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Tang M, Khan R, Ruiz Buenrostro A, Andersen CR, Lau J, Hui D, Zimmermann C, Bruera E. Subcutaneous administration of drugs and hydration in acute palliative care units: Physician attitudes and beliefs in the United States and Canada. Palliat Support Care 2024; 22:535-538. [PMID: 38126334 DOI: 10.1017/s1478951523001943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
OBJECTIVES The objective of this study was to compare the attitudes and beliefs of PCU physicians leaders in the United States versus Canada regarding the subcutaneous method in the administration of medications and hydration in order to gain a better understanding as to why variations in practice exist. METHODS This survey trial took place from November 2022 to May 2023. The MD Anderson Cancer Center institutional review board in Houston, Texas, approved this study. The participants were the physician leaders of the acute palliative care units (PCUs) in the United States and Canada. The survey comprised questions formulated by the study investigators regarding the perceived comfort, efficiency, and preference of using the subcutaneous versus the intravenous method. The consent form and survey links were emailed to the participants. RESULTS Sixteen PCUs were identified in the United States and 15 PCUs in Canada. Nine US and 8 Canadian physicians completed the survey. Physicians in Canada were more likely to use the subcutaneous route for administering opioids, antiemetics, neuroleptics, and hydration. They preferred subcutaneous over intravenous or intramuscular routes (p = 0.017). Canadian physicians felt their nursing staff was more comfortable with subcutaneous administration (p = 0.022) and that it was easier to administer (p = 0.02). US physicians felt the intravenous route was more efficient (p = 0.013). SIGNIFICANCE OF RESULTS The study results suggest that exposure to the subcutaneous route influences a physician's perception. Further research is needed to explore ways to incorporate its use to a greater degree in the US healthcare system.
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Affiliation(s)
- Michael Tang
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rida Khan
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alejandra Ruiz Buenrostro
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Clark R Andersen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jenny Lau
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Leriquier C, Freire M, Llido M, Beauchamp G, Montasell X, Gagnon D, Benito J. Comparison of sedation with dexmedetomidine/atipamezole administered subcutaneously at GV20 acupuncture point with usual routes of administration in dogs presented for orthopaedic radiographs. J Small Anim Pract 2023; 64:759-768. [PMID: 37559443 DOI: 10.1111/jsap.13668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 06/08/2023] [Accepted: 07/12/2023] [Indexed: 08/11/2023]
Abstract
OBJECTIVES To evaluate the efficacy of subcutaneous administration of dexmedetomidine/atipamezole at the Governing Vessel 20 (GV20) acupuncture point compared with other administration routes (intramuscular and intravenous) in dogs presented for orthopaedic radiographs. MATERIALS AND METHODS Prospective, randomised, blinded, controlled clinical study. Sixty-four client-owned dogs were randomly injected with 200 μg/m2 of dexmedetomidine intramuscular (lumbar muscles) (n=20), intravenous (n=23) or subcutaneous at the GV20 point (n=21). Following radiographs, dogs received 2000 μg/m2 of atipamezole intramuscular (n=31), or subcutaneous at the GV20 point (n=27). Degree and time to sedation and recovery were assessed using a sedation scale and a Dynamic and Interactive Visual Analog Scale (DIVAS). Clinical physiological variables and adverse events were used. Statistical linear mixed-effect models (analysis of variance) and Cox models were performed. Significance was set at P-value <0.05. RESULTS Sedation was insufficient to perform orthopaedic radiographs in six dogs in the intramuscular group. The time to sedation was significantly longer, and sedation scale and DIVAS scores were significantly lower in the intramuscular group. The intravenous group had significantly higher sedation scale and DIVAS scores than the GV20 group. No significant differences were observed between the intramuscular and GV20 recovery groups, although the time effect was significantly more pronounced in the GV20 recovery group. CLINICAL SIGNIFICANCE Subcutaneous administration of dexmedetomidine and atipamezole at GV20 provided effective sedation and recovery in dogs undergoing orthopaedic radiographic studies. GV20 administration provided a clinically similar level of sedation to the intravenous route, and greater and faster sedation and similar recovery to intramuscular.
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Affiliation(s)
- C Leriquier
- Small Animal Surgery Service, Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Montreal, Saint-Hyacinthe, QC, J2S 2M2, Canada
| | - M Freire
- Small Animal Surgery Service, Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Montreal, Saint-Hyacinthe, QC, J2S 2M2, Canada
| | - M Llido
- Small Animal Surgery Service, Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Montreal, Saint-Hyacinthe, QC, J2S 2M2, Canada
| | - G Beauchamp
- Faculty of Veterinary Medicine, University of Montreal, Saint-Hyacinthe, QC, J2S 2M2, Canada
| | - X Montasell
- Small Animal Surgery Service, Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Montreal, Saint-Hyacinthe, QC, J2S 2M2, Canada
| | - D Gagnon
- Small Animal Surgery Service, Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Montreal, Saint-Hyacinthe, QC, J2S 2M2, Canada
| | - J Benito
- Anaesthesia Service, Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Montreal, Saint-Hyacinthe, QC, J2S 2M2, Canada
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Abstract
Injectable filler is one of the most common cosmetic procedures performed annually. An aging face shows a characteristic loss of volume in the deep fat pads of the midface. The goal of midfacial rejuvenation with injectable filler is to restore lost volume, with the suborbicularis fat pad and deep medial cheek fat being the most critical areas. Filler can be instilled here with a cannula or needle with successful outcomes. However, this procedure is not without complications if proper technique and underlying anatomy are not respected.
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Affiliation(s)
- Hillary A Newsome
- Division of Facial Plastic & Reconstructive Surgery, Washington University Facial Plastic Surgery Center, Washington University in St. Louis-School of Medicine, 660 S Euclid AveCampus Box 8115St. Louis, MO 63110, USA
| | - John J Chi
- Division of Facial Plastic & Reconstructive Surgery, Washington University Facial Plastic Surgery Center, Washington University in St. Louis-School of Medicine, 660 S Euclid AveCampus Box 8115St. Louis, MO 63110, USA.
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Curreri AM, Kim J, Dunne M, Angsantikul P, Goetz M, Gao Y, Mitragotri S. Deep Eutectic Solvents for Subcutaneous Delivery of Protein Therapeutics. Adv Sci (Weinh) 2023; 10:e2205389. [PMID: 36642846 PMCID: PMC9982585 DOI: 10.1002/advs.202205389] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 11/17/2022] [Indexed: 05/14/2023]
Abstract
Proteins are among the most common therapeutics for the treatment of diabetes, autoimmune diseases, cancer, and metabolic diseases, among others. Despite their common use, current protein therapies, most of which are injectables, have several limitations. Large proteins such as monoclonal antibodies (mAbs) suffer from poor absorption after subcutaneous injections, thus forcing their administration by intravenous injections. Even small proteins such as insulin suffer from slow pharmacokinetics which poses limitations in effective management of diabetes. Here, a deep eutectic-based delivery strategy is used to offer a generalized approach for improving protein absorption after subcutaneous injections. The lead formulation enhances absorption of mAbs after subcutaneous injections by ≈200%. The same composition also improves systemic absorption of subcutaneously injected insulin faster than Humalog, the current gold-standard of rapid acting insulin. Mechanistic studies reveal that the beneficial effect of deep eutectics on subcutaneous absorption is mediated by their ability to reduce the interactions of proteins with the subcutaneous matrix, especially collagen. Studies also confirm that these deep eutectics are safe for subcutaneous injections. Deep eutectic-based formulations described here open new possibilities for subcutaneous injections of therapeutic proteins.
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Affiliation(s)
- Alexander M. Curreri
- John A. Paulson School of Engineering and Applied SciencesHarvard University150 Western AveAllstonMA02134USA
- Wyss Institute for Biologically Inspired Engineering at Harvard University3 Blackfan StBostonMA02115USA
| | - Jayoung Kim
- John A. Paulson School of Engineering and Applied SciencesHarvard University150 Western AveAllstonMA02134USA
- Wyss Institute for Biologically Inspired Engineering at Harvard University3 Blackfan StBostonMA02115USA
| | - Michael Dunne
- John A. Paulson School of Engineering and Applied SciencesHarvard University150 Western AveAllstonMA02134USA
- Wyss Institute for Biologically Inspired Engineering at Harvard University3 Blackfan StBostonMA02115USA
| | - Pavimol Angsantikul
- John A. Paulson School of Engineering and Applied SciencesHarvard University150 Western AveAllstonMA02134USA
- Wyss Institute for Biologically Inspired Engineering at Harvard University3 Blackfan StBostonMA02115USA
- Present address:
The Population CouncilOne Dag Hammarskjold PlazaNew YorkNY10017USA
| | - Morgan Goetz
- John A. Paulson School of Engineering and Applied SciencesHarvard University150 Western AveAllstonMA02134USA
- Wyss Institute for Biologically Inspired Engineering at Harvard University3 Blackfan StBostonMA02115USA
| | - Yongsheng Gao
- John A. Paulson School of Engineering and Applied SciencesHarvard University150 Western AveAllstonMA02134USA
- Wyss Institute for Biologically Inspired Engineering at Harvard University3 Blackfan StBostonMA02115USA
| | - Samir Mitragotri
- John A. Paulson School of Engineering and Applied SciencesHarvard University150 Western AveAllstonMA02134USA
- Wyss Institute for Biologically Inspired Engineering at Harvard University3 Blackfan StBostonMA02115USA
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Yang B, Han L, Wang Y, Cheng K. Effectiveness of continuous subcutaneous insulin infusion versus multiple daily injections on glycaemic control among older adults with type 2 diabetes: protocol for systematic review and meta-analysis. BMJ Open 2023; 13:e063161. [PMID: 36631237 PMCID: PMC9835874 DOI: 10.1136/bmjopen-2022-063161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION Insulin therapy plays an irreplaceable role in glycaemic control among older adults with type 2 diabetes mellitus (T2DM) and can be administered by either multiple daily injections (MDI) of insulin or by a continuous subcutaneous insulin infusion (CSII) pump. Many clinical trials have compared the effects of CSII pumps and MDI in various diabetic populations, but there has been no systematic review and meta-analysis focusing on older adults with T2DM. This study aims to determine whether the CSII pump is associated with better glycaemic control relative to the MDI in older adults with T2DM. METHODS AND ANALYSIS PubMed, Medline, Cochrane Library, Web of Science core collection, China National Knowledge Infrastructure (CNKI), Wan Fang Database, Chinese Science and Technology Journal Database (VIP) and Chinese Biomedical Literature Database (SinoMed) will be searched from inception to December 2021. Only randomised controlled trials will be included, and the language of the selected studies will be restricted to English and Chinese. Two researchers will independently screen the studies, extract data, assess the risk of bias and evaluate the quality of evidence. Any disagreement will be resolved by consensus or by a third researcher. Data analysis and synthesis will be conducted using RevMan V.5.3. Subgroup analysis, sensitivity analysis and publication bias assessment will be performed, as necessary. ETHICS AND DISSEMINATION As this study will not contain personal information, ethical approval will not be required. The results of the study will be published in a peer-reviewed journal or at relevant conference. PROSPERO REGISTRATION NUMBER CRD42021283729.
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Affiliation(s)
- Bei Yang
- School of Nursing, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Lin Han
- School of Nursing, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yin Wang
- School of Nursing, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Kangyao Cheng
- School of Nursing, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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Boen M, Alhaddad M, Goldman MP, Kollipara R, Hoss E, Wu DC. A Randomized, Evaluator-Blind, Split-Face Study Evaluating the Safety and Efficacy of Calcium Hydroxylapatite for Jawline Augmentation. Dermatol Surg 2022; 48:76-81. [PMID: 33731569 DOI: 10.1097/dss.0000000000002582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Jawline augmentation with calcium hydroxylapatite has not yet been evaluated in a prospective study with a split-face design. This study aims to perform the first randomized controlled, split-face study on the efficacy and safety of calcium hydroxylapatite for jawline augmentation using the needle and cannula technique. OBJECTIVE To perform the first randomized controlled, split-face study on the efficacy and safety of calcium hydroxylapatite for jawline augmentation using the needle and cannula technique. MATERIALS AND METHODS This is a single-site, randomized, evaluator-blind trial enrolling a total of 10 healthy subjects with at least Grade 1 (mild) on a 4-point Jawline Scale. One side of the face was randomized to receive 1 to 2 syringes of calcium hydroxylapatite with lidocaine (total of 3 mL) for correction of wrinkles and folds along the jawline using both the cannula and needle method, and a balancing treatment will be performed 1 month later. Blinded investigator and subject evaluations will be performed immediately after treatment and at the 30-, 60-, and 90-day visits. RESULTS Ten subjects were enrolled and completed the trial. There was a improvement in the degree of wrinkling and skin sagging in the 4-point Jawline Scale, with an average of a 1.3-point improvement in the scale on the day of treatment and at the Day 30 visit, which remained improved greater than baseline after 3 months as graded by blinded investigators. The Clinician Global Aesthetic Improvement Score for the treated side versus control, as assessed by blinded investigators, demonstrated a improvement with a 2.3-point improvement on the 5-point scale, and by the final visit on Day 90, most patients had a much improved appearance from baseline. CONCLUSION This study demonstrates that calcium hydroxylapatite is effective and safe for restoration and augmentation of the jawline using the unique needle and cannula technique.
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Affiliation(s)
- Monica Boen
- Cosmetic Laser Dermatology, San Diego, California
| | | | - Mitchel P Goldman
- Cosmetic Laser Dermatology, San Diego, California
- University of California, San Diego, California
| | | | - Elika Hoss
- Cosmetic Laser Dermatology, San Diego, California
| | - Douglas C Wu
- Cosmetic Laser Dermatology, San Diego, California
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Ascanelli S, Zamboni P, Campioni D, Grazia Sibilla M, Chimisso L, Zollino I, Valpiani G, Carcoforo P. Efficacy and Safety of Treatment of Complex Idiopathic Fistula-in-Ano Using Autologous Centrifuged Adipose Tissue Containing Progenitor Cells: A Randomized Controlled Trial. Dis Colon Rectum 2021; 64:1276-1285. [PMID: 34016825 DOI: 10.1097/dcr.0000000000001924] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Mesenchymal stem cells derived from adipose tissue have been successfully used to promote sphincter-saving anal fistula healing. OBJECTIVE The aim of this study was to evaluate the efficacy and safety of the use of autologous centrifuged adipose tissue in the healing process of cryptoglandular complex anal fistulas. DESIGN This is a randomized controlled trial. SETTINGS This study was conducted at a single center. PATIENTS Patients with complex perianal fistulas not associated with Crohn's disease were included. Rectovaginal fistulas were not included. INTERVENTIONS Patients were randomly allocated to receive treatment with centrifuged adipose tissue injection (experimental group) and without injection (control group) in combination with fistula surgery. MAIN OUTCOME MEASURES The primary outcome was defined as the proportion of patients with complete fistula closure at 4 weeks (short-term outcome) and 6 months after surgery (long-term outcome). Healing was defined as when the external opening was closed with no perianal discharge on clinical assessment. The secondary outcome was safety that was evaluated by the analysis of adverse events up to 3 months after surgery. Pelvic MRI was performed at 3 months to assure safety and the accuracy of the clinical determination of healing. Postoperative pain, return to work/daily activities, persistent closure at 6 months, fecal incontinence, and patient satisfaction were evaluated. RESULTS Fifty-eight patients who received centrifuged adipose tissue injection and 58 patients who did not receive centrifuged adipose tissue injection were included in the safety and efficacy analysis. After 4 weeks, the healing rate was 63.8% in the experimental group compared with 15.5% in the control group (p < 0.001). No major adverse events were recorded. Postoperative anal pain was significantly lower in the injection group. Time taken to return to work/daily activities was significantly shorter in the experimental group (3 days) than in the control group (17 days). At 6 months, persistent closure was similar in the 2 groups (86.2% vs 81%). Fecal Incontinence Score at 6 months after surgery was identical to the preoperative score. Patient satisfaction was high in both groups. LIMITATIONS The absence of blinding, the lack of correlation between stem cell content, and the clinical outcome were limitations of the study. CONCLUSIONS Autologous centrifuged adipose tissue injection may represent a safe, efficacious, and inexpensive option for the treatment of complex fistula-in-ano. See Video Abstract at http://links.lww.com/DCR/B607. CLINICAL TRIALS REGISTRATION URL: https://www.clinicaltrials.gov. Identifier: NCT04326907. EFICACIA Y SEGURIDAD DEL TRATAMIENTO DE LA FSTULA ANAL COMPLEJA IDIOPTICA UTILIZANDO TEJIDO ADIPOSO CENTRIFUGADO AUTLOGO QUE CONTIENE CLULAS PROGENITORAS UN ENSAYO CONTROLADO ALEATORIO ANTECEDENTES:Las células madre mesenquimales derivadas del tejido adiposo se han utilizado con éxito para promover la curación de la fístula anal con preservación de esfínter.OBJETIVO:El objetivo de este estudio fue evaluar la eficacia y seguridad del uso de tejido adiposo autólogo centrifugado en el proceso de cicatrización de fístulas anales complejas de origen criptoglandular.DISEÑO:Ensayo controlado aleatorio.ENTORNO CLÍNICO:Estudio unicéntrico.PACIENTES:Se incluyeron pacientes con fístulas perianales complejas no asociadas a Enfermedad de Crohn. No se incluyeron las fístulas rectovaginales.INTERVENCIONES:Los pacientes fueron asignados aleatoriamente para recibir tratamiento con inyección de tejido adiposo centrifugado (grupo experimental) y sin inyección (grupo de control) en combinación con cirugía de fístula.PRINCIPALES MEDIDAS DE VALORACIÓN:El resultado primario se definió como la proporción de pacientes con cierre completo de la fístula a las 4 semanas (resultado a corto plazo) y 6 meses después de la cirugía (resultado a largo plazo). La curación se definió cuando orificio externo se cerró sin secreción perianal en la valoración clínica. El resultado secundario fue la seguridad que se evaluó mediante el análisis de los eventos adversos (EA) hasta 3 meses después de la cirugía. La resonancia magnética pélvica se realizó a los 3 meses para garantizar la seguridad y la precisión clínica de la curación. Se evaluó el dolor postoperatorio, el regreso al trabajo / actividades diarias, el cierre persistente a los 6 meses, la incontinencia fecal y la satisfacción del paciente.RESULTADOS:Cincuenta y ocho pacientes que recibieron inyección de tejido adiposo centrifugado y 58 pacientes que no recibieron inyección de tejido adiposo centrifugado se incluyeron en el análisis de seguridad y eficacia. Después de 4 semanas, la tasa de curación fue del 63,8% en el grupo experimental en comparación con el 15,5% en el grupo de control (p <0,001). No se registraron eventos adversos importantes. El dolor anal posoperatorio fue significativamente menor en el grupo de inyección. El tiempo necesario para volver al trabajo / actividades diarias fue significativamente menor en el grupo experimental (3 días) con respecto al grupo de control (17 días). A los 6 meses, el cierre persistente fue similar en los dos grupos (86,2% vs 81%). La puntuación de incontinencia fecal a los 6 meses después de la cirugía fue idéntica a la puntuación preoperatoria. La satisfacción del paciente fue muy alta en ambos grupos.LIMITACIONES:Ausencia de cegamiento, falta de correlación entre el contenido de células madre y el resultado clínico.CONCLUSIONES:La inyección de tejido adiposo centrifugado autólogo puede representar una opción segura, eficaz y económica para el tratamiento de la fístula anal compleja.Registro de ensayos clínicos: www.clinicaltrials.gov, identificador NCT04326907; No patrocinado.Consulte Video Resumen en http://links.lww.com/DCR/B607.
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Affiliation(s)
- Simona Ascanelli
- Department of Morphology, Surgery and Experimental Medicine, Section General Surgery, University of Ferrara, Italy
| | - Paolo Zamboni
- Department of Morphology, Surgery and Experimental Medicine, Section of Translational of Medicine and Surgery, University of Ferrara, Italy
| | - Diana Campioni
- Provincial Unique Laboratory Department, University Hospital Ferrara, Italy
| | - Maria Grazia Sibilla
- Department of Morphology, Surgery and Experimental Medicine, Section General Surgery, University of Ferrara, Italy
| | - Laura Chimisso
- Department of Morphology, Surgery and Experimental Medicine, Section General Surgery, University of Ferrara, Italy
| | - Ilaria Zollino
- Department of Morphology, Surgery and Experimental Medicine, Section of Translational of Medicine and Surgery, University of Ferrara, Italy
| | - Giorgia Valpiani
- Research Innovation Quality and Accreditation Unit, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Paolo Carcoforo
- Department of Morphology, Surgery and Experimental Medicine, Section General Surgery, University of Ferrara, Italy
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Alcantara M, Hartung HP, Lawo JP, Durn BL, Mielke O, Bril V. Electrophysiological predictors of response to subcutaneous immunoglobulin therapy in chronic inflammatory demyelinating polyneuropathy. Clin Neurophysiol 2021; 132:2184-2190. [PMID: 34293528 DOI: 10.1016/j.clinph.2021.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/19/2021] [Accepted: 05/18/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To assess axonal function prior to subcutaneous immunoglobulin (SCIG) therapy or placebo in relation to relapse in chronic inflammatory demyelinating polyneuropathy (CIDP) to determine whether axonal damage can predict therapy response. METHODS Relapse rates in patients from the Polyneuropathy and Treatment with Hizentra (PATH) study, where patients were treated with placebo or SCIG (IgPro20), were analyzed by baseline (post-intravenous immunoglobulin stabilization) axonal damage (≤1 mV peroneal compound muscle action potential) status. RESULTS In patients with non-axonal damage, relapses were significantly higher with placebo (73.0%) than IgPro20 (0.2 g/kg: 39.1%, 0.4 g/kg: 19.2%). In patients with axonal damage, IgPro20 had no effect on relapse (placebo: 25.0%, IgPro20: 0.2 g/kg: 30.0%, 0.4 g/kg: 19.4%). Patients with axonal damage relapsed significantly less on placebo versus non-axonal damage, but they also demonstrated higher baseline disability. CONCLUSION Axonal damage may correspond to relapse upon treatment withdrawal; patients with axonal damage relapse less, possibly reflecting poor response to immunoglobulin therapy, while non-axonal damage patients may experience more relapse, perhaps indicating better treatment response. SIGNIFICANCE In CIDP patients with axonal loss, immunoglobulin therapy may not be as effective. Assessing axonal damage could help guide therapy, with immunoglobulins ideally used before substantial axonal damage arises.
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Affiliation(s)
- Monica Alcantara
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Hans-Peter Hartung
- Department of Neurology, UKD and Center for Neurology and Neuropsychiatry, LVR Klinikum, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Brain and Mind Centre, University of Sydney, Australia; Medical University of Vienna, Austria
| | | | | | | | - Vera Bril
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada.
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Abstract
BACKGROUND Heparin is an anticoagulant medication that is usually injected subcutaneously. Subcutaneous administration of heparin may result in complications such as bruising, haematoma, and pain at the injection site. One of the factors that may affect pain, haematoma, and bruising is injection speed. Several studies have been carried out to determine if speed of injection affects the amount of pain and bruising where the injection is given; however, the results of these studies have differed, and study authors have not reached a clear final conclusion. This is the second update of a review first published in 2014. OBJECTIVES To assess the effects of duration (speed) of subcutaneous heparin injection on pain and bruising at the injection site in people admitted to hospitals or clinics who require treatment with unfractionated heparin (UFH) or low molecular weight heparin (LMWH). We also looked at haematoma at the injection site. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 22 June 2020. We undertook reference checking of included studies to identify additional studies. SELECTION CRITERIA We searched for randomised controlled trials (RCTs) comparing the effects of different durations of subcutaneous injection of heparin on pain, bruising, and haematoma at the injection site. DATA COLLECTION AND ANALYSIS For this update, two review authors independently selected studies and extracted data via Covidence software and assessed methodological quality using Cochrane's risk of bias tool. The primary outcomes of interest were pain intensity at injection site and size and incidence of bruising. The secondary outcomes of interest were size and incidence of haematoma at injection site. We calculated the odds ratio (OR), mean difference (MD), or standardised mean difference (SMD) with corresponding 95% confidence intervals (CIs). We assessed the certainty of the evidence using GRADE criteria. MAIN RESULTS We identified one new study for this update, resulting in a total of five included studies with 503 participants who received subcutaneous injections of LMWH into the abdomen. Given the nature of the intervention, it was not possible to blind participants and caregivers (personnel) in any of the included studies. Two studies described blinding of outcome assessors. Overall, the methodological quality of included studies was moderate. The duration of the fast injection was 10 seconds, and the duration of the slow injection was 30 seconds in all included studies. Four studies reported site pain intensity after each injection at different time points. Two studies assessed site pain intensity immediately after each injection; meta-analysis showed no evidence of a difference in site pain intensity immediately after slow injection when compared to fast injection (MD -1.52, 95% CI -3.56 to 0.53; 140 participants; low-certainty evidence). Meta-analysis of three studies indicated that site pain intensity may be slightly reduced 48 hours after the slow heparin injection compared to fast injection (MD -1.60, 95% CI -2.69 to -0.51; 103 participants; low-certainty evidence). Five studies assessed bruise size at 48 hours, and two studies assessed bruise size at 60 hours. Meta-analysis showed there may be a reduction in bruise size 48 hours (SMD -0.54, 95% CI -1.05 to -0.02; 503 participants; 5 studies; very low-certainty evidence) and 60 hours (SMD -0.49, 95% CI -0.93 to -0.06; 84 participants; 2 studies; low-certainty evidence) after slow injection compared to fast injection. There was no evidence of a difference in bruise size 72 hours after slow injection compared to fast injection (SMD -0.27, 95% CI -0.61 to 0.06; 140 participants; 2 studies; low-certainty evidence). Three studies evaluated incidence of bruising and showed there may be a reduction in bruise incidence 48 hours (OR 0.39, 95% CI 0.26 to 0.60; 444 participants; low-certainty evidence) and 60 hours (OR 0.25, 95% CI 0.10 to 0.65; 84 participants; 2 studies; low-certainty evidence) after slow injection compared to fast injection. We downgraded the certainty of the evidence due to risk of bias concerns, imprecision, and inconsistency. None of the included studies measured size or incidence of haematoma. AUTHORS' CONCLUSIONS Administering medication safely and enhancing patient comfort are the main aims of clinical nurses. In this review, we identified five RCTs that evaluated the effect of subcutaneous heparin injection duration on pain intensity, bruise size and incidence. We found that pain may be slightly reduced 48 hours after slow injection. Similarly, there may be a reduction in bruise size and incidence after slow injection compared to fast injection 48 and 60 hours postinjection. We downgraded the certainty of the evidence for all outcomes to low or very low due to risk of bias concerns, imprecision, and inconsistency. Accordingly, new trials with a more robust design, more participants, and a focus on different injection speeds will be useful in strengthening the certainty of the available evidence.
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Affiliation(s)
- Mina Mohammady
- Community Health Research Center, Isfahan (Khorasgan) Branch, Islamic Azad University, Isfahan, Iran
| | - Maryam Radmehr
- Department of Nursing, Dezful Branch, Islamic Azad University, Dezful, Iran
| | - Leila Janani
- Imperial Clinical Trials Unit, Imperial College London, London, UK
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10
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Galadari H, Krompouzos G, Kassir M, Gupta M, Wollina U, Katsambas A, Lotti T, Jafferany M, Navarini AA, Vasconcelos Berg R, Grabbe S, Goldust M. Complication of Soft Tissue Fillers: Prevention and Management Review. J Drugs Dermatol 2021; 19:829-832. [PMID: 33026743 DOI: 10.36849/jdd.2020.10.36849/jdd.2020.5084] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The use of dermal fillers has increased manifold over the past decade, which has been attributed to the ever-increasing need of the population for being young. Fillers have become quite popular both among patients and treating physicians due to their quick and quite predictable results. Filler injection is a safe procedure in the hands of an experienced provider using appropriate technique. Nevertheless, various adverse effects to fillers have been reported that range from mild injection site complications, such as pain and bruising, to severe complications, like tissue necrosis, retinal artery occlusion, and infections. The esthetic provider should be aware of and be able to quickly recognize such complications, and be confident in managing them. In this article we highlight the various adverse effects noted with the use of fillers and discuss prevention and management. J Drugs Dermatol. 2020;19(9):829-832. doi:10.36849/JDD.2020.5084.
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11
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Cong LY, Kong XX, Luo CE, Luo SK. Three-Dimensional Computed Tomography of the Detoured Facial Artery: Variations and Implications for Nasojugal Groove Correction. Dermatol Surg 2021; 47:785-790. [PMID: 33941736 DOI: 10.1097/dss.0000000000003000] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND When performing filler injection procedures to the nasojugal groove, there is the risk of iatrogenic damage to the detoured facial artery. OBJECTIVE To determine the 3-dimensional location of the detoured facial artery. MATERIALS AND METHODS The branches of the facial arteries from 118 cadaveric hemifaces were scanned using computed tomography and reconstructed using the Mimics software program. RESULTS Detoured facial arteries were found in 47 of the 118 hemifaces (39.8%). Two main arterial patterns were identified: in Type I (29 of 47 cases), there were both detoured and nasolabial trunks where the facial artery originated, whereas in Type II (18 of 47 cases), there was only a detoured trunk. The detoured trunk originated 32.0 ± 5.3 mm from the midsagittal line, 5.0 ± 2.8 mm from the occlusion plane, and 5.9 ± 3.5 mm below the skin layer; the inflection of the detoured trunk was located 30.0 ± 5.6 mm laterally, 26.2 ± 4.4 mm superiorly, and 5.7 ± 2.6 mm deep. The meeting point with the inferior orbital rim plane was located 17.1 ± 3.4 mm laterally, 43.4 ± 3.1 mm superiorly, and 2.8 ± 1.7 mm deep. CONCLUSION The 3-dimensional location of the detoured facial artery as reported here will help clinicians to avoid iatrogenic damage when they are performing filler injection procedures.
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Affiliation(s)
- Li-Yao Cong
- All authors are affiliated with the Department of Plastic and Reconstructive Surgery, Guangdong Second Provincial General Hospital, Guangzhou, China
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12
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Money SM, Wall WB, Davis LS, Edmondson AC. An Anatomical Guide to the Terminal Facial Artery: Lumen Diameter and Associated Anatomy Relevant to Dermatologic Procedures. Dermatol Surg 2021; 47:797-801. [PMID: 33731568 DOI: 10.1097/dss.0000000000002992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Dermal filler injection in the vicinity of the terminal facial artery (FA) can lead to vascular compromise with devastating consequences, including tissue necrosis, blindness, and stroke. OBJECTIVE The purpose of this study was to examine lumen diameter and other anatomical features of the terminal FA relevant to dermal filler injection. MATERIALS AND METHODS Eighteen embalmed adult cadavers were dissected along the distribution of the terminal FA. Gross and microscopic measurements were taken at predetermined points in its course. RESULTS Mean lumen diameter was largest at the midpoint between the oral commissure and the lateral supra-alar crease (0.81 ± 0.36 mm; point P1) and smallest at the midpoint between the lateral supra-alar crease and the medial canthus (0.43 ± 0.23 mm; point P3). Mean cutaneous depth was deepest at the lateral supra-alar crease (5.06 ± 1.84 mm; point P2) and most superficial at the midpoint between the lateral supra-alar crease and the medial canthus (3.13 ± 2.07 mm; point P3). CONCLUSION The large-caliber lumen diameter of the terminal FA creates the potential for intra-arterial injection with commonly used filler needles and blunt-tipped cannulas at all points in its course in the nasolabial fold and midface.
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Affiliation(s)
- Silas M Money
- Medical College of Georgia at Augusta University, Augusta, Georgia
| | | | | | - Anna C Edmondson
- Cellular Biology and Anatomy, Medical College of Georgia at Augusta University, Augusta, Georgia
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13
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Frank K, Schenck TL, Gavril D, Swift A, Liew S, Freytag DL, Kaiser A, Green JB, Beleznay K, Cotofana S. Influence of Rheological Properties and Needle Size on Extrusion Forces of Hyaluronic Acid Based Soft Tissue Fillers. J Drugs Dermatol 2021; 20:498-502. [PMID: 33938685 DOI: 10.36849/jdd.5237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND To date no precise data are available for extrusion forces related to the G-prime and G-double-prime of fillers in combination with different 27G and 30G needles. Therefore, the objective of this study was to analyze extrusion forces of various product-needle-combinations containing two different 27G and two different 30G needles in combination with fillers of a wide range of elastic moduli starting from 2.0 – 166.0 Pa. MATERIAL AND METHODS Four different fillers with the following elastic moduli 1.87, 11.65, 61.80, 165.50 Pa were combined with four different needles: 27G ½”, internal diameter: 0.300 μm; 27G ½”, internal diameter: 0.241 μm; 30G ½”, internal diameter: 0.241 μm and 30G ½“, internal diameter: 0.240 μm. Product-needle-combination were subjected to uni-axial mechanical testing and the respective extrusion force was measured. RESULTS The results of this study revealed that the G-prime and the G-double-prime of a product are statistically significantly related to their extrusion force, with higher G-prime/G-double-prime products requiring higher extrusion forces. The results additionally revealed that whether the size of the needle was described as 27G or 30G by the respective manufacturer statistically significant differences between the measured extrusion forces were detected. CONCLUSION Injectors need to be aware that not every 27G/30G needle has the same extrusion force even though the external diameter is similar (27G or 30G); this might additionally influence the ability to withdraw blood during a pre-injection aspiration manoeuvre. J Drugs Dermatol. 20(5): doi:10.36849/JDD.5237.
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14
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Abstract
Botulinum toxin type A (BoNTA) is a powerful neurotoxin that inhibits acetylcholine release from presynaptic vesicles. The potency and safety profile of BoNTA grant the toxin vast therapeutic potential. It has been used off-label for a variety of dermatologic conditions. This review aims to analyze published literature regarding the benefits and risks of the off-label use of BoNTA beyond facial lines, including eccrine hidrocystomas, enlarged pores, keloids and hypertrophic scars, hidradenitis suppurativa, hyperhidrosis, masseter muscle hypertrophy, and salivary gland hypertrophy, among others. A MEDLINE search from January 2000 to December 2019 was conducted on the off-label uses of botulinum toxin in dermatology.
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Affiliation(s)
- Tina S Alster
- Washington Institute of Dermatologic Laser Surgery, 1430 K St NW, Suite 200, Washington, DC, 20005, USA.
| | - Iris S Harrison
- Washington Institute of Dermatologic Laser Surgery, 1430 K St NW, Suite 200, Washington, DC, 20005, USA
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15
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Baumann K, Alm J, Norberg M, Ejehorn M. Immediate Use After Reconstitution of a Biostimulatory Poly-L-Lactic Acid Injectable Implant. J Drugs Dermatol 2020; 19:1199-1203. [PMID: 33346524 DOI: 10.36849/jdd.2020.5228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Poly-L-lactic acid (PLLA) is a biodegradable, synthetic polymer that stimulates collagen production and can improve skin quality, volume, and thickness. The current reconstitution procedure for Sculptra, a PLLA-containing injectable device involves 2 hours standing time before use. OBJECTIVE To evaluate and validate an immediate-use procedure for reconstituting a PLLA-containing injectable device. METHODS AND MATERIALS Three batches of the product were shaken for 1 minute immediately after reconstitution with 8 mL of sterile water. Different physicochemical tests including viscosity, concentration of excipients (sodium carboxymethylcellulose and mannitol), pH, and particle size distribution were performed for standing times 0, 2, 24, and 72 hours after immediate shaking, and compared with the standard 2 hours standing time before shaking. The recovery and stability of optional addition of 1 mL of 2% lidocaine hydrochloride was also assessed. RESULTS All physiochemical parameters evaluated were equivalent, regardless of reconstitution procedure, showing that shaking vigorously for 1 minute dissolves the excipients of the product properly without a required standing time and with no impact to the PLLA particles. There were no differences in lidocaine hydrochloride content of suspensions after 0 and 72 hours. CONCLUSION The PLLA-containing product can be used immediately after reconstitution including vigorous shaking, as shown from physicochemical analyses. Optional addition of lidocaine hydrochloride is feasible. J Drugs Dermatol. 2020;19(12): doi:10.36849/JDD.2020.5228.
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16
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Sadideen H, Akhavani MA, Mosahebi A, Harris PA. Current perceptions of 'Brazilian butt lift' (BBL) surgery in the UK: A BAAPS-led survey of BAAPS members. J Plast Reconstr Aesthet Surg 2020; 73:1966-1975. [PMID: 32919948 DOI: 10.1016/j.bjps.2020.08.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/28/2020] [Accepted: 08/01/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND The BAAPS advice against Brazilian butt lift (BBL) surgery in the UK was set in October 2018. A Delphi study conducted by BAAPS highlighted the importance of defining current practice and perceptions amongst UK surgeons, as this is currently unknown. OBJECTIVES To evaluate BAAPS members' current practice and perceptions around BBL surgery to ensure patient safety and propose better recommendations. METHODS A BAAPS-commissioned survey was emailed to all BAAPS members through an on-line link. The survey collected quantitative and qualitative information in several domains. RESULTS This survey received a 44% response rate. Of 102 respondents, 32 surgeons undertook BBL surgery before the BAAPS advice to halt it. There was a wide variation in actual fat volumes injected, and in perceptions of what constituted a small or large volume. Virtually all respondents (96.9%) performed only subcutaneous fat injections. There were differences in fat harvest techniques. The majority (66.7%) felt that BAAPS should maintain its recommendation against undertaking BBL surgery until further data became available. Nearly a quarter of 102 respondents (20.6%) had been treated for BBL complications, the majority as a result of surgical tourism. CONCLUSIONS The survey provides member-reported perception and experience with regard to BBL surgery in the UK. The demand for BBL surgery and its provision should be reassessed in the UK. This information will be analysed with further national and international data to better define and shape the scope of the safety of BBL surgery in the UK. BAAPS will use such data towards the production of future guidance and support for surgeons and patients.
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Affiliation(s)
- H Sadideen
- Cadogan Clinic, 120 Sloane Street, London,UK; Department of Surgery and Cancer, Imperial College London, London, UK.
| | - M A Akhavani
- Department of Plastic Surgery, Royal Free Hospital, London, UK
| | - A Mosahebi
- Department of Plastic Surgery, Royal Free Hospital, London, UK
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17
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Rotkopf H, Lévy M, Copie-Bergman C, Dupuis J, Verlinde-Carvalho M, Itti E, Gagniere C, Belhadj K, Tannoury J, Le Bras F, Sobhani I, Haioun C, Amiot A. Effectiveness and Safety of Subcutaneous Rituximab for Patients With Gastric MALT Lymphoma: A Case-Control Comparison With Intravenous Rituximab. Clin Lymphoma Myeloma Leuk 2020; 21:e32-e38. [PMID: 32921592 DOI: 10.1016/j.clml.2020.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/12/2020] [Accepted: 08/17/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Rituximab is a standard treatment for gastric mucosa-associated lymphoid tissue (MALT) lymphoma (GML). We sought to compare the effectiveness and safety of subcutaneous and intravenous rituximab in a retrospective case-control study. PATIENTS AND METHODS All consecutive patients with GML treated with subcutaneous rituximab between January 2017 and December 2018 were included and compared to 3 matched control patients (based on Ann Arbor classification, presence of t(11;18) translocation, history of treatment, and type of current treatment) treated with intravenous rituximab between January 2000 and December 2018. Patients with t(11;18) translocation were treated with rituximab in combination with chlorambucil; the other patients were treated with rituximab alone. Effectiveness was assessed at week 52, and safety was assessed through weeks 0 to 52 and compared by the chi-square test. RESULTS Twenty-five patients were included in the subcutaneous rituximab group and 75 in the intravenous group. There was no difference between the groups in complete remission (78% vs. 76%, P = .99) or overall response rates (91% vs. 89%, P = .99) at week 52. Safety profiles were similar in both groups, with a significant decrease in postinduction grade 2 injection-related reactions and outpatient hospital length of stay in the subcutaneous rituximab group. CONCLUSION In a small case-control study, we did not find any difference in the effectiveness or safety profiles between subcutaneously and intravenously delivered rituximab for the treatment of patients with GML. We found a decrease in postinduction grade 2 injection-related reactions and outpatient hospital length of stay in the subcutaneous rituximab group.
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Affiliation(s)
- Hugo Rotkopf
- Department of Gastroenterology, Groupe Hospitalier Henri Mondor-Albert Chennevier, APHP, EC2M3-EA7375, Université Paris Est Créteil, Creteil, France
| | - Michaël Lévy
- Department of Gastroenterology, Groupe Hospitalier Henri Mondor-Albert Chennevier, APHP, EC2M3-EA7375, Université Paris Est Créteil, Creteil, France
| | - Christiane Copie-Bergman
- Department of Pathology, Groupe Hospitalier Henri Mondor-Albert Chennevier, APHP, INSERM UMR-S 955, Université Paris Est Créteil, Creteil, France
| | - Jehan Dupuis
- Lymphoid Malignancies Unit, Groupe Hospitalier Henri Mondor-Albert Chennevier, APHP, Université Paris Est Créteil, Creteil, France
| | - Muriel Verlinde-Carvalho
- Department of Pharmacy, Groupe Hospitalier Henri Mondor-Albert Chennevier, APHP, Université Paris Est Créteil, Creteil, France
| | - Emmanuel Itti
- Department of Nuclear Medicine, Groupe Hospitalier Henri Mondor-Albert Chennevier, APHP, Université Paris Est Créteil, Creteil, France
| | - Charlotte Gagniere
- Department of Gastroenterology, Groupe Hospitalier Henri Mondor-Albert Chennevier, APHP, EC2M3-EA7375, Université Paris Est Créteil, Creteil, France
| | - Karim Belhadj
- Lymphoid Malignancies Unit, Groupe Hospitalier Henri Mondor-Albert Chennevier, APHP, Université Paris Est Créteil, Creteil, France
| | - Jenny Tannoury
- Department of Gastroenterology, Groupe Hospitalier Henri Mondor-Albert Chennevier, APHP, EC2M3-EA7375, Université Paris Est Créteil, Creteil, France
| | - Fabien Le Bras
- Lymphoid Malignancies Unit, Groupe Hospitalier Henri Mondor-Albert Chennevier, APHP, Université Paris Est Créteil, Creteil, France
| | - Iradj Sobhani
- Department of Gastroenterology, Groupe Hospitalier Henri Mondor-Albert Chennevier, APHP, EC2M3-EA7375, Université Paris Est Créteil, Creteil, France
| | - Corinne Haioun
- Lymphoid Malignancies Unit, Groupe Hospitalier Henri Mondor-Albert Chennevier, APHP, Université Paris Est Créteil, Creteil, France
| | - Aurelien Amiot
- Department of Gastroenterology, Groupe Hospitalier Henri Mondor-Albert Chennevier, APHP, EC2M3-EA7375, Université Paris Est Créteil, Creteil, France.
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18
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Manning JE, Oliveira F, Coutinho-Abreu IV, Herbert S, Meneses C, Kamhawi S, Baus HA, Han A, Czajkowski L, Rosas LA, Cervantes-Medina A, Athota R, Reed S, Mateja A, Hunsberger S, James E, Pleguezuelos O, Stoloff G, Valenzuela JG, Memoli MJ. Safety and immunogenicity of a mosquito saliva peptide-based vaccine: a randomised, placebo-controlled, double-blind, phase 1 trial. Lancet 2020; 395:1998-2007. [PMID: 32534628 PMCID: PMC9151349 DOI: 10.1016/s0140-6736(20)31048-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 04/09/2020] [Accepted: 04/27/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND In animal models, immunity to mosquito salivary proteins protects animals against mosquito-borne disease. These findings provide a rationale to vaccinate against mosquito saliva instead of the pathogen itself. To our knowledge, no vector salivary protein-based vaccine has been tested for safety and immunogenicity in humans. We aimed to assess the safety and immunogenicity of Anopheles gambiae saliva vaccine (AGS-v), a peptide-based vaccine derived from four A gambiae salivary proteins, in humans. METHODS In this randomised, placebo-controlled, double-blind, phase 1 trial, participants were enrolled at the National Institutes of Health Clinical Center in Bethesda, MD, USA. Participants were eligible if they were healthy adults, aged 18-50 years with no history of severe allergic reactions to mosquito bites. Participants were randomly assigned (1:1:1), using block randomisation and a computer-generated randomisation sequence, to treatment with either 200 nmol of AGS-v vaccine alone, 200 nmol of AGS-v with adjuvant (Montanide ISA 51), or sterile water as placebo. Participants and clinicians were masked to treatment assignment. Participants were given a subcutaneous injection of their allocated treatment at day 0 and day 21, followed by exposure to feeding by an uninfected Aedes aegypti mosquito at day 42 to assess subsequent risk to mosquito bites in a controlled setting. The primary endpoints were safety and immunogenicity at day 42 after the first immunisation. Participants who were given at least one dose of assigned treatment were assessed for the primary endpoints and analysis was by intention to treat. The trial was registered with ClinicalTrials.gov, NCT03055000, and is closed for accrual. FINDINGS Between Feb 15 and Sept 10, 2017, we enrolled and randomly assigned 49 healthy adult participants to the adjuvanted vaccine (n=17), vaccine alone (n=16), or placebo group (n=16). Five participants did not complete the two-injection regimen with mosquito feeding at day 42, but were included in the safety analyses. No systemic safety concerns were identified; however, one participant in the adjuvanted vaccine group developed a grade 3 erythematous rash at the injection site. Pain, swelling, erythema, and itching were the most commonly reported local symptoms and were significantly increased in the adjuvanted vaccine group compared with both other treatment groups (nine [53%] of 17 participants in the adjuvanted vaccine group, two [13%] of 16 in the vaccine only group, and one [6%] of 16 in the placebo group; p=0·004). By day 42, participants who were given the adjuvanted vaccine had a significant increase in vaccine-specific total IgG antibodies compared with at baseline than did participants who were give vaccine only (absolute difference of log10-fold change of 0·64 [95% CI 0·39 to 0·89]; p=0·0002) and who were given placebo (0·62 [0·34 to 0·91]; p=0·0001). We saw a significant increase in IFN-γ production by peripheral blood mononuclear cells at day 42 in the adjuvanted vaccine group compared with in the placebo group (absolute difference of log10 ratio of vaccine peptide-stimulated vs negative control 0·17 [95% CI 0·061 to 0·27]; p=0·009) but we saw no difference between the IFN-γ production in the vaccine only group compared with the placebo group (0·022 [-0·072 to 0·116]; p=0·63). INTERPRETATION AGS-v was well tolerated, and, when adjuvanted, immunogenic. These findings suggest that vector-targeted vaccine administration in humans is safe and could be a viable option for the increasing burden of vector-borne disease. FUNDING Office of the Director and the Division of Intramural Research at the National Institute of Allergy and Infectious Diseases, and National Institutes of Health.
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Affiliation(s)
- Jessica E Manning
- Laboratory of Malaria and Vector Research, National Institutes of Health, Bethesda, MD, USA.
| | - Fabiano Oliveira
- Laboratory of Malaria and Vector Research, National Institutes of Health, Bethesda, MD, USA
| | | | - Samantha Herbert
- Laboratory of Malaria and Vector Research, National Institutes of Health, Bethesda, MD, USA
| | - Claudio Meneses
- Laboratory of Malaria and Vector Research, National Institutes of Health, Bethesda, MD, USA
| | - Shaden Kamhawi
- Laboratory of Malaria and Vector Research, National Institutes of Health, Bethesda, MD, USA
| | - Holly Ann Baus
- LID Clinical Studies Unit, Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Alison Han
- LID Clinical Studies Unit, Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Lindsay Czajkowski
- LID Clinical Studies Unit, Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Luz Angela Rosas
- LID Clinical Studies Unit, Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Adriana Cervantes-Medina
- LID Clinical Studies Unit, Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Rani Athota
- LID Clinical Studies Unit, Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Susan Reed
- LID Clinical Studies Unit, Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Allyson Mateja
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, sponsored by the National Cancer Institute, National Institutes of Health, Frederick, MD, USA
| | - Sally Hunsberger
- Biostatistics Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | | | | | | | - Jesus G Valenzuela
- Laboratory of Malaria and Vector Research, National Institutes of Health, Bethesda, MD, USA
| | - Matthew J Memoli
- LID Clinical Studies Unit, Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
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19
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Gilliam EA, Zuber SM, Grikscheit TC. Thermal Injection Measurement (TIM) Adds Accuracy to Injections and Can Assess Cold Chain Management. J Surg Res 2020; 255:261-266. [PMID: 32570129 DOI: 10.1016/j.jss.2020.05.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/02/2020] [Accepted: 05/05/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Inaccurate assessment of injected drug delivery may increase cost and morbidity or reduce efficacy. Yet currently most injections are evaluated solely by the formation of a visible wheal that might not truly estimate the actual area of effect. We hypothesized that thermal injection measurement (TIM) might verify appropriate temperature at the time of injection, as required for some temperature-sensitive vaccines and provide more accurate information about the area of delivery. METHODS 0.1 mL of either iced (n = 11) or room temperature (n = 17) methylene blue solution was injected subcutaneously in mice under anesthesia and photos taken with an iPhone 7 built-in camera and Thermal Seek Camera phone plug-in. After 5 min, true values were determined at necropsy. RESULTS TIM was closer in value to the measured area at necropsy than the area of the visualized skin wheal at both ice temperature and room temperature. The difference between the true value and thermal area assessment of iced solution averaged 0.15 cm2 as compared with the difference between the true value and wheal size, which averaged 0.27 cm2 (P = 0.04). At room temperature, this was maintained for thermal and visible wheal differences, 0.23 cm2 and 0.65 cm2, respectively (P = 0.0006). CONCLUSIONS TIM can assess temperature at the time of injection and is more accurate than visual inspection. TIM could be applied to colorless injections and areas that are hard to visualize such as scar. As a portable phone plug-in, it might be a useful adjunct to aid the evaluation of injected drug delivery including in resource-limited settings.
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Affiliation(s)
- Elizabeth A Gilliam
- Developmental Biology and Regenerative Medicine Program, The Saban Research Institute at Children's Hospital Los Angeles, Los Angeles, California
| | - Samuel M Zuber
- Developmental Biology and Regenerative Medicine Program, The Saban Research Institute at Children's Hospital Los Angeles, Los Angeles, California
| | - Tracy C Grikscheit
- Developmental Biology and Regenerative Medicine Program, The Saban Research Institute at Children's Hospital Los Angeles, Los Angeles, California.
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20
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McCrary K, Leiding JW, Duff C. High-flow 20% subcutaneous immunoglobulin G in patients with primary immunodeficiency disease. Ann Allergy Asthma Immunol 2020; 125:344-346. [PMID: 32473202 DOI: 10.1016/j.anai.2020.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 05/19/2020] [Accepted: 05/21/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Kaley McCrary
- Office of Graduate Medication, Pediatric Residency Training Program, Department of Pediatrics, University of South Florida, St. Petersburg, Florida
| | - Jennifer W Leiding
- Division of Allergy and Immunology, Department of Pediatrics, University of South Florida, St. Petersburg, Florida
| | - Carla Duff
- Division of Allergy and Immunology, Department of Pediatrics, University of South Florida, St. Petersburg, Florida.
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Garibyan L, Moradi Tuchayi S, Javorsky E, Farinelli WA, Wang Y, Purschke M, Tam J, Ni P, Lian CG, Anderson RR. Subcutaneous Fat Reduction with Injected Ice Slurry. Plast Reconstr Surg 2020; 145:725e-733e. [PMID: 32221206 DOI: 10.1097/prs.0000000000006658] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cryolipolysis is a noninvasive method for removal of subcutaneous fat for body contouring. Conventional cryolipolysis with topical cooling requires extracting heat from subcutaneous fat by conduction across the skin, thus limiting the amount and the location of the fat removed. The authors hypothesized that local injection of a physiological ice slurry directly into target adipose tissue would lead to more efficient and effective cryolipolysis. METHODS Injectable slurries containing 20 percent and 40 percent ice content were made using common parenteral agents (normal saline and glycerol), then locally injected into the subcutaneous fat of swine. Ultrasound imaging, photography, histological, and gross tissue responses were monitored before and periodically up to 8 weeks after injection. RESULTS Fat loss occurred gradually over several weeks following a single ice slurry injection. There was an obvious and significant 55 ± 6 percent reduction in adipose tissue thickness compared with control sites injected with the same volume of melted slurry (p < 0.001, t test). The amount of fat loss correlated with the total volume of ice injected. There was no scarring or damage to surrounding tissue. CONCLUSION Physiological ice slurry injection is a promising new strategy for selective and nonsurgical fat removal.
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Affiliation(s)
- Lilit Garibyan
- From the Wellman Center for Photomedicine, Massachusetts General Hospital; and the Department of Dermatology, Harvard-MIT Health Sciences and Technology, and the Department of Pathology, Harvard Medical School; and Brigham and Women's Hospital
| | - Sara Moradi Tuchayi
- From the Wellman Center for Photomedicine, Massachusetts General Hospital; and the Department of Dermatology, Harvard-MIT Health Sciences and Technology, and the Department of Pathology, Harvard Medical School; and Brigham and Women's Hospital
| | - Emilia Javorsky
- From the Wellman Center for Photomedicine, Massachusetts General Hospital; and the Department of Dermatology, Harvard-MIT Health Sciences and Technology, and the Department of Pathology, Harvard Medical School; and Brigham and Women's Hospital
| | - William A Farinelli
- From the Wellman Center for Photomedicine, Massachusetts General Hospital; and the Department of Dermatology, Harvard-MIT Health Sciences and Technology, and the Department of Pathology, Harvard Medical School; and Brigham and Women's Hospital
| | - Ying Wang
- From the Wellman Center for Photomedicine, Massachusetts General Hospital; and the Department of Dermatology, Harvard-MIT Health Sciences and Technology, and the Department of Pathology, Harvard Medical School; and Brigham and Women's Hospital
| | - Martin Purschke
- From the Wellman Center for Photomedicine, Massachusetts General Hospital; and the Department of Dermatology, Harvard-MIT Health Sciences and Technology, and the Department of Pathology, Harvard Medical School; and Brigham and Women's Hospital
| | - Josh Tam
- From the Wellman Center for Photomedicine, Massachusetts General Hospital; and the Department of Dermatology, Harvard-MIT Health Sciences and Technology, and the Department of Pathology, Harvard Medical School; and Brigham and Women's Hospital
| | - Peiyun Ni
- From the Wellman Center for Photomedicine, Massachusetts General Hospital; and the Department of Dermatology, Harvard-MIT Health Sciences and Technology, and the Department of Pathology, Harvard Medical School; and Brigham and Women's Hospital
| | - Christine G Lian
- From the Wellman Center for Photomedicine, Massachusetts General Hospital; and the Department of Dermatology, Harvard-MIT Health Sciences and Technology, and the Department of Pathology, Harvard Medical School; and Brigham and Women's Hospital
| | - R Rox Anderson
- From the Wellman Center for Photomedicine, Massachusetts General Hospital; and the Department of Dermatology, Harvard-MIT Health Sciences and Technology, and the Department of Pathology, Harvard Medical School; and Brigham and Women's Hospital
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22
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Koulakis JP, Rouch J, Huynh N, Wu HH, Dunn JCY, Putterman S. Tumescent Injections in Subcutaneous Pig Tissue Disperse Fluids Volumetrically and Maintain Elevated Local Concentrations of Additives for Several Hours, Suggesting a Treatment for Drug Resistant Wounds. Pharm Res 2020; 37:51. [PMID: 32043171 PMCID: PMC7010616 DOI: 10.1007/s11095-020-2769-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 01/23/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE Bolus injection of fluid into subcutaneous tissue results in accumulation of fluid at the injection site. The fluid does not form a pool. Rather, the injection pressure forces the interstitial matrix to expand to accommodate the excess fluid in its volume, and the fluid becomes bound similar to that in a hydrogel. We seek to understand the properties and dynamics of externally tumesced (swollen) subcutaneous tissue as a first step in assessing whether tumescent antibiotic injections into wounds may provide a novel method of treatment. METHODS Subcutaneous injections of saline are performed in live and dead pigs and the physical properties (volume, expansion ratio, residence time, apparent diffusion constant) of the resulting fluid deposits are observed with diffusion-weighted magnetic resonance imaging, computed tomography, and 3D scanning. RESULTS Subcutaneous tissue can expand to a few times its initial volume to accommodate the injected fluid, which is dispersed thoroughly throughout the tumescent volume. The fluid spreads to peripheral unexpanded regions over the course of a few minutes, after which it remains in place for several hours. Eventually the circulation absorbs the excess fluid and the tissue returns to its original state. CONCLUSIONS Given the evidence for dense fluid dispersal and several-hour residence time, a procedure is proposed whereby tumescent antibiotic injections are used to treat drug-resistant skin infections and chronic wounds that extend into the subcutaneous tissue. The procedure has the potential to effectively treat otherwise untreatable wounds by keeping drug concentrations above minimum inhibitory levels for extended lengths of time.
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Affiliation(s)
- John P Koulakis
- Department of Physics and Astronomy, University of California Los Angeles, California, Los Angeles, 90095, USA.
| | - Joshua Rouch
- Department of Surgery, Division of Pediatric Surgery, University of California Los Angeles, California, Los Angeles, 90095, USA
| | - Nhan Huynh
- Department of Surgery, Division of Pediatric Surgery, University of California Los Angeles, California, Los Angeles, 90095, USA
| | - Holden H Wu
- Department of Radiological Sciences, University of California Los Angeles, California, Los Angeles, 90095, USA
| | - James C Y Dunn
- Department of Surgery. Division of Pediatric Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Alway M116, Stanford, CA, 94305, USA
| | - Seth Putterman
- Department of Physics and Astronomy, University of California Los Angeles, California, Los Angeles, 90095, USA
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23
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Laugesen C, Schmidt S, Tetzschner R, Nørgaard K, Ranjan AG. Glucose Sensor Accuracy After Subcutaneous Glucagon Injections Near to Sensor Site. Diabetes Technol Ther 2020; 22:131-135. [PMID: 31560217 DOI: 10.1089/dia.2019.0278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background: Integrated hormone delivery and glucose sensing is warranted, but system performance could be challenged by glucose sensor susceptibility to pharmacological interferences. The aim of this study was to compare sensor accuracy (Medtronic Enlite 2®) after subcutaneous (s.c.) administration of low-dose glucagon near to versus remote from sensor site. Methods: Twelve adults with insulin-pump-treated type 1 diabetes wore two continuous glucose monitors (CGMglucagon and CGMcontrol) placed on each side of the abdomen before, during, and after two overnight 14-h in-clinic visits. During each visit, a s.c. 100 μg glucagon injection was administered 2 cm next to the CGMglucagon followed by another injection of 100 μg glucagon 2 h later at the same site. CGM performance was evaluated using 4-h in-clinic Yellow Spring Instrument (YSI) measurements and 3-day self-monitoring of blood glucose (SMBG) in free-living conditions. Results: Using YSI as comparator, no difference in the median absolute relative difference (MARD) for CGMglucagon (15.7%) and CGMcontrol (13.4%) was found (P = 0.195). Similarly, no difference in MARD was found between CGMglucagon (11.0%) and CGMcontrol (6.2%) using SMBG as comparator (P = 0.148). Values in zone A + B of Clarke error grid analysis did not differ between CGMglucagon and CGMcontrol using YSI (93.9% vs. 91.1%, P = 0.250) and SMBG (97.3% vs. 95.0%, P = 0.375) as reference measurement. The precision absolute relative deviation between sensors was 13.7%. Conclusions: Sensor accuracy was not significantly affected by administration of s.c. glucagon near to sensor site.
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Affiliation(s)
| | - Signe Schmidt
- Steno Diabetes Center Copenhagen, Clinical Research, Gentofte, Denmark
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Danish Diabetes Academy, Odense, Denmark
| | - Rikke Tetzschner
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Kirsten Nørgaard
- Steno Diabetes Center Copenhagen, Clinical Research, Gentofte, Denmark
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Ajenthen G Ranjan
- Steno Diabetes Center Copenhagen, Clinical Research, Gentofte, Denmark
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Danish Diabetes Academy, Odense, Denmark
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24
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Somali M, Paschou SA, Mouslech Z. Insulin pumps use in Greece: Efficacy and safety data from 140 patients with type 1 diabetes mellitus. Diabetes Res Clin Pract 2020; 160:108026. [PMID: 31954749 DOI: 10.1016/j.diabres.2020.108026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 12/18/2019] [Accepted: 01/13/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the efficacy and safety of continuous subcutaneous insulin infusion (CSII) regarding glycaemic control and quality of life in patients with type 1 diabetes mellitus (T1DM), who were previously treated with multiple daily injections (MDI). PATIENTS AND METHODS 140 patients with T1DM [mean age 33.7 ± 22.1 years; 54 males, 76 females, 10 children; duration of diabetes 19.1 ± 8.4 years; total daily insulin usage while on MDI (IU/day) 57.86 ± 15.32; HbA1c at the beginning of CSII treatment 8.67 ± 1.54%] were included in the study. HbA1c, glucose levels, BMI, severe hypoglycemic and diabetic ketoacidosis (DKA) episodes were recorded and compared to the data prior to CSII introduction. The evaluation of the quality of life was assessed with a self-questionnaire adjusted from the SF-12 and diabetes quality of life (DQoL) questionnaires. RESULTS HbA1c was reduced from 8.67 ± 1.54 to 6.85 ± 0.52% (p < 0.001). This reduction was independent of age, gender, body mass index (BMI) and diabetes duration. Daily insulin requirements were lower at the end of the follow-up (36.40 ± 12.20 IU/day) compared with the needs during enrolment (57.86 ± 15.32 IU/day) (p < 0.001). BMI presented no significant alterations. Ten (10) severe hypoglycemic episodes were recorded but the overall rate was decreased by 71.5% (p < 0.001). Only 3 cases of ketoacidosis were recorded. Quality of life parameters were remarkably improved. CONCLUSIONS This study provided evidence that CSII treatment was superior to MDI for patients with T1DM in Greece. CSII offered a safe, effective alternative to MDI, while improving glycaemic control, side-effects and quality of life.
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Affiliation(s)
- Maria Somali
- Department of Endocrinology, Diabetes and Metabolism, Euromedica General Clinic, Thessaloniki, Greece
| | - Stavroula A Paschou
- Division of Endocrinology and Diabetes, "Aghia Sophia" Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Zadalla Mouslech
- Department of Endocrinology, Diabetes and Metabolism, Euromedica General Clinic, Thessaloniki, Greece.
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Derosa G, Catena G, Scelsi L, D'Angelo A, Raddino R, Cosentino E, Maggi A, Pasini G, Borghi C, Maffioli P. Glyco-metabolic control, inflammation markers, and cardiovascular outcomes in type 1 and type 2 diabetic patients on insulin pump or multiple daily injection (italico study). Diabetes Metab Res Rev 2020; 36:e3219. [PMID: 31642581 DOI: 10.1002/dmrr.3219] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 08/19/2019] [Accepted: 09/16/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND To evaluate if the positive effects recorded on glycaemic control with continuous subcutaneous insulin infusion (CSII) were maintained on the long-term compared with multiple daily injection (MDI). The secondary objective was to evaluate if there is a reduction of type and number of cardiovascular events (CV). METHODS This retrospective, observational study evaluated glycaemic control and the number of CV in 104 patients with type 1 or 2 diabetes previously treated with MDI and initiating CSII therapy with tubed insulin pumps compared with 109 patients previously treated with MDI continuing MDI. RESULTS After 8 years, the glycaemic control including glycated haemoglobin (HbA1c ), fasting plasma glucose (FPG), and prandial plasma glucose (PPG) improved with both CSII and MDI compared with baseline; however, HbA1c , FPG, and PPG recorded with CSII were lower than data recorded with MDI. During the 8 years, there were fewer CV events with CSII, compared with MDI, and in particular, there were fewer cases of atrial fibrillation, premature ventricular contractions, acute coronary infarction, angina pectoris, heart failure, and peripheral vascular ischemia. We did not record any reduction of ischemic stroke events. CONCLUSION Our preliminary data suggest that CSII treatment seems to reduce the rates of CV compared with MDI therapy. Moreover, CSII also improved glycaemic control, without increasing the number of hypoglycaemia. However, given the observational design of this trial, our data should be validated in a randomized clinical trial; if they will be confirmed, CSII could be chosen for fully informed and motivated patients at higher risk of developing CV.
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Affiliation(s)
- Giuseppe Derosa
- Centre of Diabetes and Metabolic Diseases, Department of Internal Medicine and Therapeutics, University of Pavia and Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Laboratory of Molecular Medicine, University of Pavia, Pavia, Italy
| | | | - Laura Scelsi
- Cardiology Division, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Angela D'Angelo
- Centre of Diabetes and Metabolic Diseases, Department of Internal Medicine and Therapeutics, University of Pavia and Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Laboratory of Molecular Medicine, University of Pavia, Pavia, Italy
| | | | - Eugenio Cosentino
- Medical and Surgery Sciences Department, University of Bologna, Bologna, Italy
| | - Antonio Maggi
- Cardiologic Unit, Poliambulanza Foundation, Brescia, Italy
| | - Gianfranco Pasini
- Cardiologic Unit, Presidio Ospedaliero di Gavardo, Gavardo, Brescia, Italy
| | - Claudio Borghi
- Medical and Surgery Sciences Department, University of Bologna, Bologna, Italy
| | - Pamela Maffioli
- Centre of Diabetes and Metabolic Diseases, Department of Internal Medicine and Therapeutics, University of Pavia and Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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26
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Varkhede N, Bommana R, Schöneich C, Forrest ML. Proteolysis and Oxidation of Therapeutic Proteins After Intradermal or Subcutaneous Administration. J Pharm Sci 2020; 109:191-205. [PMID: 31408633 PMCID: PMC6937400 DOI: 10.1016/j.xphs.2019.08.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/05/2019] [Accepted: 08/06/2019] [Indexed: 12/12/2022]
Abstract
The intradermal (ID) and subcutaneous (SC) routes are commonly used for therapeutic proteins (TPs) and vaccines; however, the bioavailability of TPs is typically less than small molecule drugs given via the same routes. Proteolytic enzymes in the dermal, SC, and lymphatic tissues may be responsible for the loss of TPs. In addition, the TPs may be exposed to reactive oxygen species generated in the SC tissue and the lymphatic system in response to injection-related trauma and impurities within the formulation. The reactive oxygen species can oxidize TPs to alter their efficacy and immunogenicity potential. Mechanistic understandings of the dominant proteolysis and oxidative routes are useful in the drug discovery process, formulation development, and to assess the potential for immunogenicity and altered pharmacokinetics (PK). Furthermore, in vitro tools representing the ID or SC and lymphatic system can be used to evaluate the extent of proteolysis of the TPs after the injection and before systemic entry. The in vitro clearance data may be included in physiologically based pharmacokinetic models for improved PK predictions. In this review, we have summarized various physiological factors responsible for proteolysis and oxidation of TPs after ID and SC administration.
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Affiliation(s)
- Ninad Varkhede
- Department of Pharmaceutical Chemistry, The University of Kansas, Lawrence, Kansas 66047; Department of Pharmacokinetics, Pharmacodynamics & Drug Metabolism (PPDM), Merck Research Laboratories, West Point, Pennsylvania 19486
| | - Rupesh Bommana
- Department of Pharmaceutical Chemistry, The University of Kansas, Lawrence, Kansas 66047; MedImmune, Gaithersburg, Maryland 20878
| | - Christian Schöneich
- Department of Pharmaceutical Chemistry, The University of Kansas, Lawrence, Kansas 66047
| | - M Laird Forrest
- Department of Pharmaceutical Chemistry, The University of Kansas, Lawrence, Kansas 66047.
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Abstract
The subcutaneous administration route is widely used to administer different types of drugs given its high bioavailability and rapid onset of action. However, the sensation of pain at the injection site might reduce patient adherence. Apart from a direct effect of the drug itself, several factors can influence the sensation of pain: needle features, injection site, volume injected, injection speed, osmolality, viscosity and pH of formulation, as well as the kind of excipients employed, including buffers and preservatives. Short and thin needles, conveniently lubricated and with sharp tips, are generally used to minimize pain, although the anatomic injection site (abdomen versus thigh) also affects the sensation of pain. Large subcutaneous injection volumes are associated with pain. In this sense, the maximum volume generally accepted is around 1.5 ml, although volumes of up to 3 ml are well tolerated when injected in the abdomen. Injected volumes of up to 0.5–0.8 ml are not expected to increase substantially the pain produced by the needle insertion. Ideally, injectable products should be formulated as isotonic solutions (osmolality of about 300 mOsm/kg) and no more than 600 mOs/kg have to be used in order to prevent pain. A pH close to the physiological one is recommended to minimize pain, irritation, and tissue damage. Buffers are frequently added to parenteral formulations to optimize solubility and stability by adjusting the pH; however, their strength should be kept as low as possible to avoid pain upon injection. The data available recommend the concentration of phosphate buffer be limited to 10 mM and that the concentration of citrate buffer should be lower than 7.3 mM to avoid an increased sensation of pain. In the case of preservatives, which are required in multiple-dose preparations, m-cresol seems to be more painful than benzyl alcohol and phenol. Funding: Sandoz SA.
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Affiliation(s)
- Iris Usach
- Department of Pharmacy and Pharmaceutical Technology and Parasitology, Faculty of Pharmacy, University of Valencia, Valencia, Spain
| | - Rafael Martinez
- Department of Medical Affairs, Sandoz SA PE Parque Norte, Edificio Roble, C/Serrano Galvache, Madrid, Spain
| | - Teodora Festini
- Department of Global Medical Affairs, Sandoz Biopharmaceuticals, Holzkirchen, Germany
| | - José-Esteban Peris
- Department of Pharmacy and Pharmaceutical Technology and Parasitology, Faculty of Pharmacy, University of Valencia, Valencia, Spain.
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28
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Dawood RM, Salum GM, Abdelhafez TH, El Shenawy R, Ibrahim NE, El Awady MK. Safety and tolerability of mice to repeated subcutaneous injections of a peptide mix as a potential vaccine against HCV infection. Hum Antibodies 2019; 27:105-110. [PMID: 30594921 DOI: 10.3233/hab-180354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS In this study, the safety and tolerability of new candidate HCV vaccine named Cenv6 were screened in mice. Cenv6 peptide is composed of 6 synthetic HCV peptides (3 structural and 3 nonstructural peptides). METHODS Forty eight mice were enrolled in this study, 12 controls and 36 mice (the thirty-six mice were categorized into 3 groups according to administered doses (3 monthly doses of 800 ng, 1600 ng, and 16 μg/25 gm mouse body weight (bw))). Hematological, biochemical and histopathological changes were appraised. RESULTS Our data indicated that the doses of 800 ng and 1600 ng of Cenv6 per 25 gm mouse body weight were safe as compared to the dose 16 μg/25 gm bw (10 times more than the potential therapeutic dose) for all examined tissues while the 16 μg Cenv6 dose provoked histopathological changes in kidneys, liver and lungs. CONCLUSIONS The extravagant histopathological changes in different organs have exiled the 16 μg dose out of acceptable range and validated that Cenv6 is safe and tolerable at the two lower doses (800 and 1600 ng/25 gm bw).
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Abstract
Intravenous immunoglobulin (IVIg) is well-established in the treatment of patients with chronic inflammatory demyelinating polyneuropathy (CIDP). Immune globulin subcutaneous (human) 20% liquid (Hizentra®; referred to as IgPro20 hereafter) has recently been approved in a number of countries, including the USA and those of the EU, as maintenance therapy in patients with CIDP. In the pivotal phase III PATH trial in adults with CIDP who were first stabilized on IVIg therapy, maintenance therapy with IgPro20 for 24 weeks significantly reduced CIDP relapse or study withdrawal rates versus placebo. Efficacy was sustained during ≤ 48 weeks of additional treatment with IgPro20 in the open-label PATH extension study. IgPro20 was generally well tolerated, with low rates of systemic adverse events (AEs); the most common AEs were local reactions (e.g. infusion-site erythema, infusion-site swelling). In PATH, more than one-half of IgPro20 recipients preferred this therapy to their previous IVIg therapy. IgPro20 offers a convenient alternative to IVIg with a better systemic AEs profile and thus extends the options for maintenance therapy in CIDP.
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Affiliation(s)
- Yvette N Lamb
- Springer, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
| | - Yahiya Y Syed
- Springer, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand
| | - Sohita Dhillon
- Springer, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand
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30
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Ness S. Differentiating characteristics and evaluating intravenous and subcutaneous immunoglobulin. Am J Manag Care 2019; 25:S98-S104. [PMID: 31318515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Clinicians have a range of options for treating patients with disease states that require the use of immunoglobulin (Ig). Traditionally, intravenous immunoglobulin (IVIG) administration has provided effective therapy for a variety of disease states. More recently, subcutaneous immunoglobulin (SCIG) administration has become available for patients with primary immunodeficiencies and chronic inflammatory demyelinating polyneuropathy (CIDP). Ig is used as replacement therapy in patients with primary or secondary immunodeficiencies and has been shown to reduce morbidity due to bacterial infections associated with antibody deficiency. The mechanism of action for use of Ig in the treatment of autoimmune disorders is complex and partially understood, but immunomodulatory effects have been suggested in CIDP and multifocal motor neuropathy. The available IVIG and SCIG products differ in their pharmaceutical properties (eg, pH, osmolality, IgA content, sodium content, and stabilizer), which can affect safety and tolerability in some patients. The pharmacokinetics of Ig also differ based on the route of administration. With IVIG administration every 3 or 4 weeks, peak concentrations are greater and trough concentrations are lower, which can increase the propensity of systemic adverse effects (AEs) and impact tolerability of therapy. SCIG infusions are typically administered more frequently (ie, biweekly, weekly, and even daily based on patient need), resulting in steady state concentrations with fewer fluctuations in Ig plasma levels. The route of administration plays a major role in the types of AEs seen in patients receiving Ig therapy, with systemic AEs associated with IV administration and local reactions more commonly seen with SC administration. By understanding the differences in IVIG and SCIG products, which are not interchangeable, and the patient characteristics that guide product selection, clinicians and managed care providers can better serve patients with immunodeficiency disorders and other disease states.
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Affiliation(s)
- Stacey Ness
- Senior Director, Specialty Clinical Services, Managed Health Care Associates, Inc, Florham Park, NJ; President, Immune Globulin National Society.
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31
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Cotofana S, Koban K, Pavicic T, Yankonva M, Frank K, Green JB, Gotkin RH, Etzel L, Giunta RE, Schenck TL. Clinical Validation of the Surface Volume Coefficient for Minimally Invasive Treatment of the Temple. J Drugs Dermatol 2019; 18:533. [PMID: 31251545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Objective: The aim of the present study is to compare the temporal surface volume coefficient obtained in the cadaveric model from subdermal and supraperiosteal injections to the clinical setting when treating temporal hollowing. Material and Methods: A total of 36 subjects were included in this investigation, 17 patients (16 females, 1 male; 46.3 ± 8.9 years; 25.5 ± 2.8 kg/m2) and 19 cadaveric specimens (11 females, 8 males; 76.4 ± 11.5 years; 24.0 ± 5.1 kg/m2). Subdermal and supraperiosteal injections were performed and live subjects were evaluated and followed for 12 months. The surface volume coefficients were calculated using 3D surface volume scanning and compared for validity. Results: No statistically significant difference was detected between the clinical outcome scores of the subdermal vs supraperiosteal injection technique. The supraperiosteal injection technique utilized significantly more product 1.20 ± 0.5 cc [range: 0.50 – 2.6 cc] compared to the subdermal 0.71 ± 0.2 cc [range: 0.30 – 1.20 cc] vs with P< 0.001. This difference was consistent with the different values of the cadaveric surface volume coefficient (subdermal vs supraperiosteal): 1.00 ± 0.2 vs 0.70 ± 0.2. At 12-month follow-up, the product loss was 19% for the subdermal injection and 21% for patients treated with supraperiosteal injections. Conclusion: The results of the study support the clinical validity of the surface volume coefficient. They demonstrate that the different injection volumes necessary to deliver aesthetically appealing results when utilizing the subdermal vs the supraperiosteal technique can be explained by the region-specific surface volume coefficient. J Drugs Dermatol. 2019;18(6):533-540.
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Abstract
INTRODUCTION AND OBJECTIVE Continuous subcutaneous apomorphine (APO) treatment is one of the 3 therapeutic options for advanced Parkinson's disease (PD), in addition to deep brain stimulation (DBS) and intrajejunal levodopa. Data from previously performed studies show that few PD patients can achieve APO infusion as monotherapy. The current pilot study presents the authors' experience in achieving APO monotherapy. MATERIAL AND METHODS During the last 2 years, 9 patients with APO were treated in the Department of Neurology of the Medical University of Lublin; each patient was offered a 5-day duration APO treatment as monotherapy. The main indication for the APO therapy was advanced PD with motor fluctuations and the patient's non-agreement for DBS therapy. Mean age of treated patients - 65.11 years, mean disease duration - 7.67 years, mean Hoehn-Yahr - 2.67, mean L-dopa equivalent before APO treatment - 1751.11 mg, mean daily dose of apomorphine as monotherapy - 106.11 ± 14.09 mg. RESULTS All treated patients managed to achieve APO monotherapy. A statistically significant reduction was found in the duration of the 'off' states in the observed PD patients on APO monotherapy (p<0.05). No significant improvement was observed in the III motor score of the UPDRS on APO treatment, compared to optimized oral therapy used before APO treatment. CONCLUSIONS APO monotherapy can be achieved in advanced PD, and seems to be a good therapeutic option for this group of patients, especially in that it allows a significant reduction in the off-time which significantly simplifies the drug regime. Nevertheless, hospital admission with experienced neurologist supervision is recommended when establishing a PD patient's APO monotherapy.
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Affiliation(s)
- Ewa Papuć
- Department of Neurology, Medical University of Lublin, Poland.
| | | | - Konrad Rejdak
- Department of Neurology, Medical University of Lublin, Poland.
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Mendes FH, Viterbo F, Deffunne E, Domingues MAC, Golim MA, Gabas JM, Rossoni R, Nunes HC. Fragmented Fat: A new method for harvesting and processing of lipograft. J Plast Reconstr Aesthet Surg 2019; 72:1030-1048. [PMID: 30824381 DOI: 10.1016/j.bjps.2019.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 01/17/2019] [Accepted: 02/12/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Flavio Henrique Mendes
- Division of Plastic Surgery, Botucatu Medical School, Paulista State University (UNESP). São Paulo, Brazil.
| | - Fausto Viterbo
- Division of Plastic Surgery, Botucatu Medical School, Paulista State University (UNESP). São Paulo, Brazil
| | - Elenice Deffunne
- Division of Tissue Engineering, Botucatu Medical School, Paulista State University (UNESP). São Paulo, Brazil
| | | | - Marjorie Assis Golim
- Division of Tissue Engineering, Botucatu Medical School, Paulista State University (UNESP). São Paulo, Brazil
| | - José Marcos Gabas
- Division of Plastic Surgery, Botucatu Medical School, Paulista State University (UNESP). São Paulo, Brazil
| | - Renan Rossoni
- Division of Plastic Surgery, Botucatu Medical School, Paulista State University (UNESP). São Paulo, Brazil
| | - Helga Caputo Nunes
- Division of Tissue Engineering, Botucatu Medical School, Paulista State University (UNESP). São Paulo, Brazil
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Gauntt J, Vaidyanathan P, Basu S. Utilizing serum bicarbonate instead of venous pH to transition from intravenous to subcutaneous insulin shortens the duration of insulin infusion in pediatric diabetic ketoacidosis. J Pediatr Endocrinol Metab 2019; 32:11-17. [PMID: 30530908 DOI: 10.1515/jpem-2018-0394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 11/02/2018] [Indexed: 11/15/2022]
Abstract
Background Standard therapy of diabetic ketoacidosis (DKA) in pediatrics involves intravenous (IV) infusion of regular insulin until correction of acidosis, followed by transition to subcutaneous (SC) insulin. It is unclear what laboratory marker best indicates correction of acidosis. We hypothesized that an institutional protocol change to determine correction of acidosis based on serum bicarbonate level instead of venous pH would shorten the duration of insulin infusion and decrease the number of pediatric intensive care unit (PICU) therapies without an increase in adverse events. Methods We conducted a retrospective (pre/post) analysis of records for patients admitted with DKA to the PICU of a large tertiary care children's hospital before and after a transition-criteria protocol change. Outcomes were compared between patients in the pH transition group (transition when venous pH≥7.3) and the bicarbonate transition group (transition when serum bicarbonate ≥15 mmol/L). Results We evaluated 274 patient records (n=142 pH transition group, n=132 bicarbonate transition group). Duration of insulin infusion was shorter in the bicarbonate transition group (18.5 vs. 15.4 h, p=0.008). PICU length of stay was 3.2 h shorter in the bicarbonate transition group (26.0 vs. 22.8 h, p=0.04). There was no difference in the number of adverse events between the groups. Conclusions Transitioning patients from IV to SC insulin based on serum bicarbonate instead of venous pH led to a shorter duration of insulin infusion with a reduction in the number of PICU therapies without an increase in the number of adverse events.
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Affiliation(s)
- Jennifer Gauntt
- Division of Cardiology, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA, Phone: +614-722-0596
| | - Priya Vaidyanathan
- Division of Endocrinology and Diabetes, Children's National Health System, Washington, DC, USA
| | - Sonali Basu
- Division of Critical Care Medicine, Children's National Health System, Washington, DC, USA
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Affiliation(s)
| | | | - Lutz Heinemann
- Science Consulting in Diabetes GmbH, Neuss, Germany
- Lutz Heinemann, PhD, Science-Consulting in Diabetes GmbH, Geulenstr 50, 41462 Neuss, 0160 8877401, Germany.
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Abstract
Subcutaneous delivery of biotherapeutics has become a valuable alternative to intravenous administration across many disease areas. Although the pharmacokinetic profiles of subcutaneous and intravenous formulations differ, subcutaneous administration has proven effective, safe, well-tolerated, generally preferred by patients and healthcare providers and to result in reduced drug delivery-related healthcare costs and resource use. The aim of this article is to discuss the differences between subcutaneous and intravenous dosing from both health-economic and scientific perspectives. The article covers different indications, treatment settings, administration volumes, and injection devices. We focus on biotherapeutics in rheumatoid arthritis (RA), immunoglobulin-replacement therapy in primary immunodeficiency (PI), beta interferons in multiple sclerosis (MS), and monoclonal antibodies (mAbs) in oncology. While most subcutaneous biotherapeutics in RA, PI, and MS are self-administered at home, mAbs for oncology are still only approved for administration in a healthcare setting. Beside concerns around the safety of biotherapeutics in oncology, a key challenge for self-administration in this area is that doses and dosing volumes can be comparatively large; however, this difficulty has recently been overcome to some extent by the development of high-concentration solutions, the use of infusion pumps, and the coadministration of the dispersion enhancer hyaluronidase. Furthermore, given the increasing number of biotherapeutics being considered for combination therapy and the high dosing complexity associated with these, especially when administered intravenously, subcutaneous delivery of fixed-dose combinations might be an alternative that will diminish these burdens on healthcare systems.
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Affiliation(s)
- Beate Bittner
- Product Optimization, Global Product Strategy, F. Hoffmann-La Roche Ltd, Grenzacher Strasse 124, 4070, Basel, Switzerland.
| | - Wolfgang Richter
- Roche Pharmaceutical Research and Early Development, Pharmaceutical Sciences, Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd, Grenzacher Strasse 124, 4070, Basel, Switzerland
| | - Johannes Schmidt
- Product Optimization, Global Product Strategy, F. Hoffmann-La Roche Ltd, Grenzacher Strasse 124, 4070, Basel, Switzerland
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Barlow-Evans R, Jaffer K, Gupta JK. Essential anatomy: why anatomical words matter when it comes to subdermal implants. BMJ Sex Reprod Health 2018; 44:315-316. [PMID: 30305411 DOI: 10.1136/bmjsrh-2018-200217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- R Barlow-Evans
- Community Sexual and Reproductive Health, Umbrella Sexual Health Services, University Hospitals Birmingham, Birmingham, UK
| | - K Jaffer
- Sexual and Reproductive Health, Umbrella Sexual Health Services, University Hospitals Birmingham, Birmingham, UK
| | - J K Gupta
- Obstetrics and Gynaecology, Birmingham Women's NHS Foundation Trust, Birmingham, UK
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O'Neil PM, Birkenfeld AL, McGowan B, Mosenzon O, Pedersen SD, Wharton S, Carson CG, Jepsen CH, Kabisch M, Wilding JPH. Efficacy and safety of semaglutide compared with liraglutide and placebo for weight loss in patients with obesity: a randomised, double-blind, placebo and active controlled, dose-ranging, phase 2 trial. Lancet 2018; 392:637-649. [PMID: 30122305 DOI: 10.1016/s0140-6736(18)31773-2] [Citation(s) in RCA: 366] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 07/18/2018] [Accepted: 07/24/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Obesity is a major public health issue, and new pharmaceuticals for weight management are needed. Therefore, we evaluated the efficacy and safety of the glucagon-like peptide-1 (GLP-1) analogue semaglutide in comparison with liraglutide and a placebo in promoting weight loss. METHODS We did a randomised, double-blind, placebo and active controlled, multicentre, dose-ranging, phase 2 trial. The study was done in eight countries involving 71 clinical sites. Eligible participants were adults (≥18 years) without diabetes and with a body-mass index (BMI) of 30 kg/m2 or more. We randomly assigned participants (6:1) to each active treatment group (ie, semaglutide [0·05 mg, 0·1 mg, 0·2 mg, 0·3 mg, or 0·4 mg; initiated at 0·05 mg per day and incrementally escalated every 4 weeks] or liraglutide [3·0 mg; initiated at 0·6 mg per day and escalated by 0·6 mg per week]) or matching placebo group (equal injection volume and escalation schedule to active treatment group) using a block size of 56. All treatment doses were delivered once-daily via subcutaneous injections. Participants and investigators were masked to the assigned study treatment but not the target dose. The primary endpoint was percentage weight loss at week 52. The primary analysis was done using intention-to-treat ANCOVA estimation with missing data derived from the placebo pool. This study is registered with ClinicalTrials.gov, number NCT02453711. FINDINGS Between Oct 1, 2015, and Feb 11, 2016, 957 individuals were randomly assigned (102-103 participants per active treatment group and 136 in the pooled placebo group). Mean baseline characteristics included age 47 years, bodyweight 111·5 kg, and BMI 39·3 kg/m2. Bodyweight data were available for 891 (93%) of 957 participants at week 52. Estimated mean weight loss was -2·3% for the placebo group versus -6·0% (0·05 mg), -8·6% (0·1 mg), -11·6% (0·2 mg), -11·2% (0·3 mg), and -13·8% (0·4 mg) for the semaglutide groups. All semaglutide groups versus placebo were significant (unadjusted p≤0·0010), and remained significant after adjustment for multiple testing (p≤0·0055). Mean bodyweight reductions for 0·2 mg or more of semaglutide versus liraglutide were all significant (-13·8% to -11·2% vs -7·8%). Estimated weight loss of 10% or more occurred in 10% of participants receiving placebo compared with 37-65% receiving 0·1 mg or more of semaglutide (p<0·0001 vs placebo). All semaglutide doses were generally well tolerated, with no new safety concerns. The most common adverse events were dose-related gastrointestinal symptoms, primarily nausea, as seen previously with GLP-1 receptor agonists. INTERPRETATION In combination with dietary and physical activity counselling, semaglutide was well tolerated over 52 weeks and showed clinically relevant weight loss compared with placebo at all doses. FUNDING Novo Nordisk A/S.
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Affiliation(s)
| | - Andreas L Birkenfeld
- Department and Outpatient Department of Medicine III, Carl Gustav Carus University Hospital Dresden, Dresden, Germany
| | | | - Ofri Mosenzon
- Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Sue D Pedersen
- C-endo Diabetes and Endocrinology Clinic, Calgary, AB, Canada
| | - Sean Wharton
- York University and Wharton Weight Management Clinic, Toronto, ON, Canada
| | | | | | | | - John P H Wilding
- Obesity and Endocrinology Research, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK.
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Gordon KB, Strober B, Lebwohl M, Augustin M, Blauvelt A, Poulin Y, Papp KA, Sofen H, Puig L, Foley P, Ohtsuki M, Flack M, Geng Z, Gu Y, Valdes JM, Thompson EHZ, Bachelez H. Efficacy and safety of risankizumab in moderate-to-severe plaque psoriasis (UltIMMa-1 and UltIMMa-2): results from two double-blind, randomised, placebo-controlled and ustekinumab-controlled phase 3 trials. Lancet 2018; 392:650-661. [PMID: 30097359 DOI: 10.1016/s0140-6736(18)31713-6] [Citation(s) in RCA: 388] [Impact Index Per Article: 64.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 07/18/2018] [Accepted: 07/19/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Risankizumab is a humanised IgG1 monoclonal antibody that binds to the p19 subunit of interleukin-23, inhibiting this key cytokine and its role in psoriatic inflammation. We aimed to assess the efficacy and safety of risankizumab compared with placebo or ustekinumab in patients with moderate-to-severe chronic plaque psoriasis. METHODS UltIMMa-1 and UltIMMa-2 were replicate phase 3, randomised, double-blind, placebo-controlled and active comparator-controlled trials done at 139 sites in Australia, Austria, Belgium, Canada, Czech Republic, France, Germany, Japan, Mexico, Poland, Portugal, South Korea, Spain, and the USA. Eligible patients were 18 years or older, with moderate-to-severe chronic plaque psoriasis. In each study, patients were stratified by weight and previous exposure to tumour necrosis factor inhibitor and randomly assigned (3:1:1) by use of interactive response technology to receive 150 mg risankizumab, 45 mg or 90 mg ustekinumab (weight-based per label), or placebo. Following the 16-week double-blind treatment period (part A), patients initially assigned to placebo switched to 150 mg risankizumab at week 16; other patients continued their originally randomised treatment (part B, double-blind, weeks 16-52). Study drug was administered subcutaneously at weeks 0 and 4 during part A and at weeks 16, 28, and 40 during part B. Co-primary endpoints were proportions of patients achieving a 90% improvement in the Psoriasis Area Severity Index (PASI 90) and a static Physician's Global Assessment (sPGA) score of 0 or 1 at week 16 (non-responder imputation). All efficacy analyses were done in the intention-to-treat population. These trials are registered with ClinicalTrials.gov, numbers NCT02684370 (UltIMMa-1) and NCT02684357 (UltIMMa-2), and have been completed. FINDINGS Between Feb 24, 2016, and Aug 31, 2016, 506 patients in UltIMMa-1 were randomly assigned to receive 150 mg risankizumab (n=304), 45 mg or 90 mg ustekinumab (n=100), or placebo (n=102). Between March 1, 2016, and Aug 30, 2016, 491 patients in UltIMMa-2 were randomly assigned to receive 150 mg risankizumab (n=294), 45 mg or 90 mg ustekinumab (n=99), or placebo (n=98). Co-primary endpoints were met for both studies. At week 16 of UltIMMa-1, PASI 90 was achieved by 229 (75·3%) patients receiving risankizumab versus five (4·9%) receiving placebo (placebo-adjusted difference 70·3% [95% CI 64·0-76·7]) and 42 (42·0%) receiving ustekinumab (ustekinumab-adjusted difference 33·5% [22·7-44·3]; p<0·0001 vs placebo and ustekinumab). At week 16 of UltIMMa-2, PASI 90 was achieved by 220 (74·8%) patients receiving risankizumab versus two (2·0%) receiving placebo (placebo-adjusted difference 72·5% [95% CI 66·8-78·2]) and 47 (47·5%) receiving ustekinumab (ustekinumab-adjusted difference 27·6% [16·7-38·5]; p<0·0001 vs placebo and ustekinumab). In UltIMMa-1, sPGA 0 or 1 at week 16 was achieved by 267 (87·8%) patients receiving risankizumab versus eight (7·8%) receiving placebo (placebo-adjusted difference 79·9% [95% CI 73·5-86·3]) and 63 (63·0%) receiving ustekinumab (ustekinumab-adjusted difference 25·1% [15·2-35·0]; p<0·0001 vs placebo and ustekinumab). In UltIMMa-2, 246 (83·7%) patients receiving risankizumab versus five (5·1%) receiving placebo (placebo-adjusted difference 78·5% [95% CI 72·4-84·5]) and 61 (61·6%) receiving ustekinumab achieved sPGA 0 or 1 at week 16 (ustekinumab-adjusted difference 22·3% [12·0-32·5]; p<0·0001 vs placebo and ustekinumab). The frequency of treatment-emergent adverse events in UltIMMa-1 and UltIMMa-2 was similar across risankizumab (part A: 151 [49·7%] of 304 and 134 [45·6%] of 294; part B: 182 [61·3%] of 297 and 162 [55·7%] of 291), placebo (part A: 52 [51·0%] of 102 and 45 [45·9%] of 98), ustekinumab (part A: 50 [50·0%] of 100 and 53 [53·5%] of 99; part B: 66 [66·7%] of 99 and 70 [74·5%] of 94), and placebo to risankizumab (part B: 65 [67·0%] of 97 and 61 [64·9%] of 94) treatment groups throughout the study duration. INTERPRETATION Risankizumab showed superior efficacy to both placebo and ustekinumab in the treatment of moderate-to-severe plaque psoriasis. Treatment-emergent adverse event profiles were similar across treatment groups and there were no unexpected safety findings. FUNDING AbbVie and Boehringer Ingelheim.
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Affiliation(s)
| | - Bruce Strober
- University of Connecticut Health Center and Probity Medical Research, Farmington, CT, USA
| | - Mark Lebwohl
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Yves Poulin
- Centre Dermatologique du Québec Métropolitain, Québec, QC, Canada
| | - Kim A Papp
- K Papp Clinical Research and Probity Medical Research, Waterloo, ON, Canada
| | - Howard Sofen
- University of California, Los Angeles, CA, USA; School of Medicine, Los Angeles, CA, USA
| | - Lluís Puig
- Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Peter Foley
- University of Melbourne, Parkville, Skin & Cancer Foundation Inc, Carlton, Probity Medical Research, Carlton, and St Vincent's Hospital Melbourne, Fitzroy VIC, Australia
| | | | - Mary Flack
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT, USA
| | | | | | | | | | - Hervé Bachelez
- Saint-Louis Hospital, AP-HP, Sorbonne Paris Cité Université Paris Diderot, INSERUM UMR 1163, Institut Imagine, Paris, France.
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Kampmann U, Madsen LR, Bjerg L, Witte DR, Hasselstrøm K, Østergård T, Alstrup K, Møller MK, Dylmer D, Hansen KW. Prevalence and geographical distribution of insulin pump therapy in the Central Denmark Region and its association with metabolic parameters. Diabetes Res Clin Pract 2018; 141:148-155. [PMID: 29733870 DOI: 10.1016/j.diabres.2018.04.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 04/10/2018] [Accepted: 04/26/2018] [Indexed: 10/17/2022]
Abstract
AIMS Insulin treatment in type 1 diabetes encompasses multiple daily insulin injections (MDI) or continuous subcutaneous insulin infusion (CSII). Both population-based studies and comparative studies regarding CSII use are sparse. The aim of the current study was to describe the prevalence and distribution of CSII use among adults with type 1 diabetes in the Central Denmark Region and to compare metabolic control in CSII-treated patients to those treated with MDI. METHODS A database was constructed using the Danish Adult Diabetes Registry in 2014/2015 in combination with an audit of the patients' medical records. RESULTS 3909 adults with type 1 diabetes patients were included. The proportion of patients treated with CSII differed significantly between the 8 regional hospitals from 12.0% to 31.1%. CSII users had a significantly lower HbA1c compared to MDI treated patients (7.6% (60 mmol/mol) versus 8.0% (64 mmol/mol)) in unadjusted analyses. After adjustment for clinically relevant characteristics the difference between CSII and MDI-treated patients was attenuated, but remained statistically significant. CONCLUSION The distribution of CSII differed markedly between hospitals and CSII users had better glycemic control, even after adjustment for sex, age, BMI, diabetes duration, smoking, use of lipid-lowering and blood pressure-lowering medication.
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Affiliation(s)
- Ulla Kampmann
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Denmark.
| | - Lene Ring Madsen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Denmark
| | - Lasse Bjerg
- Department of Public Health, Section of General Practice, Aarhus University, Denmark; Department of Clinical Epidemiology, Steno Diabetes Center Copenhagen, Gentofte, Denmark
| | - Daniel R Witte
- Department of Public Health, Section of General Practice, Aarhus University, Denmark; Danish Diabetes Academy, Odense, Denmark
| | | | - Torben Østergård
- Department of Internal Medicine, Viborg Regional Hospital, Denmark
| | - Kirsten Alstrup
- Department of Internal Medicine, Randers Regional Hospital, Denmark
| | | | - Dorrit Dylmer
- Department of Internal Medicine, Holstebro Regional Hospital, Denmark
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Hung CH, Shieh JP, Chiu CC, Wang JJ, Chen YW. Subcutaneous infiltration of doxylamine on cutaneous analgesia in rats. Pharmacol Rep 2018; 70:565-569. [PMID: 29679880 DOI: 10.1016/j.pharep.2017.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 11/28/2017] [Accepted: 12/19/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND We aimed to evaluate the effect of doxylamine, a first generation antihistamine, as a local analgesic agent by comparing its effect to bupivacaine. METHODS After blocking the cutaneous trunci muscle reflex (CTMR) by subcutaneous injection of doxylamine, we assessed doxylamine's cutaneous analgesic effect in rats. The dose-related effect and duration of doxylamine on infiltrative cutaneous analgesia were compared with that of bupivacaine. RESULTS We demonstrated that doxylamine, as well as the local anesthetic bupivacaine produced the cutaneous analgesic effects in a dose-related fashion. At the equipotent dose (50% effective doses (ED50)), the relative potency was bupivacaine (0.41 (0.36-0.48) mmol)> doxylamine (7.39 (6.91-7.91)mmol) (p<0.01). On an equipotent basis (ED25, ED50 and ED75), subcutaneous doxylamine resulted in greater duration of action (p<0.01) than bupivacaine at producing cutaneous analgesia. CONCLUSIONS The result of this experiment indicated that doxylamine has the local anesthetic property less potent than bupivacaine, but its nociceptive block duration is longer than that of bupivacaine at an equianalgesic dose.
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Affiliation(s)
- Ching-Hsia Hung
- Department of Physical Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ja-Ping Shieh
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan; Center for General Education, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Chong-Chi Chiu
- Department of General Surgery, Chi Mei Medical Center, Tainan and Liouying, Taiwan; Department of Electrical Engineering, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Jhi-Joung Wang
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Yu-Wen Chen
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan; Department of Physical Therapy, College of Health Care, China Medical University, Taichung, Taiwan.
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Altun İ. May the Z-Tracking Technique to Minimize or Avoid the Pain of Insulin Injection Be an Alternative to the 10-Second Waiting Technique? J Diabetes Sci Technol 2018; 12:731-732. [PMID: 29281892 PMCID: PMC6154241 DOI: 10.1177/1932296817750405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- İnsaf Altun
- Faculty of Health Sciences, Department
of Fundamentals in Nursing, İstinye University, Cevizlibağ, İstanbul, Turkey
- İnsaf Altun, RN, MSN, PhD, Faculty of Health
Sciences, Department of Fundamentals in Nursing, İstinye University, Cevizlibağ,
İstanbul, 34010, Turkey
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Cura Della Redazione A. [How to perform a subcutaneous injection]. Assist Inferm Ric 2018; 37:101-105. [PMID: 29991831 DOI: 10.1702/2940.29557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Altun İ. May the Z-Tracking Technique to Prevent Any Leakage in Insulin Injection Be an Alternative to the 10-Second Waiting Technique? J Diabetes Sci Technol 2018; 12:537-538. [PMID: 28918650 PMCID: PMC5851219 DOI: 10.1177/1932296817730378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- İnsaf Altun
- Department of Fundamentals in Nursing, İstinye University, Faculty of Health Sciences, Cevizlibağ, İstanbul, Turkey
- İnsaf Altun, RN, MSN, PhD, Department of Fundamentals in Nursing, İstinye University, Faculty of Health Sciences, Cevizlibağ, İstanbul 34010, Turkey.
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Charles-de-Sá L, Gontijo-de-Amorim NF, Takiya CM, Borojevic R, Benati D, Bernardi P, Sbarbati A, Rigotti G. Effect of Use of Platelet-Rich Plasma (PRP) in Skin with Intrinsic Aging Process. Aesthet Surg J 2018; 38:321-328. [PMID: 29040421 DOI: 10.1093/asj/sjx137] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND In previous papers, we demonstrated that the treatment of human photoaged skin with stromal-vascular fraction-enriched fat or expanded adipose-derived stem cells showed a decrease of elastosis and the appearance of new oxytalan elastic fibers in dermis and an increase in the vascular network. The utilization of fat plus platelet-rich plasma (PRP) led to an increase in the vascular permeability and reactivity of the nervous component. OBJECTIVES The purpose of this study was to analyze the histologic and ultrastructural changes of human skin after the injection of only PRP in the retroauricular area that was not exposed to sun and did not present the photoaging process, in comparison with our previous results. METHODS This study was performed in 13 patients who were candidates for facelift and whose ages ranged between 45 and 65 years. The PRP injection was performed in the mastoidea area. Fragments of skin were removed before and 3 months after treatment and analyzed by optical and electron microscopy. RESULTS After the injection of PRP, we observed an increase of reticular dermis thickness because of the deposition of elastic fibers and collagen, with a fibrotic aspect. A modified pattern of adipose tissue was also found at the dermohypodermal junction. Significative regenerative aspects were not found at histologic and ultrastructural analysis. The presence of foci of moderate inflammation and microangiopathy were observed. CONCLUSIONS Treatment with PRP increased reticular dermis thickness with a fibrotic aspect. In the long term, the presence of inflammation and microangiopathy caused by PRP injection could lead to trophic alteration of the skin and the precocious aging process. LEVEL OF EVIDENCE 4
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Affiliation(s)
| | | | | | - Radovan Borojevic
- Postgraduate Program in Surgical Science, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | - Andrea Sbarbati
- Department of Neurological and Motor Science, Section of Anatomy and Histology, University of Verona, Verona, Italy
| | - Gino Rigotti
- Regenerative Surgery Unit, San Francesco Clinic, Verona, Italy
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Zhou K, Williams MF, Esquivel MA, Song A, Rahman F, Bena J, Lam SW, Rathz DA, Lansang MC. Transitioning from intravenous to subcutaneous insulin in the medical intensive care unit. Diabetes Res Clin Pract 2017; 134:199-205. [PMID: 29154154 DOI: 10.1016/j.diabres.2017.05.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 04/05/2017] [Accepted: 05/16/2017] [Indexed: 01/04/2023]
Abstract
BACKGROUND There is a paucity of studies on transitions from IV insulin infusion (IVII) to subcutaneous (SC) insulin in the medical ICU (MICU). METHODS We conducted a retrospective study of patients admitted to the Cleveland Clinic MICU from June 2013 to January 2014 who received IVII. We compared blood glucose (BG) control between 3 cohorts based on timing of basal insulin dose: (1) NB (no basal), (2) IB (incorrect basal), (3) CB (correct basal) at 5 time points post-IVII discontinuation (1, 4, 8, 12, and 24h). Insulin doses used for transitioning were compared with 80% of estimated 24h IVII total. Analysis was done using chi-square, ANOVA and t-tests. RESULTS There were 269 patients (NB 166, IB 45, CB 58), 55% male with a mean age 58±16years. 103 patients (38%) had a transition attempted (IB 21%, CB 17%). The NB cohort had better BG than the IB cohort at all time points (p<0.001) but also lower HbA1c, prior DM diagnosis and home insulin use (p<0.001). IB and CB did not have significantly different BG with mean BG>180mg/dL at 4/5 time intervals. However, the dose of basal insulin used was less than 80% of estimated 24h IVII total (IB 21.4 vs 49.6U, CB 25vs 57.1U). Despite this, 15% of patients in the IB cohort and 24% of patients in the CB had hypoglycemic events. CONCLUSION The low rates of IV to SC insulin transitions raises the question of challenges to transitions.
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Affiliation(s)
- Keren Zhou
- Cleveland Clinic Foundation, Department of Endocrinology, Diabetes and Metabolism, 9500 Euclid Avenue, Mail Code: F-20, Cleveland, OH 44195, USA.
| | - Mia F Williams
- Cleveland Clinic Foundation, Department of Endocrinology, Diabetes and Metabolism, 9500 Euclid Avenue, Mail Code: F-20, Cleveland, OH 44195, USA.
| | - Mary Angelynne Esquivel
- Cleveland Clinic Foundation, Department of Endocrinology, Diabetes and Metabolism, 9500 Euclid Avenue, Mail Code: F-20, Cleveland, OH 44195, USA.
| | - Anne Song
- Cleveland Clinic Foundation, Department of Endocrinology, Diabetes and Metabolism, 9500 Euclid Avenue, Mail Code: F-20, Cleveland, OH 44195, USA.
| | - Farah Rahman
- Cleveland Clinic Foundation, Department of Endocrinology, Diabetes and Metabolism, 9500 Euclid Avenue, Mail Code: F-20, Cleveland, OH 44195, USA.
| | - James Bena
- Cleveland Clinic Foundation, Department of Quantitative Health Science, 9500 Euclid Avenue, Mail Code: JJN3, Cleveland, OH 44195, USA.
| | - Simon W Lam
- Cleveland Clinic Foundation, Department of Pharmacy, 9500 Euclid Avenue, Mail Code: JJN1, Cleveland, OH 44195, USA.
| | - Deborah A Rathz
- Cleveland Clinic Foundation, Department of Critical Care Medicine, Mail Code: L22, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
| | - M Cecilia Lansang
- Cleveland Clinic Foundation, Department of Endocrinology, Diabetes and Metabolism, 9500 Euclid Avenue, Mail Code: F-20, Cleveland, OH 44195, USA.
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Abstract
BACKGROUND Heparin is an anticoagulant medication that is usually injected subcutaneously. Subcutaneous administration of heparin may result in complications such as bruising, haematoma, and pain at the injection site. One of the factors that may affect pain, haematoma, and bruising is injection speed. For patients and healthcare providers, strategies that can reduce pain and bruising are considered important. Reducing patients' discomfort and concerns whenever and wherever possible is an important aim of nursing. Several studies have been carried out to see if speed of injection affects the amount of pain and bruising where the injection is given, but results of these studies have differed and study authors have not reached a clear final conclusion. This is the first update of the review first published in 2014. OBJECTIVES To assess the effects of duration (speed) of subcutaneous heparin injection on pain, haematoma, and bruising at the injection site in people admitted to hospitals or clinics who require treatment with unfractionated heparin (UFH) or low molecular weight heparin (LMWH). SEARCH METHODS For this update, the Cochrane Vascular Information Specialist (CIS) searched the Specialised Register (last searched March 2017) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 2). The CIS also searched trials registries for details of ongoing or unpublished studies. Review authors searched two Persian databases - Iranmedex and Scientific Information Database (SID) - as well as Google Scholar. SELECTION CRITERIA We sought randomised controlled trials (RCTs) comparing the effects of different durations of subcutaneous injection of heparin on pain, bruising, and haematoma at the injection site. DATA COLLECTION AND ANALYSIS Two review authors (MM, LJ), working independently, extracted data onto a structured form and assessed study quality. We used the criteria recommended by Cochrane to assess the risk of bias of included studies. For the outcomes, we calculated the mean difference (MD) or the standardised MD (SMD) with corresponding 95% confidence intervals (CIs). We pooled data using fixed-effect and random-effects models. We used GRADE to assess the overall quality of evidence supporting outcomes assessed in this review. MAIN RESULTS For this update, we identified three new studies and therefore included in the Review four studies with a total of 459 participants who received subcutaneous injections of LMWH into the abdomen. Only one trial reported the injected drug volume (0.4 mL). Owing to the nature of the intervention, it was not possible to blind participants and care givers (personnel) in any included study. Two studies described blinding of outcome assessors; therefore overall, the methodological quality of included studies was moderate. The duration of the fast injection was 10 seconds and the duration of the slow injection was 30 seconds in all included studies.Three studies reported site pain intensity after each injection at different time points. Two studies assessed site pain intensity immediately after each injection, and meta-analysis on 140 participants showed no clear difference in site pain intensity immediately post slow injection when compared to fast injection (low-quality evidence; P = 0.15). In contrast, meta-analysis of two studies with 59 participants showed that 48 hours after the heparin injection, slow injection was associated with less pain intensity compared to fast injection (low-quality evidence; P = 0.007). One study (40 participants) reported pain intensity at 60 and 72 hours after injection. This study described no clear difference in site pain intensity at 60 and 72 hours post slow injection compared to fast injection.All four included studies assessed bruise size at 48 hours after each injection. Meta-analysis on 459 participants showed no difference in bruise size after slow injection compared to fast injection (low-quality evidence; P = 0.07). None of the included studies measured the incidence of haematoma as an outcome. AUTHORS' CONCLUSIONS We found four RCTs that evaluated the effect of subcutaneous heparin injection duration on pain intensity and bruise size. Owing to the small numbers of participants, we found insufficient evidence to determine any effect on pain intensity immediately after injection or at 60 and 72 hours post injection. However, slow injection may reduce site pain intensity 48 hours after injection (low-quality evidence). We observed no clear difference in bruise size after slow injection compared to fast injection (low-quality evidence). We judged this evidence to be of low quality owing to imprecision and inconsistency.
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Affiliation(s)
- Mina Mohammady
- Isfahan (Khorasgan) Branch, Islamic Azad UniversityDepartment of NursingIsfahanIran
| | - Leila Janani
- Iran University of Medical SciencesDepartment of Biostatistics, School of Public HealthHemmat HighwayTehranIran0098
| | - Ali Akbari Sari
- Tehran University of Medical SciencesDepartment of Health Management and Economics, School of Public HealthPoorsina StTehranIran1653867944
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Campinos C, Le Floch JP, Petit C, Penfornis A, Winiszewski P, Bordier L, Lepage M, Fermon C, Louis J, Almain C, Morel D, Hirsch L, Strauss KW. An Effective Intervention for Diabetic Lipohypertrophy: Results of a Randomized, Controlled, Prospective Multicenter Study in France. Diabetes Technol Ther 2017; 19:623-632. [PMID: 29058477 PMCID: PMC5750448 DOI: 10.1089/dia.2017.0165] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Lipohypertrophy (LH) is highly prevalent and is potentially harmful to insulin-injecting patients. METHODS In this study, we assessed the impact of injection technique (IT) education, including use of a 4-mm pen needle on insulin-treated patients with clinically observed LH in a randomized, controlled, prospective multicenter study in France with follow-up of 6 months. Intensive education and between-visit reinforcement were given to the intervention group. Control patients received similar messages at study outset. RESULTS A total of 123 patients were recruited (age 52.1 ± 15.7 years; men 70.7%; body mass index >30 kg/m2: 34.2%; type 1: 53.7%; years with diabetes mellitus: 18.1 ± 10.5), of which 109 patients were included in the final analysis. The intervention group (n = 53) showed a significant decrease of total daily dose of insulin (average at baseline: 54.1 IU) at 3 months (T-3) and 6 months (T-6), reaching just over 5 IU versus baseline (P = 0.035). Corresponding, although not significant, decreases occurred in controls (n = 56); between-group differences were not significant. There were significant decreases in HbA1c (up to 0.5%) at T-3 and T-6 in both groups, with no significant differences between groups. A significant number of intervention patients improved their IT habits; about half achieved ideal IT habits by T-3 versus a quarter of control patients. By T-6, 2/3 of intervention patients achieved either ideal or acceptable IT habits, while only 1/3 of control patients did. CONCLUSIONS Our intervention was effective in both study arms, however, to a greater degree and more rapidly in the intervention group. Widespread application of this intervention could be highly cost-effective.
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Affiliation(s)
| | | | - Catherine Petit
- CH Sud Francilien Diabetes Service, Corbeil-Essonnes, France
| | - Alfred Penfornis
- Université Paris Sud Diabetes Service, CH Sud Francilien, Corbeil-Essonnes, France
| | | | - Lyse Bordier
- H.I.A. Begin Diabetes Service, Saint Mande, France
| | - Marie Lepage
- C.H.B. Diabetes Service, Boulogne sur Mer Cedex, France
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49
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Abstract
BACKGROUND Heparin is an anticoagulant medication that is usually injected subcutaneously. Subcutaneous administration of heparin may result in complications such as bruising, haematoma, and pain at the injection site. One of the factors that may affect pain, haematoma, and bruising is injection speed. For patients and healthcare providers, strategies that can reduce pain and bruising are considered important. Reducing patients' discomfort and concerns whenever and wherever possible is an important aim of nursing. Several studies have been carried out to see if speed of injection affects the amount of pain and bruising where the injection is given, but results of these studies have differed and study authors have not reached a clear final conclusion. This is the first update of the review first published in 2014. OBJECTIVES To assess the effects of duration (speed) of subcutaneous heparin injection on pain, haematoma, and bruising at the injection site in people admitted to hospitals or clinics who require treatment with unfractionated heparin (UFH) or low molecular weight heparin (LMWH). SEARCH METHODS For this update, the Cochrane Vascular Information Specialist (CIS) searched the Specialised Register (last searched March 2017) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 2). The CIS also searched trials registries for details of ongoing or unpublished studies. Review authors searched two Persian databases - Iranmedex and Scientific Information Database (SID) - as well as Google Scholar. SELECTION CRITERIA We sought randomised controlled trials (RCTs) comparing the effects of different durations of subcutaneous injection of heparin on pain, bruising, and haematoma at the injection site. DATA COLLECTION AND ANALYSIS Two review authors (MM, LJ), working independently, extracted data onto a structured form and assessed study quality. We used the criteria recommended by Cochrane to assess the risk of bias of included studies. For the outcomes, we calculated the mean difference (MD) or the standardised MD (SMD) with corresponding 95% confidence intervals (CIs). We pooled data using fixed-effect and random-effects models. We used GRADE to assess the overall quality of evidence supporting outcomes assessed in this review. MAIN RESULTS For this update, we identified three new studies and therefore included in the Review four studies with a total of 459 participants who received subcutaneous injections of LMWH into the abdomen. Only one trial reported the injected drug volume (0.4 mL). Owing to the nature of the intervention, it was not possible to blind participants and care givers (personnel) in any included study. Two studies described blinding of outcome assessors; therefore overall, the methodological quality of included studies was moderate. The duration of the fast injection was 10 seconds and the duration of the slow injection was 30 seconds in all included studies.Three studies reported site pain intensity after each injection at different time points. Two studies assessed site pain intensity immediately after each injection, and meta-analysis on 140 participants showed no clear difference in site pain intensity immediately post slow injection when compared to fast injection (low-quality evidence; P = 0.15). In contrast, meta-analysis of two studies with 59 participants showed that 48 hours after the heparin injection, slow injection was associated with less pain intensity compared to fast injection (low-quality evidence; P = 0.007). One study (40 participants) reported pain intensity at 60 and 72 hours after injection. This study described no clear difference in site pain intensity at 60 and 72 hours post slow injection compared to fast injection.All four included studies assessed bruise size at 48 hours after each injection. Meta-analysis on 459 participants showed no difference in bruise size after slow injection compared to fast injection (low-quality evidence; P = 0.07). None of the included studies measured the incidence of haematoma as an outcome. AUTHORS' CONCLUSIONS We found four RCTs that evaluated the effect of subcutaneous heparin injection duration on pain intensity and bruise size. Owing to the small numbers of participants, we found insufficient evidence to determine any effect on pain intensity immediately after injection or at 60 and 72 hours post injection. However, slow injection may reduce site pain intensity 48 hours after injection (low-quality evidence). We observed no clear difference in bruise size after slow injection compared to fast injection (low-quality evidence). We judged this evidence to be of low quality owing to imprecision and inconsistency.
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Affiliation(s)
- Mina Mohammady
- Islamic Azad University of Isfahan (Khorasgan) BranchDepartment of NursingIsfahanIran
| | - Leila Janani
- Iran University of Medical SciencesDepartment of Biostatistics, School of Public HealthHemmat HighwayTehranIran0098
| | - Ali Akbari Sari
- Tehran University of Medical SciencesDepartment of Health Management and Economics, School of Public HealthPoorsina StTehranIran1653867944
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50
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Colivicchi F, Zambon A. [The FOURIER study]. G Ital Cardiol (Rome) 2017; 18:533-540. [PMID: 28714995 DOI: 10.1714/2729.27819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Furio Colivicchi
- Divisione di Cardiologia, Presidio Ospedaliero San Filippo Neri, ASL Roma 1, Roma
| | - Alberto Zambon
- Dipartimento di Medicina - DIMED, Università degli Studi, Padova
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