for LA-PrEP were measured in HIV-negative, sexually active MSM in the 2020 American Men's Internet Survey. Respondents answered a discrete choice experiment with paired profiles of hypothetical LA-PrEP characteristics with an opt-out option (no LA-PrEP). Conditional and mixed logit models were run; the final model was a dummy-coded mixed logit that interacted with the opt-out.

SETTING

US national online sample.

RESULTS

Among 2506 MSM respondents, most (75%) indicated a willingness to use LA-PrEP versus daily oral PrEP versus no PrEP. Respondents were averse to side effects and increasing costs and preferred increasing levels of protection. Respondents preferred a 2-hour time to obtain LA-PrEP vs 1 hour, with a strong aversion to 3 hours. Overall, there was an aversion to opting out of LA-PrEP, with variations: those with only one partner, no/other insurance or who were Black, Indigenous or People of Colour were significantly less likely to prefer LA-PrEP, while those who were Hispanic/Latino, college educated and <40 years significantly preferred LA-PrEP.

CONCLUSIONS

A large proportion of MSM expressed a preference for LA-PrEP over daily oral pills. Most respondents chose LA-PrEP regardless of cost, clinic time, side effects or protection level; however, preferences varied by sociodemographics. These varied groups likely require tailored intervention strategies to achieve maximum LA-PrEP uptake and persistence.

A systematic review and meta-analysis on sodium tanshinone IIA sulfonate injection for the adjunctive therapy of pulmonary heart disease

AIMS

Sodium tanshinone IIA sulfonate (STS) injection has been widely used as adjunctive therapy for pulmonary heart disease (PHD) in China. Nevertheless, the efficacy of STS injection has not been systematically evaluated so far. Hence, the efficacy of STS injection as adjunctive therapy for PHD was explored in this study.

METHODS

Randomized controlled trials (RCTs) were screened from China Science and Technology Journal Database, China National Knowledge Infrastructure, Wanfang Database, PubMed, Sino-Med, Google Scholar, Medline, Chinese Biomedical Literature Database, Cochrane Library, Embase and Chinese Science Citation Database until 20 January 2024. Literature searching, data collection and quality assessment were independently performed by two investigators. The extracted data was analyzed with RevMan 5.4 and STATA 14.0. Basing on the methodological quality, dosage of STS injection, control group measures and intervention time, sensitivity analysis and subgroup analysis were performed.

RESULTS

19 RCTs with 1739 patients were included in this study. Results showed that as adjunctive therapy, STS injection combined with Western medicine showed better therapeutic efficacy than Western medicine alone for PHD by increasing the clinical effective rate (RR = 1.22; 95% CI, 1.17 to 1.27; p < 0.001), partial pressure of oxygen (MD = 10.16; 95% CI, 5.07 to 15.24; p < 0.001), left ventricular ejection fraction (MD = 8.66; 95% CI, 6.14 to 11.18; p < 0.001) and stroke volume (MD = 13.10; 95% CI, 11.83 to 14.38; p < 0.001), meanwhile decreasing the low shear blood viscosity (MD = -1.16; 95% CI, -1.57 to -0.74; p < 0.001), high shear blood viscosity (MD = -0.64; 95% CI, -0.86 to -0.42; p < 0.001), plasma viscosity (MD = -0.23; 95% CI, -0.30 to -0.17; p < 0.001), hematokrit (MD = -8.52; 95% CI, -11.06 to -5.98; p < 0.001), fibrinogen (MD = -0.62; 95% CI, -0.87 to -0.37; p < 0.001) and partial pressure of carbon dioxide (MD = -8.56; 95% CI, -12.09 to -5.02; p < 0.001).

CONCLUSION

STS injection as adjunctive therapy seemed to be more effective than Western medicine alone for PHD. However, due to low quality of the included RCTs, more well-designed RCTs were necessary to verify the efficacy of STS injection.

Advancing injection force modeling and viscosity-dependent injectability evaluation for prefilled syringes

The development of PFS requires a detailed understanding of the forces occurring during the drug administration process and patient's capability. This research describes an advanced mathematic injection force model that consisting hydrodynamic force and friction force. The hydrodynamic force follows the basic law of Hagen-Poiseuille but refines the modeling approach by delving into specific properties of drug viscosity (Newtonian and Shear-thinning) and syringe shape constant, while the friction force was accounted from empty barrel injection force. Additionally, we take actual temperature of injection into consideration, providing more accurate predication. The results show that the derivation of the needle dimension constant and the rheological behavior of the protein solutions are critical parameters. Also, the counter pressure generated by the tissue has been considered in actual administration to address the issue of the inaccuracies of current injection force evaluation preformed in air, especially when the viscosity of the injected drug solution is below 9.0 cP (injecting with 1 mL L PFS staked with 29G ½ inch needle). Human factor studies on patients' capability against medication viscosity filled the gap in design space of PFS drug product and available viscosity data in very early phase.

Consideration of the diameter of superficial temporal arteries related to filler injections in the temporal region

BACKGROUND

The concavity of the temple due to adipose tissue atrophy from aging accentuates the zygomatic arch and lateral orbital rim, leading to an aged appearance. The use of hyaluronic acid filler in the temporal region has gained popularity due to its procedural simplicity and consistent outcomes.

OBJECTIVE

To evaluate the safety of administering hyaluronic acid filler in the temporal region concerning the frontal branch of the superficial temporal artery, which is at risk of injury.

METHODS

Empirical observations were conducted on the internal diameter of the frontal branch of the superficial temporal artery, a critical anatomical site for potential injury.

RESULTS

A significant proportion of the artery segments exhibited an internal diameter below 1 mm. Given that the outer diameter of an 18-gauge cannula is 1.27 mm, this method can be considered a relatively secure approach for enhancing the temporal region.

CONCLUSION

The use of an 18-gauge cannula for hyaluronic acid filler administration in the temporal region appears to be a safe and effective method, with the potential risk to the frontal branch of the superficial temporal artery being minimal.

Causes and management of sight threatening complications of dermal filler injections: A review

Injectable dermal fillers continue to increase in popularity in aesthetic medicine. Although rare, vision loss secondary to filler injections is a devastating complication associated with a poor visual prognosis. The mechanism for vision loss is thought to be related to retrograde embolization of the dermal filler from peripheral vessels in the face into the ophthalmic arterial system. Early recognition and prompt management are essential if vision is to be salvaged. The use of retrobulbar hyaluronidase is still contentious, however when administered by a specialist, this treatment gives the best chance at visual recovery and should be considered for all cases.

The Application of Superior Laryngeal Nerve Block for Non-Cough Laryngeal Hypersensitivity

OBJECTIVE(S)

To investigate the effect of superior laryngeal nerve (SLN) block in patients with non-cough complaints relating to laryngeal who have failed conventional medical therapy.

METHODS

Retrospective chart review of 46 patients who underwent SLN block for non-cough indications between July 2019 and March 2022 was performed. Demographics, comorbidities, and patient-reported outcomes were collected. The primary diagnoses for this group included: odynophagia, throat pain, cervicalgia, muscle tension dysphonia, globus sensation, hyoid bone syndrome, and Eagle syndrome.

RESULTS

The cohort underwent an average of 1.24 bilateral injections (range 0-7) and 0.87 unilateral injections (range 0-4). About 35 of 46 patients reported an average of 51.0% improvement in their symptoms, with the treatment effect lasting 7.60 weeks on average. On subgroup analysis, the patients with spasmodic dysphonia, odynophagia, and hyoid bone syndrome had the best percent improvement on average (75%-77.5%). Patients with globus sensation had the lowest percent improvement on average in response to this therapy, reporting only about 25%. Five patients experienced a mild adverse reaction immediately following injection which resolved spontaneously.

CONCLUSION

The use of in-office SLN block for non-cough disorders involving the larynx requires further study with larger sample sizes to better delineate the efficacy of these applications.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:1765-1768, 2024.

Effectiveness and Safety of a New Hyaluronic Acid Injectable for Augmentation and Correction of Chin Retrusion

BACKGROUND

A hyaluronic acid (HA) filler intended for non-surgical improvement of chin appearance should ideally be of high strength/firmness (high G') to allow for deep injections on the bone. HASHA (Restylane Shaype) is a new hyaluronic acid (HA) injectable with high G' and high HA concentration (25 mg/mL), engineered by the new NASHA-HD (High Definition) technology. HASHA is suitable to be placed periosteally, aiming to mimic the natural shape of the bony chin. This pivotal clinical investigation evaluated effectiveness and safety of HASHA for augmentation and correction of chin retrusion.  Methods: Subjects 18 years or older with mild or moderate chin retrusion by the Galderma Chin Retrusion Scale (GCRS), were randomized 3:1 to HASHA (n=103) or no treatment (n=37). Assessments included GCRS (blinded evaluator), aesthetic improvement (Global Aesthetic Improvement Scale [GAIS]), subject satisfaction, and safety.  Results: GCRS responder rate (1-grade or greater improvement from baseline) was significantly higher for HASHA (83.3%) versus controls (10.8%) at month 3 (P<0.001) and maintained through month 12 (P<0.001). Aesthetic improvement was high throughout the study in the HASHA group, according to investigators (97% or greater) and subjects (89% or greater). Overall, subject satisfaction was high at month 3 and maintained at month 12. Product- or injection-related adverse events were mostly mild or moderate and transient. No product- or injection-related serious adverse events were reported.

CONCLUSIONS

HASHA, a new NASHA-HD injectable with extra strength/firmness, was safe and effective for chin augmentation and correction of chin retrusion, with high aesthetic improvement and subject satisfaction throughout 12 months. J Drugs Dermatol. 2024;23(4):255-261.     doi:10.36849/JDD.8145.

Direct MR arthrography of the hip joint: anterior approach without imaging guidance

PURPOSE

The purpose of this study is to describe the anterior injection approach, with anatomical landmark guidance, for direct MR arthrography (dMRA) of the hip joint, and to evaluate the effectiveness in joint distension and the security of the technique.

MATERIAL AND METHODS

Retrospective review of hip dMRAs was conducted on patients with suspected intra-articular pathology from two MR outpatient centers, performed by two radiologists with 25 and 5 years of experience, respectively. The analysis included assessing the presence of intra-articular contrast material (gadolinium-based solution), the number of injections performed, the degree of joint distension, and the degree of contrast extravasation. A multi-variant analysis was carried out to determine if the procedure success depend on any of the demographic variants or on the radiologist experience. Additionally, the presence of immediate and medium-term post-puncture complications was evaluated.

RESULTS

One hundred patients with 104 hip dMRA were included; 60 were men, with mean age of 38 years (16-63 years). Contrast material was successfully introduced intra-articularly in 100% of patients, being necessary a second puncture only in 6% of procedures. The capsular distension was considered optimal for diagnosis in 97% of cases. Different degrees of contrast extravasation were found in 30% of dMRA. There was no statistically significant relationship observed between patient variables and the performance of dMRA, nor did it show any correlation with the experience of the radiologists. No puncture-derived complications were found.

CONCLUSION

Hip dMRA through anterior injection guided by anatomical references is an effective and safe alternative for patients with suspected intra-articular pathology.

Perspectives on Injectable HIV Pre-Exposure Prophylaxis: A Qualitative Study of Health Care Providers in the United States

The introduction of injectable HIV pre-exposure prophylaxis (PrEP) has the potential to significantly change the biomedical HIV prevention landscape. However, effective implementation will require health care providers to adopt, prescribe, and administer injectable PrEP within clinical settings. This study qualitatively examined challenges and benefit of injectable PrEP implementation from the perspective of health care providers. From April to August 2022, we conducted 19 in-depth interviews with current PrEP-prescribing health care providers in New York State, including 3 physician assistants, 5 physicians, and 11 nurse practitioners. Interviews were audio-recorded, transcribed verbatim, and thematically analyzed to report semantic-level themes regarding injectable PrEP implementation. More than half of participants (61%) were aware of injectable PrEP; only 21% had experience prescribing it. Qualitative findings highlighted five themes. Three themes represented implementation challenges, including speculative concerns about side effects, appointment compliance, and practical and logistical considerations. The remaining two themes described benefits of injectable PrEP relative to oral PrEP, which included greater convenience and enhanced privacy. Findings from this qualitative study make significant applied contributions to the sparse knowledge on health care provider perspectives of injectable PrEP post-US Food and Drug Administration approval and their concerns and considerations regarding implementation in real-world clinical settings.

Comparative effectiveness of two different doses of botulinum toxin A for the treatment of mild to moderate depression

OBJECTIVE

Botulinum toxin A has been shown to be effective in managing depression. This study aimed to evaluate the antidepressant and antianxiety effects of two different doses of botulinum toxin A in patients with mild to moderate depression.

METHODS

A total of 140 patients diagnosed with mild to moderate depression at the Department of Neurology of the Second Affiliated Hospital of Soochow University from September 2020 to September 2021 were enrolled for the study. The patients were allocated into two groups and treated with two different doses of botulinum toxin A (50 units or 100 units). Depression scores (HAMD, HAMA, SDS, and SAS) were evaluated at baseline and 1, 2, 4, 8, and 12 weeks after treatment.

RESULTS

There was a significant improvement in the depressive and anxiety symptoms following treatment with the botulinum toxin A after 12 weeks compared to the baseline. However, there were no significant differences between the two groups. Further, the factor scores of anxiety/somatization, blocking, sleep disorder, and cognitive disorder were significantly decreased after 12 weeks of treatment with 50 units of botulinum toxin A compared to the baseline (P < 0.05). Further, the factor scores of somatic and mental anxiety were significantly decreased at different time points after treatment with 50 units of botulinum toxin A compared to the baseline (P < 0.05).

CONCLUSION

Local injections of 50 units and 100 units of botulinum toxin A shows equal efficacy. Therefore, 50 units of botulinum toxin A could be used clinically to manage mild to moderate depression.

Botulinum toxin injection in outpatients for chronic anal fissure

OBJECTIVES

The aim of the study was to evaluate the effect of botulinum toxin (BT) injection on fissure healing in the treatment of chronic anal fissure (CAF) in outpatient conditions without any analgesia and sedation to the internal anal sphincter (IAS). The primary outcome measure was post-procedural pain. The secondary outcome measures were fissure healing and complications.

METHODS

Prospectively preserved data of 67 patients who received BT injections for CAF were analyzed prospectively. Demographic data, duration of symptomatic improvement, fissure location and number, parity, post-procedural pain, complications, continence status, response to treatment, and duration of follow-up were examined. Participants received bilateral (50 + 50 units) BT injections into the internal anal sphincter (IAS) in an outpatient setting.

RESULTS

Symptomatic improvement was observed in 58% of patients within 1 week. The complete response rate to treatment was 82% at a mean follow-up of 6 months. Patients with partial response to treatment (10%) were successfully treated with topical therapy, and patients with persisting fissures (8%) were successfully treated with partial lateral internal sphincterotomy (LIS). 14 patients (21%) reported some degree of transient incontinence at follow-up. Multiparous women experienced more symptoms of Incontinence (p = 0.00). Pre- and post-procedural Vas Score median values were 4. The 7th-week VAS score median value was 3.

CONCLUSION

Dysport injection under sedation-free outpatient conditions is an effective and safe alternative to LIS for the treatment of CAF, with tolerable procedural pain. All patients should be warned of transient incontinence.

Intrathecal Vector Delivery in Juvenile Rats via Lumbar Cistern Injection

Gene therapy is a powerful technology to deliver new genes to a patient for the treatment of disease, be it to introduce a functional gene, inactivate a toxic gene, or provide a gene whose product can modulate the biology of the disease. The delivery method for the therapeutic vector can take many forms, ranging from intravenous infusion for systemic delivery to direct injection into the target tissue. For neurodegenerative disorders, it is often desirable to skew transduction towards the brain and/or spinal cord. The least invasive approach to target the entire central nervous system involves injection into the cerebrospinal fluid (CSF), allowing the therapeutic to reach a large fraction of the central nervous system. The safest approach to deliver a vector into the CSF is the lumbar intrathecal injection, where a needle is introduced into the lumbar cistern of the spinal cord. This technique, also known as a lumbar puncture, has been widely used in neonatal and adult rodents and in large animal models. While the technique is similar across species and developmental stages, subtle differences in size, structure, and elasticity of tissues surrounding the intrathecal space require accommodations in the approach. This article describes a method for performing lumbar puncture in juvenile rats to deliver an adeno-associated serotype 9 vector. Here, 25-35 µL of vector were injected into the lumbar cistern, and a green fluorescent protein (GFP) reporter was used to evaluate the transduction profile resulting from each injection. The benefits and challenges of this approach are discussed.

An Intraperitoneal Injection Technique in Adult Zebrafish that Minimizes Body Damage and Associated Mortality

The adult zebrafish (Danio rerio), which is genetically accessible, is being employed as a valuable vertebrate model to study human disorders such as cardiomyopathy. Intraperitoneal (IP) injection is an important method that delivers compounds to the body for either testing therapeutic effects or generating disease models such as doxorubicin-induced cardiomyopathy (DIC). Currently, there are two methods of IP injection. Both methods have limitations when handling toxic compounds such as doxorubicin, which result in side effects manifesting as severe damage to the body shape and fish death. While these shortcomings could be overcome by extensive investigator training, a new IP injection method that has minimal side effects is desirable. Here, a unique IP injection method that is able to handle toxic compounds is reported. Consistently reduced cardiac function can result without incurring significant fish death. The technique can be easily mastered by researchers who have minimal experience with adult zebrafish.

Africa may lead rollout of long-lasting HIV drug

U.S. agency plans to make inexpensive prevention shots widely available for people at risk.

Smart distribution network voltage estimation using PMU technology considering zero injection constraints

To properly control the network of the power system and ensure its protection, Phasor measurement units (PMUs) must be used to monitor the network's operation. PMUs can provide synchronized real-time measurements. These measurements can be used for state estimation, fault detection and diagnosis, and other grid control applications. Conventional state estimation methods use weighting factors to balance the different types of measurements, and zero injection measurements can lead to large weighting factors that can introduce computational errors. The offered methods are designed to ensure that these zero injection criteria can be strictly satisfied while calculating the voltage profile and observability of the various distribution networks without sacrificing computing efficiency. The proposed method's viability is assessed using standard IEEE distribution networks. MATLAB coding is used to simulate the case analyses. Overall, the study provides a valuable contribution to the field of power distribution system monitoring and control by simplifying the process of determining the optimal locations for PMUs in a distribution network and assessing the impact of ZI buses on the voltage profile of the system.

Construction of an Injectable Composite Double-Network Hydrogel as a Liquid Embolic Agent

Conventional embolists disreputably tend to recanalization arising from the low filling ratio due to their rigidity or instability. As a result, intelligent hydrogels with a tunable modulus may meaningfully improve the therapeutic efficacy. Herein, an injectable composite double-network (CDN) hydrogel with high shear responsibility was prepared as a liquid embolic agent by cross-linking poly(vinyl alcohol) (PVA) and carboxymethyl chitosan (CMC) via dynamic covalent bonding of borate ester and benzoic-imine. A two-dimensional nanosheet, i.e., layered double hydroxide (LDH), was incorporated into the network through physical interactions which led to serious reduction of yield stress for the injection of the hydrogel and the capacity for loading therapeutic agents like indocyanine green (ICG) and doxorubicin (DOX) for the functions of photothermal therapy (PTT) and chemotherapy. The CDN hydrogel could thus be transported through a thin catheter and further in situ strengthened under physiological conditions, like in blood, by secondarily cross-linking with phosphate ions for longer degradation duration and better mechanical property. These characteristics met the requirements of arterial interventional embolization, which was demonstrated by renal embolism operation on rabbits, and meanwhile favored the inhibition of subcutaneous tumor growth on an animal model. Therefore, this work makes a breakthrough in the case of largely reducing the embolism risks, thus affording a novel generation for interventional embolization.

Multifocal strokes and vision loss from PDLLA filler injections

BACKGROUND

Poly-D, L-lactic acid (PDLLA) is increasingly used as a commercial dermal filler due to its lasting cosmetic properties. Consequently, PDLLA-related vascular complications are increasingly recognized and described. Herein, we describe the first known occurrence of multifocal strokes from the use of PDLLA as a cosmetic dermal filler, and discuss the mechanisms facilitating PDLLA's entry into the intracranial arterial system.

CASE PRESENTATION

A middle-aged female presented with acute vision loss of both eyes immediately after dermal injections of PDLLA to her nasolabial folds and infraorbital regions. There were no additional neurological deficits. Dilated fundal examination revealed retinal edema bilaterally, with deposition of filler material in the retinal arteries. Magnetic resonance imaging of her brain and orbits demonstrated multifocal strokes (left caudate head, right medial frontal lobe) and ischemia of the left optic nerve. The temporal proximity of the dermal injections to her symptoms, guided by fundal examination and neuroimaging findings, allowed us to attribute her strokes and ischemic optic neuropathy to PDLLA's entry into, and embolism within, the intracranial arterial system. She was treated with hyperbaric oxygen therapy and experience improvement to her right eye's vision, although poor vision persisted in her left eye.

CONCLUSION

While PDLLA is generally considered safe, its increasing use as a cosmetic filler renders it crucial for physicians to be cognizant of its vascular complications, especially when early recognition and treatment are essential in mitigating their devastating ramifications.

Factors Influencing the Successful Treatment of Recurrent Trigger Finger With Repeated Corticosteroid Injections: A Prospective Cohort Study

PURPOSE

The aim of this study was to determine the success rate, duration of disease control, and predictive factors of success of repeated corticosteroid injections for recurrent trigger finger.

METHODS

This prospective cohort study involved patients who had recurrent trigger finger and a history of corticosteroid injections. A total 114 patients were treated with repeated corticosteroid injections and followed for 12 months. Data on demographic characteristics, comorbid conditions, and possible predictive factors for successful treatment from medical chart reviews and direct patient interviews were compared. Patients were classified into success or failure groups at one, three, six, and 12 months after the initial injection. The relationship between hypothesized predictors and success or failure after repeated corticosteroid injection was analyzed with multivariable logistic regression.

RESULTS

The overall success rates from repeated cortisone injections after one, three, six, and 12 months were 97.4%, 84.2%, 68.4%, and 49.1%, respectively. Multivariable logistic regression modeling revealed that a high grade of disease (grade III or IV based on the Quinnell system), a body mass index (BMI) ≥ 25 kg/m2, and a short symptom-free period (< six months) after a previous injection were strong predictors of symptom recurrence (odds ratio = 3.6 [95% CI 1.5-8.4], odds ratio = 2.5 [95% CI 1.1-5.9], and odds ratio = 1.8 [95% CI 1.1-3.0], respectively). The average success rates for patients at 1-year according to the number of risk factors were as follows: none of the three risk factors, 73.3%; one risk factor, 54.2% to 63.6% (54.2% for grade III-IV triggering, 63.6% for BMI ≥ 25 kg/m2 and 63.6% for < 6-month symptom-free period); two risk factors, 30% to 75% (30% for a combination of grade III-IV and BMI ≥ 25 kg/m2, 45.5% with grade II-IV and < 6-month period, and 75% with a combination of < 6-month period and BMI ≥ 25 kg/m2); and all three risk factors, 11.8%.

CONCLUSIONS

Repeated corticosteroid injections for recurrent trigger finger should be considered in patients who prefer nonsurgical treatment, especially in those without factors predictive of failure.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Clinical Implications of the Relationship Between Naltrexone Plasma Levels and the Subjective Effects of Heroin in Humans

BACKGROUND

Extended-release naltrexone (NTX) is an opioid antagonist approved for relapse prevention after medical withdrawal. Its therapeutic effect is dependent on the NTX plasma level, and as it decreases, patients may lack protection against relapse and overdose. Therefore, identifying the minimally effective NTX level needed to block opioid-induced subjective effects has important clinical implications.

METHODS

This secondary, individual-level analysis of data collected in a human laboratory study was conducted to evaluate the relationship between NTX levels and subjective effects of an intravenously administered 25-mg challenge dose of heroin in non-treatment-seeking participants with opioid use disorder (N = 12). Subjective ratings of drug liking using a 100-mm visual analog scale (VAS) and NTX levels were measured across 6 weeks after participants received a single injection of either extended-release NTX 192 mg (N = 6) or 384 mg (N = 6). Cubic spline mixed-effects models were used to provide 95% prediction intervals for individual changes in liking scores as a function of NTX levels.

RESULTS

Naltrexone levels above 2 ng/mL blocked nearly all VAS ratings of drug liking after intravenous heroin administration. Participants with NTX levels ≥ 2 ng/mL had minimal (≤20 mm) changes from placebo in VAS ratings of drug liking based on 95% prediction intervals. In contrast, NTX levels < 2 ng/mL were associated with greater variability in individual-level subjective responses.

CONCLUSIONS

In clinical practice, a plasma level range of 1 to 2 ng/mL is considered to be therapeutic in providing heroin blockade. The current findings suggest that a higher level (>2 ng/mL) may be needed to produce a consistent blockade.

Efficacy of Long-Acting Injectable Antipsychotics Versus Oral Antipsychotics in Preventing Psychiatric Rehospitalizations

PURPOSE/BACKGROUND

Schizophrenia is a chronic, debilitating mental illness that incurs a large economic burden. Decreasing hospital readmissions is a priority in health care to improve patient quality of life and decrease health care costs. Determining ways to prevent readmissions such as improving access to long-acting injectable (LAI) antipsychotics is important to assess.

METHODS/PROCEDURES

A single-center retrospective review was conducted comparing readmission rates of patients diagnosed with schizophrenia or schizoaffective disorder discharged on LAI or oral antipsychotics between August 1, 2019, and June 30, 2022. The primary outcome was the 30-day psychiatric readmission rate. Secondary outcomes included chlorpromazine equivalent doses and use of anticholinergic medications.

FINDINGS/RESULTS

The 30-day readmission rate was 1.9% for the LAI antipsychotic group and 8.3% for the oral antipsychotic group ( P = 0.03; 95% confidence interval, 1.05-20.02). The average chlorpromazine equivalent antipsychotic dose of patients discharged on LAI versus oral antipsychotic medications was 477.3 and 278.6 mg/d, respectively ( P < 0.001). In addition, the prevalence of medications used to treat extrapyramidal symptom was 22.3% (n = 23) for the LAI antipsychotic group and 30.8% (n = 74) for the oral antipsychotic group ( P = 0.12). Sixty-four percent of LAI antipsychotics utilized were obtained from pharmaceutical company hospital inpatient free trial programs.

IMPLICATIONS/CONCLUSIONS

Long-acting injectable antipsychotics showed a statistically significant reduction in 30-day rehospitalizations as compared with oral antipsychotics and hospital inpatient free trial programs aided in LAI antipsychotic acquisition.

Impurities in Hyaluronic Acid Dermal Fillers? A Narrative Review on Nonanimal Cross-Linked Fillers

Importance: Nonanimal cross-linked hyaluronic acid (HA) dermal fillers are among the most versatile tools in minimal invasive esthetic medicine. Filler injections aim to volumize, provide contour, and reduce wrinkles and skinfolds. In the hand of the experienced user, HA fillers have an excellent safety profile. Nevertheless, adverse events have been reported related to poor injection techniques, infection, and immune reactions. Observations: In this review, the focus is on filler impurities. Impurities can originate from the fermentation process, crosslinking, packaging, and contamination. Impurities consist of particular and nonparticular matter. We discuss possible risks for the patient to be treated with HA fillers. Conclusions and Relevance: Impurities of dermal fillers bear a potential risk for patients, such as delayed autoimmune and inflammatory reactions, biofilm formation, and exposure to leachable Endocrine Disrupting Chemicals. Amount and quality of impurities can be considered as one of the quality parameters of commercially fillers. Considering patient safety, filler impurities should be further reduced.

A structured approach with Swiss cheese model to reduce vascular adverse events of filler injections

BACKGROUND

Filler injection is among the most popular nonsurgical aesthetic procedures worldwide. Though relatively noninvasive, filler injection can lead to severe vascular adverse events. Even though the incidence is rare, it may cause devastating and irreversible outcomes. A Swiss cheese model has been widely applied for risk analysis and management approach in medical field.

AIMS

In this review article, we adopt the Swiss cheese model and create a structured approach to prevent severe vascular complications caused by filler injections.

METHODS

We reviewed the current literature regarding the knowledge and techniques of preventing vascular adverse events in the filler injection.

RESULTS

We propose four structured strategies in this model to reduce the risk of severe vascular adverse events of filler injections, including clinical facial anatomy, safe filler injection principles, real time imaging and auxiliary instruments, and implication of checklist.

CONCLUSION

This review provides clinicians a structured approach before and during the filler injection procedure to reduce the risk of vascular adverse events and improve its safety and outcome.

Nerve Distribution Method is Superior to the Conventional Method in BoNT-A Treatment of Trapezius Hypertrophy: A Randomized Controlled Trial

The contour of the neck and shoulder is defined by the trapezius muscle (TM). Beyond facial procedures, botulinum toxin A (BoNT-A) injections has been increasingly adopted to create a smooth shoulder line. Several studies described the intramuscular nerve branching and the pattern of perforating branch of the accessory nerve in the trapezius muscle, providing essential information for botulinum neurotoxin injection. To this date, research groups seldom perform clinical investigations, especially randomized controlled trials, that demonstrates whether BoNT-A injections using the nerve distribution method for aesthetic purposes is more effective. Patients met the criteria for inclusion were randomized to either the Nerve Distribution group (ND group) or control group. Control group patients received injection using the conventional method while ND group patients received the nerve distribution method. Photographic and ultrasonographic evaluations were carried out at baseline, one month, three months, and six months after the procedure. Patients were also required to complete a questionnaire to evaluate their feedbacks to the injection. After screening, 30 healthy young Chinese women were included. At one-month follow-up, no statistically significant difference was observed between the two methods. At the three-month follow-up, the reduction of the TM thickness for the ND group (0.21 ± 0.09 cm) was more than that for the control group (0.27 ± 0.08 cm), with p = 0.047*. Similar differences were observed for the reduction of the shoulder area proportion (p = 0.031*) and the shoulder angle (p = 0.035*). At the six-month follow-up, the reduction in TM thickness in the ND group (0.2 ± 0.09 cm) was more than that of the control group (0.28 ± 0.06 cm), with p = 0.041*. The global aesthetic improvement scale feedbacks of the two methods showed no significant difference (3.4 ± 0.71 vs 3.8 ± 0.91, p = 0.207). The patients did not experience severe side effects. Compared to the conventional injection method, the nerve distribution method is more effective in reducing the trapezius muscle thickness, shoulder area proportion, and shoulder angle at three months, and shows longer lasting effects. The results of this study introduce unique insights into the design and tailoring of treatment protocols for shoulder-line contouring using BoNT-A.Level of Evidence I This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Evidence-Based Use of Bevacizumab in the Management of Neovascular Age-Related Macular Degeneration

Indicated for colorectal cancer for decades, bevacizumab has been widely used off label to treat retinal diseases, and the benefits of its use, specifically in neovascular age-related macular degeneration, have been demonstrated in multiple clinical trials. The intravitreal delivery of bevacizumab requires it to be aseptically repackaged into individual syringes by compounding pharmacies for use in the eye. Although the repackaging process is permitted by the US Food and Drug Administration, the resultant product does not meet the specific standards of products approved for use as ophthalmic injectables nor is the parenteral innovator solution compliant with ophthalmic standards. Studies have also demonstrated variability in the quality and quantity of repackaged bevacizumab. This narrative review summarizes the evidence and discusses the role of off-label bevacizumab in the treatment and management of retinal diseases, its mechanism of action, current challenges and provides a critical appraisal of current evidence, clinical implications, and future directions. [Ophthalmic Surg Lasers Imaging Retina 2024;55:155-162.].

[Augmentation mammaplasty using injected polyacrylamide hydrogel: Report of a recent case and literature review]

Polyacrylamide hydrogel (PAAG) is a filler that has been strictly prohibited in France for many years. It first appeared on the market in 1980, used as an injectable for breast and facial augmentation, mainly in Asia and Eastern Europe. Like many other materials, it has shown unfavourable results and complications due to a foreign body reaction. It was banned in 2006, but continues to be injected illegally. With the influx of migrants, we are faced with the problem of how to manage complications, which can occur more than a decade later. We report our experience of a recent case in our department that required complete removal of the product and iterative lipofilling, with a result that remains sub-optimal, and we systematically review the literature.

Adjusting Injectable Contraceptive Use for Months Since the Last Injection

Injectables are one of the most popular methods of contraception worldwide, particularly in sub-Saharan Africa. An advantage of injectables over shorter-acting methods is that they provide additional flexibility by not requiring re-supply as frequently. However, there is a risk that injectable users may delay their next injection and may therefore have reduced or no protection from pregnancy. In surveys, women may report that they are using contraception in the form of injectables when the time since they had their last injection (more than four months) would imply that they have reduced protection against the risk of pregnancy. We carried out two field studies in urban Malawi, and we record reported injectable contraceptive use while also asking the number of months since women received their last injection. We observe that 13.8 percent of women who report using injectables also report that they received their last injection more than four months ago, and 11 percent report that they received their last injection more than six months ago. Our analysis highlights the need for additional follow-up with women who report using injectables in surveys to confirm whether they are, in fact, using the method effectively.

Local and Systemic Side Effects of Corticosteroid Injections for Musculoskeletal Indications

Corticosteroid injections can be associated with a range of potential side effects, which may be classified as local or systemic and further stratified as immediate or delayed in onset. Radiologists performing image-guided musculoskeletal injections should recognize the potential side effects of corticosteroid medication when counseling patients before injection and consider such side effects in planning individual injections. This Review summarizes the available evidence regarding the local and systemic side effects of corticosteroid injections performed for musculoskeletal indications. Local side effects include postinjection flare, skin hypopigmentation and atrophy, infection, tendon rupture, accelerated progression of osteoarthritis, and osseous injury. Systemic side effects include adrenal suppression or insufficiency, facial flushing, hypertension, hyperglycemia, and osteoporosis. Additional targeted counseling is warranted regarding side effects that are specific to certain patient populations (i.e., premenopausal women, patients with diabetes, athletes, and pediatric patients). Corticosteroid injections are contraindicated in the presence of superficial or deep infection, fracture, or a prosthetic joint. Guidelines on the frequency, duration, and maximal lifetime use of corticosteroid injections are currently lacking. Further research is needed regarding the long-term complications of continuous corticosteroid use, particularly with regard to osseous effects.

Sihler's staining technique: How to and guidance for botulinum neurotoxin injection in human muscles

The Sihler's stain is a whole-mount nerve staining technique that allows visualization of the nerve distribution and permits mapping of the entire nerve supply patterns of the organs, skeletal muscles, mucosa, skin, and other structures that contain myelinated nerve fibers. Unlike conventional approaches, this technique does not require extensive dissection or slide preparation. To date, the Sihler's stain is the best tool for demonstrating the precise intramuscular branching and distribution patterns of skeletal muscles. The intramuscular neural distribution is used as a guidance tool for the application of botulinum neurotoxin injections. In this review, we have identified and summarized the ideal botulinum neurotoxin injection points for several human tissues.

Effects of intracordal trafermin injection on mutational voice disorder

INTRODUCTION

Mutational voice disorder is the inability of the voice to adjust to the changes in the larynx during puberty, resulting in the speaking fundamental frequency failing to decrease. Standard treatments for mutational voice disorder are voice therapy and thyroplasty. However, voice therapy takes time to show its effects, and thyroplasty is highly invasive. Herein, we present a case of mutational voice disorder successfully treated with intracordal trafermin injection.

CASE SUMMARY

A 31-year-old male patient was diagnosed with mutational voice disorder and offered standard treatment, but he requested a less invasive treatment with early effects. We performed intracordal trafermin injection with his consent. Two months after the procedure, the speaking fundamental frequency decreased from 155.5 Hz to 93.0 Hz, and the voice handicap index decreased from 14 to 2.

DISCUSSION

This case suggests that intracordal trafermin injection is an effective treatment option for mutational voice disorder. Furthermore, compared with the standard treatment methods, it is less invasive and provides effects shortly with only one injection.

Comparison of the efficacy and adverse effects of unilateral or bilateral botulinum toxin injections for adductor spasmodic dysphonia: a systematic review and meta-analysis

PURPOSE

This study aims to aggregate and analyze existing clinical evidence to compare the efficacy and adverse effects of unilateral or bilateral botulinum toxin injections for the treatment of adductor spasmodic dysphonia (ADSD).

METHODS

Reports from non-randomized controlled trials and cohort studies pertaining to the efficacy and adverse effects of unilateral and bilateral botulinum toxin injections for ADSD were identified and retrieved from four electronic databases from inception to July 2023. The meta-analysis employed fixed or random effects models to assess pooled relative risks (RR), mean differences (MDs), and standard mean differences (SMDs) with their corresponding 95% confidence intervals (CIs).

RESULTS

We included two non-randomized controlled trials and seven cohort studies comprising 854 total patients. Meta-analysis of the included studies showed that bilateral botulinum toxin injections associated with a longer duration of vocal improvement (MD =  - 2.89, 95% CI - 3.13 to - 2.65, I2 = 0%, P < 0.00001). However, bilateral botulinum toxin injections associated with an increase in adverse effects, including a longer duration of breathy voice quality (SMD =  - 0.51, 95% CI - 0.79 to - 0.22, I2 = 35%, P = 0.0005) and a higher occurrence of swallowing difficulties (RR = 0.46, 95% CI 0.35 to 0.11, I2 = 0%, P < 0.00001).

CONCLUSION

Bilateral botulinum toxin injections for ADSD showed a longer duration of vocal improvement, a longer breathy voice duration and a higher dysphagia occurrence and duration than unilateral injections.

Ultrasound-Guided Injections for Treatment of Facial Paralysis Sequelae: A Randomized Study on Body Donors

BACKGROUND

Botulinum toxin injection is the accepted standard treatment for synkinesis and gustatory hyperlacrimation in patients with facial paralysis. However, poor injection accuracy can result in inconsistent treatment outcomes, variable treatment durations, and complications. Ultrasound guidance should increase injection accuracy in the facial region; however, this has not been proven.

METHODS

Twenty-six hemifaces of nonembalmed cadavers were studied in a randomized split-face manner. Ink was injected with ultrasound or landmark guidance into the lacrimal gland and three common synkinetic muscles: the orbicularis oculi, depressor anguli oris, and mentalis. Injection accuracy was evaluated using several measures.

RESULTS

Using ultrasound guidance, most ink (>50%) was found inside the correct target in 88% of cases, compared with 50% using landmark guidance ( P < 0.001). This was most pronounced in the lacrimal gland (62% versus 8%), depressor anguli oris (100% versus 46%), and mentalis (100% versus 54%) ( P < 0.05). All ink was found inside the correct target (no ink outside) in 65% using ultrasound guidance versus 29% without ( P < 0.001). Injection accuracy (any ink in target) was 100% when using ultrasound guidance versus 83% without ( P < 0.01). Twenty-three percent of the landmark-guided depressor anguli oris injections stained the facial artery ( P = 0.22).

CONCLUSIONS

Ultrasound guidance significantly increased injection accuracy and reduced the amount of ink lost in the surrounding tissue compared with landmark guidance. Clinical trials are needed to explore the effects of ultrasound guidance on treatment outcome, duration, and complications in patients with facial paralysis.

Needle Fracture During Injection Medialization Laryngoplasty

OBJECTIVES

Awake injection medialization laryngoplasty is one of the most common therapeutic procedures done by laryngologists in the office or at the bedside. Complications of injection needle fracture are rarely reported.

METHODS

This is a case report of a 59-year-old male inpatient who developed left vocal fold immobility with significant glottic insufficiency after pneumonectomy for a large left-sided lung cancer. During bedside injection medialization using thyrohyoid approach, the 25 G needle fractured at the hub and was embedded partly in pre-epiglottic space and partly extending over rima glottidis.

RESULTS

Fractured needle was successfully retrieved at the bedside with an endoscopic biopsy forcep using flexible bronchoscope.

CONCLUSION

It is imperative to be aware of rare complications of routine procedures like injection laryngoplasty so they can be managed timely and effectively.

Locoregional drug delivery for cancer therapy: Preclinical progress and clinical translation

Systemic drug delivery is the current clinically preferred route for cancer therapy. However, challenges associated with tumor localization and off-tumor toxic effects limit the clinical effectiveness of this route. Locoregional drug delivery is an emerging viable alternative to systemic therapies. With the improvement in real-time imaging technologies and tools for direct access to tumor lesions, the clinical applicability of locoregional drug delivery is becoming more prominent. Theoretically, locoregional treatments can bypass challenges faced by systemic drug delivery. Preclinically, locoregional delivery of drugs has demonstrated enhanced therapeutic efficacy with limited off-target effects while still yielding an abscopal effect. Clinically, an array of locoregional strategies is under investigation for the delivery of drugs ranging in target and size. Locoregional tumor treatment strategies can be classified into two main categories: 1) direct drug infusion via injection or implanted port and 2) extended drug elution via injected or implanted depot. The number of studies investigating locoregional drug delivery strategies for cancer treatment is rising exponentially, in both preclinical and clinical settings, with some approaches approved for clinical use. Here, we highlight key preclinical advances and the clinical relevance of such locoregional delivery strategies in the treatment of cancer. Furthermore, we critically analyze 949 clinical trials involving locoregional drug delivery and discuss emerging trends.

Efficacy and safety of a submucosal injection solution of sodium alginate for endoscopic resection in a porcine model

Endoscopic resection techniques require the use of submucosal injection. Normal saline and sodium hyaluronate solutions are mainly used for this purpose, but an ideal solution has not yet been developed. The aim of this study was to assess a new solution, MC-003-a novel submucosal injection solution developed with sodium alginate as the main ingredient. Normal saline, a commercial sodium hyaluronate solution (Endo-Ease), and MC-003 were examined. A total of 18 gastric submucosal cushions were created in the stomachs of six pigs. The height of mucosal elevation was measured sequentially using endoscopic sonography. After euthanizing the animals either 2 h or 5 days after the procedure, pathologic examination was performed for each injection site. Although not statistically significant over the entire study period, MC-003 showed a superior result to normal saline and an equivalent result to Endo-Ease in the submucosal cushion height and its rate of decrease. There were no adverse outcomes after injection of the three solutions and there was no pathologically identified detrimental change in the resected specimens. MC-003 creates a sufficient submucosal fluid cushion without apparent tissue damage. It can be considered as an effective submucosal injection material.