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Introduction Studies on the durability of an intensive, structured education protocol on best insulin injection practice are missing for people with type 2 diabetes mellitus (T2DM). The aim of this study was to assess the durability of an intensive, structured education-based rehabilitation protocol on best insulin injection practice in well-trained subjects from our previous intensive, multimedia intervention study registered as the ISTERP-1 study. A total of 158 subjects with T2DM from the well-trained group of the 6-month-long ISTERP-1 study, all of whom had successfully attained lower glucose levels compared to baseline levels with lower daily insulin doses and with less frequent and severe hypoglycemic episodes, participated in the present investigation involving an additional 6-month follow-up period, called the ISTERP-2 study. Methods Participants were randomized into an intervention group and a control group, depending on whether they were provided or not provided with further education refresher courses for 6 months. At the end of the 6 months, the two groups were compared in terms of injection habits, daily insulin dose requirement, number of severe or symptomatic hypoglycemic events, and glycated hemoglobin (HbA1c) levels. Results Despite being virtually superimposable at baseline, the two groups behaved quite differently during the follow-up. The within-group analysis of observed parameters showed that the subjects in the intervention group maintained and even improved the good behavioral results learned during the ISTERP-1 study by further reducing both the rate of injection technique errors (p

Introduction Despite the availability of sophisticated devices and suitable recommendations on how to best perform insulin injections, lipohypertrophy (LH) and bruising (BR) frequently occur as a consequence of improper injection technique. Aim The purpose of this nationwide survey was to check literature-reported LH risk factors or consequences for any association with BR Method This was a cross-sectional, observational, multicenter study based on the identification of skin lesions at all patient-reported insulin injection sites in 790 subjects with diabetes. General and injection habit-related elements were investigated as possible BR risk factors. Results While confirming the close relationship existing between LH and a full series of factors including missed injection site rotation, needle reuse, long-standing insulin treatment, frequent hypoglycemic events (hypos), and great glycemic variability (GV), the observed data could find no such association with BR, which anyhow came with high HbA1c levels, missed injection site rotation, and long-standing insulin treatment. Conclusion BR most likely depends on the patient’s habit of pressing the injection pen hard onto the skin. Despite being worrisome and affecting quality of life, BR seems to represent a preliminary stage of LH but does not affect the rate of hypos and GV. Trial Registration 207/19.09.2017

Introduction The aim of this randomized controlled trial was to assess the impact of providing intensive injection technique (IT) education to patients routinely injecting insulin into sites of lipohypertrophy (LH). Methods Between November 2016 and May 2018, insulin-injecting patients with LH treated at Tianjin Metabolism Hospital (a public tertiary medical institution), Tianjin, China, were included in a 6-month prospective randomized controlled trial and randomized into either the intervention (the IT-education group) or the control (control group) arm. The control and IT-education groups were seen by different groups of trained nurses on different clinic days. IT education emphasized moving injections to normal tissue sites, within-and between-site injection rotation, an initial reduction of insulin total daily dose (TDD), and stopping needle reuse. Needles were provided to the IT group, while controls acquired needles in their usual way. Differences in changes in glycated hemoglobin (HbA1c) and insulin TDD were the primary and main secondary endpoints, respectively. Results The control (n = 104) and IT-education (N = 106) groups had similar demographic parameters (97% with type 2 diabetes) and baseline IT behavior. HbA1c reduction was similar in the IT-education and control group in the intention-to-treat (ITT) analysis (6-month between-group difference 0.16% [1.7 mmol/mol], 95% confidence interval [CI] − 0.11, 0.43 [− 1.2, 4.7]; p = 0.239) but was significant by the per-protocol (PP) analysis (difference 0.31% [3.4 mmol/mol], 95% CI 0.02, 0.60 [0.2, 6.6]; p = 0.038). Changes in TDD insulin in the IT-education group were approximately − 7 and − 8 IU by the ITT and PP analyses, respectively, versus − 1 IU (nonsignificant) in the controls (both between-group differences p ≤ 0.05). Despite the study design, IT education “contamination” (unplanned adoption of IT-intervention behaviors) was documented in 63 control patients. By post hoc analyses, HbA1c in “contaminated” controls decreased by 0.70% (7.7 mmol/mol) vs. 0.20% (2.2 mmol/mol) in “non-contaminated’ patients (p = 0.019) at 6 months. Conclusions Proper IT, including learning to not inject into sites of LH, proper within- and between site rotation, needle reuse reduction, and the use of 4-mm, 32-G needles in Chinese patients injecting into sites of LH enables a safe reduction of TDD insulin while maintaining overall glycemic control. Trial Registration Trial registration: ChiCTR-IOR-16009270 in the Chinese Clinical Trials Registry. Supplementary Information The online version contains supplementary material available at 10.1007/s13300-021-01013-1.

Raffaele Nuzzi, Simona Scalabrin, Alice Becco Eye Clinic, Department of Surgical Sciences, University of Turin, AOU Città della Salute e della Scienza, Turin, ItalyCorrespondence: Raffaele NuzziEye Clinic of University of Turin, Turin, ItalyTel +39 0116337225Fax +39 0116335481Email prof.nuzzi_raffaele@hotmail.itPurpose: This study aims to evaluate the effectiveness of different decompressive injection techniques in reducing intraocular pressure (IOP) spikes, if compared to the injection without pressure applied on the eye, following the intravitreal injection of bevacizumab.Patients and Methods: Two hundred patients with indication to intravitreal therapy were randomized into five arms: 40 received intravitreal injection without ocular decompression (arm A), 40 with pre-injection scleral indentation with cotton swab (arm B), 40 with pre-injection digital ocular massage (arm C), 40 with post-injection scleral indentation with cotton swab (arm D) and 40 with post-injection digital ocular massage (arm E). All patients underwent measurement of the IOP with Goldamm applanation tonometer 10 minutes before and 10 minutes after the injection. The primary endpoint of the study was variation of the post- injection IOP with the different techniques.Results: An increase in post-injection IOP was observed in all the arms, if compared to pre-injection values. The greatest increase was observed in arm A with a mean IOP rise of 17.60 mmHg. All other techniques showed lower mean IOP increases: arm B 10.76 mmHg, arm C 9.35 mmHg, arm D 8.8 mmHg, arm E 3.4 mmHg. The post-injection IOP differences of innovative techniques compared to the technique without ocular decompression were all statistically significant (p-value < 0.01). If compared to arm A (35%), a reduction in IOP spike ≥ 40 mmHg frequency was also observed. The status of phakia/pseudophakia, a previous diagnosis of glaucoma and the underlying pathology for which indication was given to inject bevacizumab did not significantly alter the post-injection IOP in any of the protocols.Conclusion: The introduction of new injection protocols, such as injections performed before or after decompressive treatments, could be a safe and effective approach to control post-injection IOP increase.Keywords: bevacizumab injection, injection technique, intraocular pressure spike, digital ocular massage, scleral indentation, applanation tonometry

AIMS: To investigate whether single use of 4 mm needles combined with education about injection technique and lipohypertrophy affects HbA1c, hypoglycaemia and glucose variability. METHODS: Insulin-injecting people with diabetes recruited from nine Belgian diabetes centres were prospectively followed for 6 months. They were provided 4 mm pen needles and education concerning injection technique using an online platform (BD and Me™) based on the international Forum for Injection Technique & Therapy Recommendations focused on avoidance of lipohypertrophy zones and reduction of needle reuse. RESULTS: A total of 171 people with diabetes were included of which 146 completed the study. At baseline, lipohypertrophy was present in 63.0% of those who completed the study, with 51.4% injecting in zones of lipohypertrophy, 37.0% incorrectly rotating and 95.9% reusing needles. After the intervention, 7.5% still injected in a lipohypertrophy zone, 4.1% rotated incorrectly and needle reuse decreased to 21.2%. The number of participants with severe hypoglycaemias (from 15.8% to 4.1%, p < 0.001), unexplained hypoglycaemias (from 46.6% to 16.4%, p < 0.001) and high glucose variability (from 64.4% to 29.5%, p < 0.001) was significantly reduced. HbA1c and total daily insulin dose remained stable. CONCLUSION: The combination of 4 mm pen needles and online education on injection techniques significantly reduced the number of people with severe hypoglycaemic episodes, unexplained hypoglycaemia and high glucose variability but did not improve HbA1c control nor lower insulin needs. TRIAL REGISTRATION: ClinicalTrials.gov NCT04659330.

Aesthetic improvement of the lips with hyaluronic acid fillers is a popular procedure. A comprehensive, modular, and highly individualizable method has been developed: the Lip Omnicomprehensive Volume Enhancement (LOVE) approach. The present study assessed the safety and effectiveness of LOVE across different patient age groups.Methods: This was a prospective, single-center study of women aged 20-70 years seeking nonsurgical lip enhancement or asymmetry correction. Three equally sized groups were formed based on patient age: 20-34, 35-45, and 46 years or older. Individualized treatment plans were developed taking into account patient preferences expressed in a pre-injection questionnaire. Treatment used one or more of the three modules of LOVE: lip shape [vermilion border, Vycross (VYC)-17.5]; volume (vermilion body, VYC-17.5); and hydration (submucosal area, VYC-12). Follow-up lasted 6 months.Results: Sixty patients were enrolled (mean age: 41.3 ± 13.3 years; n = 20 per age group), all of whom were White. Most were treated with all three LOVE modules. Mean filler quantities increased with age: 20-34 years, 1.1 ± 0.1 mL; 35-45 years, 1.5 ± 0.1 mL; 46 years or older, 1.6 mL ± 0.2 mL. Mean patient satisfaction at 4 weeks [on a seven-point scale from 0 (extremely dissatisfied) to 6 (extremely satisfied)] was 4.8-4.9 in each age group. Apart from minor and transient edema/bruising, there was only one complication: a case of lumps that resolved with home massage.Conclusion: The LOVE approach is safe and effective across a range of ages, with high levels of patient satisfaction.

Jani van Loghem,1 Sonja Sattler,2 Gabriela Casabona,3 Sebastian Cotofana,4 Sabrina Guillen Fabi,5 Kate Goldie,6 Uliana Gout,7 Martina Kerscher,8 Ting Song Lim,9 Carla de Sanctis Pecora,10 Gerhard Sattler,2 Ada Trindade de Almeida,11 Rungsima Wanitphakdeedecha,12 Philip Werschler,13 Tatjana Pavicic14 1Falck Clinic, Aesthetic Medicine Centre, Amsterdam, the Netherlands; 2Rosenpark Clinic, Darmstadt, Germany; 3Ocean Clinic, Marbella, Spain; 4Albany Medical College, Albany, NY, USA; 5Cosmetic Laser Dermatology and University of California, San Diego, CA, USA; 6European Medical Aesthetics Ltd, London, UK; 7Aesthetic Medicine Clinic, London, UK; 8University of Hamburg, Hamburg, Germany; 9Clique Clinic, Kuala Lumpur, Malaysia; 10Dermatologie-Clínica, Cirurgia, Cosmiatria e Laser, São Paulo, Brazil; 11Clínica de Dermatologia do Hospital do Servidor Público Municipal de São Paulo, São Paulo, Brazil; 12iSKY Innovative Skin & Laser Surgery Center, Bangkok, Thailand; 13Premier Clinical Research, Spokane, WA, USA; 14Private Practice for Dermatology and Aesthetics, Munich, GermanyCorrespondence: Jani van LoghemFalck Clinic, Aesthetic Medicine Centre, Falckstraat 51, Amsterdam, 1017 VV, the NetherlandsEmail jani@falckclinic.comBackground: As the treatment indications for the Cohesive Polydensified Matrix® hyaluronic acid (CPM-HA) portfolio continue to expand and diversify, injectors new to the range or those who are expanding the treatments they offer may be unsure of the optimal product and injection technique for specific facial areas. Each product in the CPM-HA portfolio has been intentionally designed to provide the best physical properties for a specific indication and target tissue. This document has been developed to provide a comprehensive, one-stop reference for clinicians using the portfolio.Methods: An international panel of experts in the field of aesthetic medicine convened to develop guidelines on effective and safe injection technique when performing treatments with the CPM-HA range of soft-tissue fillers.Results: Consensus members considered treatment indications in the upper, middle and lower face. Landmark deficiencies and anatomical considerations are described for each indication and consensus recommendations provided on the optimal product, injection depth and treatment technique. This is supplemented by the experts advice on avoidance of complications. Throughout, an evidence-based approach to selection of products and injection techniques is provided. The result is a fully tailored approach to a range of indications covering the full portfolio of CPM-HA products, including the newest addition for skin revitalization.Conclusion: The recommendations in this consensus document are provided to assist clinicians in the selection of CPM-HA products, administration techniques and depths of injection with the aim of providing seamless and natural treatment results, enhanced safety and patient satisfaction.Keywords: anatomy, Belotero, cohesive polydensified matrix, consensus, hyaluronic acid, injection technique

Chemodenervation of cervical musculature using botulinum neurotoxin (BoNT) is established as the gold standard or treatment of choice for management of Cervical Dystonia (CD). The success of BoNT procedures is measured by improved symptomology while minimizing side effects and is dependent upon many factors including: clinical pattern recognition, identifying contributory muscles, BoNT dosage, and locating and safely injecting target muscles. In patients with CD, treatment of anterocollis (forward flexion of the neck) and anterocaput (anterocapitis) (forward flexion of the head) are inarguably challenging. The longus Colli (LoCol) and longus capitis (LoCap) muscles, two deep cervical spine and head flexor muscles, frequently contribute to these patterns. Localizing and safely injecting these muscles is particularly challenging owing to their deep location and the complex regional anatomy which includes critical neurovascular and other structures. Ultrasound (US) guidance provides direct visualization of the LoCol, LoCap, other cervical muscles and adjacent structures reducing the risks and side effects while improving the clinical outcome of BoNT for these conditions. The addition of electromyography (EMG) provides confirmation of muscle activity within the target muscle. Within this manuscript, we present a technical description of a novel US guided approach (combined with EMG) for BoNT injection into the LoCol and LoCap muscles for the management of anterocollis and anterocaput in patients with CD.

Introduction:Algeria has more than 1.7 million diabetic patients on to whom a descriptive assessment particularly on the insulin usage behaviors has not yet been initiated, although is needed. This study aims to provide a descriptive analysis of how Algerian diabetic patients perceive and apply insulin injection techniques. Methods:using the “patient” questionnaire within the Injection Technique Questionnaire (ITQ) 2016 survey, this study assessed the insulin injection practices of 100 patients recruited over a seven-month period in western Algeria at the Tlemcen University Hospital Center. The results of this study are compared to those of the ITQ 2016 survey. Results:pens are the instruments of injection for 98% of Algerians who continue to use mostly long needles of 6- and 8-mm, although 4mm needles are the recommended safer option. Insulin analogues (fast and basal) are plebiscite. Arms and thighs are the preferred injection sites; the abdomen (the preferred site elsewhere) is neglected for reasons to be investigated. The correct re-suspension technique for cloudy insulin is unknown. Extensive pen needle re-use (10+ times) for over half of the patients exposes them to both higher intramuscular (IM) injection risk and lipohypertrophy (LH). Injection training is performed in Algeria by the diabetologist. Conclusion:this study describes for the first time Algerian patients´ insulin injection technique. It highlights their skills and identifies many deficiencies which patients and professionals must correct given the issues in this area.

Inappropriate injection technique leads to incorrect insulin dosing, increased pain and impaired glucose control in patients with diabetes. This review examines in detail the results of two clinical studies, the Glycemic Impact of Insulin Injection Technique (GIIIT) and the UK Lipo Study (UKLS) that examined the effect of teaching patients proper injection techniques to achieve good glycemic control. The GIIIT study included patients with type 1 and type 2 diabetes (1870 years) who were on a regimen of multiple daily insulin injections. They were categorised into three groups: those that received structured injection technique training using 4-mm injection needles (TN), those that received injection technique training (T) and control (C). The UKLS study included 75 patients who received structured training to reduce the risk of developing lipohypertrophy. Initially, deviations from proper insulin injection technique were observed in a majority of patients in both the studies. In the GIIIT study, 6 months after training under TN and T conditions, HbA1c decreased by 1%, with no observable changes under the C condition. The daily insulin dose was increased by 6 IU in all conditions. Overall, the use of 4-mm short needles reduced post-injective pain in all patients. In the UKLS study, for 6 months, the variability of glycemia and frequency of unexplained hypoglycaemia decreased as the daily dose of insulin decreased by an average 6 IU; in addition, HbA1c level decreased from 8.6% to 8.2%. Six months after the training, both studies noted a decrease in or disappearance of lipohypertrophy in the patients. These results indicate that proper injection technique training improves glycemic control in patients with diabetes.

Purpose This study was performed to determine whether periarticular injection performed in the early stage of total knee arthroplasty (TKA) could provide a better postoperative pain relief than periarticular injection performed in the late stage of TKA. The hypothesis was based on the concept that analgesic intervention before the onset of noxious stimuli would be associated with less postoperative pain. Methods A total of 105 participants were randomly assigned to receive superficial injection just prior to arthrotomy (early stage periarticular injection group) or superficial injection after implanting the prosthesis (late-stage periarticular injection group) in patients undergoing unilateral TKA with 1:1 treatment allocation. In both groups, deep injection was performed according to the same schedule (just prior to implanting prosthesis). The solution consisted of 300 mg of ropivacaine, 8 mg of morphine, 40 mg of methylprednisolone, 50 mg of ketoprofen, and 0.3 mg of epinephrine mixed with normal saline to a final volume of 60 mL. All surgeries were managed under general anesthesia without any regional blocks. Registry-specified primary outcome was postoperative pain score at rest measured at the recovery room using a 100-mm visual analog scale (VAS). The VAS score was compared between two groups and assessed to reach the reported threshold values for the minimal clinically important difference (MCID) of 10 mm for the postoperative VAS score. Results The VAS score at the recovery room was significantly lower in the early stage periarticular injection group than the late-stage periarticular injection group (23 ± 25 mm versus 39 ± 34 mm, respectively; 95% confidence interval 4–28 mm; p = 0.0078). The mean difference in the primary outcome fulfilled the MCID value. Conclusions Bringing forward the timing of periarticular injection may provide significant and clinically meaningful improvement in pain following TKA under general anesthesia. Level of evidence I.

With an eye on the sequence of two Indian papers concurrently published in Diabetes Therapy, this paper analyzes skin differences among races and points to a lack of organized structured education sessions as the main cause of the high prevalence of lipodystrophy (LD) and consequent poor metabolic control. Only half of all insulin-treated patients reach their therapeutic targets worldwide. The factors involved in this are manifold, including the choice of overlong and repeatedly reused needles, as well as a failure to systematically rotate injection sites, all of which lead to skin LD. Regularly issued guidelines and expert recommendations provide suggestions about how to correct poor injection techniques, but LD still occurs at a high rate and is associated with poor metabolic control, a high risk of complications, frequent severe hypoglycemic episodes, and huge health and social costs. Poor knowledge of subcutaneous tissue anatomy and the physiological response to insulin injection by both health care personnel and patients may contribute to this problem. Moreover, differences in body structure among the races present in our multiethnic societies must be taken into account when choosing needle length and shooting technique in order to avoid accidental intramuscular injections.

Health-care professionals in India frequently manage injection or infusion therapies in persons with diabetes (PWD). Patients taking insulin should know the importance of proper needle size, correct injection process, complication avoidance, and all other aspects of injection technique from the first visit onward. To assist health-care practitioners in their clinical practice, Forum for Injection Technique and Therapy Expert Recommendations, India, has updated the practical advice and made it more comprehensive evidence-based best practice information. Adherence to these updated recommendations, learning, and translating them into clinical practice should lead to effective therapies, improved outcomes, and lower costs for PWD.

Objective: SIAXI (NCT02091739), a pivotal double-blind, randomised, placebo-controlled study with an extension period (EP), assessed the efficacy and safety of incobotulinumtoxinA 75 or 100 U in patients with sialorrhea due to Parkinson's disease (PD), atypical parkinsonism, stroke or traumatic brain injury. This subgroup analysis assessed the impact of injection guidance technique. Background: Literature suggests that ultrasound (US) guidance of botulinum neurotoxin injections, especially into the submandibular glands, may be needed to improve efficacy and safety. Methods: Patients were randomized (2:2:1) to incobotulinumtoxinA 75 or 100 U, or placebo, distributed in bilateral parotid and submandibular glands in a single injection cycle (IC) in the main period (MP). All eligible patients completing the MP received three further incobotulinumtoxinA ICs (75 or 100 U; each 16+/-2 weeks) in the EP. Injections were consistently guided by US or anatomical landmarks (AL) at investigators' discretion. Outcomes included unstimulated salivary flow rate (uSFR) and patients' Global Impression of Change Scale (GICS). The incidence of adverse events (AEs) was reported. Results: 184 patients were randomised and received either incobotulinumtoxinA 75 U (n=74) or 100 U (n=74), or placebo (n=36) in the MP; 173 completed the MP and entered the EP. In the MP, injections were guided by US in 56.5% of patients and by AL in 43.5%. Among patients treated with incobotulinumtoxinA in all 4 ICs, with US and AL guidance mean uSFR decreased with 75 U and 100 U from study baseline to 4 weeks post-injection, (mean [SD] change from study baseline to end of study: US, -0.15 [0.20] and -0.17 [0.25]; AL, -0.19 [0.22] and -0.17 [0.20]). Patients' GICS also showed improvement at 4 weeks post-injection with both US and AL guidance. The incidence of AEs over all ICs with incobotulinumtoxinA treatment was similar with US and AL guidance (67.0% and 61.0%). The most frequent treatment-related AEs were dry mouth (10.7% and 6.5%) and dysphagia (3.9% and 2.6%). No new safety concerns with respect to guidance technique were reported. Conclusions: In contrast to current literature, repeated incobotulinumtoxinA injections under either US or AL guidance are similarly effective and well tolerated for sialorrhea in patients with PD or other neurological disorders.

Lipohypertophy (LH) is the most common skin complication of incorrect injection technique which does not only represent an aesthetic defect but also severely disrupts insulin pharmacokinetics/pharmacodynamics. As a consequence of that, hormone release is delayed and unexplained/unpredictable hypoglycemia occurs, both deteriorating metabolic control while negatively affecting adherence to treatment and quality of life. The economic burden due to unwanted intra-LH injections is accounted for by inappropriately high insulin requirements, increased emergency-related hospitalizations, and loss of work days. Greater attention has to be paid by diabetes care teams to education programs with periodic refreshers to achieve better metabolic control and reduce the economic burden of diabetes.

The article presents the main methodological aspects of practical training at the training on «Analgesia in therapeutic dentistry». Attention is focused on the matters of classification methods and types of anesthesia of pathological processes of maxillofacial region and their advantages and disadvantages, indications and contraindications for anesthesia for therapeutic interventions on questions of select the most effective anesthetic injection systems and technology of injection itself., В статье представленны основные методические аспекты проведения практических занятий по учебной теме «Обезболивание в терапевтической стоматологии». Внимание акцентируется на вопросах классификации методов и видов обезболивания патологических процессов челюстно-лицевой области, их преимуществах и недостатках, показаниях и противопоказаниях к проведению анестезии при терапевтических вмешательствах, на вопросах выбора наиболее эффективных анестетиков, инъекционных систем и техники проведения самой инъекции., У статті представлені основні методичні аспекти проведення практичних занять з навчальної теми «Знеболювання в терапевтичній стоматології». Увага акцентована на питаннях класифікації методів і видів знеболювання патологічних процесів щелепно-лицевої зони, їх перевагах і недоліках, показаннях і протипоказаннях до проведення анестезії при терапевтичних втручаннях, на питаннях вибору найбільш ефективних анестетиків, ін'єкційних систем та техніки проведення самоін'єкції.

Lipohypertophy (LH) is the most common skin complication of incorrect injection technique which does not only represent an aesthetic defect but also severely disrupts insulin pharmacokinetics/pharmacodynamics. As a consequence of that, hormone release is delayed and unexplained/unpredictable hypoglycemia occurs, both deteriorating metabolic control while negatively affecting adherence to treatment and quality of life. The economic burden due to unwanted intra-LH injections is accounted for by inappropriately high insulin requirements, increased emergency-related hospitalizations, and loss of work days. Greater attention has to be paid by diabetes care teams to education programs with periodic refreshers to achieve better metabolic control and reduce the economic burden of diabetes.

As injectable therapies such as human insulin, insulin analogs, and glucagon-like peptide-1 receptor agonists are used to manage diabetes, correct injection technique is vital for the achievement of glycemic control. The forum for injection technique India acknowledged this need for the first time in India and worked to develop evidence-based recommendations on insulin injection technique, to assist healthcare practitioners in their clinical practice.

Introduction: Insulin remains the cornerstone of therapy in a substantial number of patients with type 2 diabetes mellitus (T2DM). Inadequate knowledge regarding insulin usage is likely to influence its acceptance and adherence, and outcome of therapy, underscoring great need to investigate knowledge, attitude, and practice of insulin usage in patients with T2DM. Methodology: A cross-sectional registry-based retrospective study analyzed data collected from 748 respondents (male: 466, female: 282), mostly from high or middle economic status, who were enrolled as outpatient in a referral clinic during last 10 years (2006–2016), to assess the general characteristics of patients with type 2 diabetes and their baseline knowledge, attitude, and practice of insulin usage and injection practices. Results: Mean ± standard deviation (SD) of duration of diabetes was 12.24 ± 7.60 years and mean ± SD duration of insulin therapy was 3.42 ± 4.18 years, which was initiated after a mean ± SD diabetes duration of 8.80 ± 6.42 years. Mean insulin dose per kilogram of body weight/day was 0.51 ± 0.27 units. Total daily dose of insulin was 33.36 ± 18.44 units and number of injections/day (mean ± SD) was 2.06 ± 0.73. Among the respondents, 58.96% were on human insulin and 35.70% were on analog insulin. Pen devices were used by 66.08% of the population whereas 31.76% used insulin syringes. The prevalence of lipohypertrophy (LH) was 12.57%, which was significantly (P < 0.001) associated with wrong technique with regard to injection angle (10.45% vs. 23.02%), site of injection (7.00% vs. 30.51%), rotation of site of injection (0.88% vs. 17.66%), and reuse of needle (5.77% vs. 15.19%). LH was also significantly (P < 0.05) associated with the use of human (14.74%) compared to analog insulin (8.24%). Conclusion: The current study highlights the unique patterns of insulin usage and associated high prevalence of LH among insulin users in India.

Aim. To consider technical aspects of antihyperglycemic injection therapy in patients with type 1 and type 2 diabetes mellitus. Methods. The analysis included 200 adult patients (60 men and 140 women) receiving injection therapy for at least 6 months. They filled a 40-iremquestionnaire designed to estimate socio-demographic parameters, the use of different devices for insulin injection, and the most frequent mistakesmade by the patients. Their mean age was 51.7?15.1 years, duration of DM 11.9?9.1 years, mean HbA 1c level 8.4?1.5%. Results. 130 (65%) patients used semiautomated injection pens, 39 (19.5%) disposable syringes, 31 (15.5%) both devices. Most patients (122, 61%)used 8 mm needles, 32 (16%) used 12.7 mm needles, 31 (15.5%) 10 mm, 28 (14%) 12 mm, 19 (9.5%) 6 mm, 18 (9.0%) 5 mm. 64 (32%) patientsused needles of different length, 25 (12.5%) could not give a definitive information about the needle length they used. Location of injection sites variedconsiderably in individual patients. 87 (43.5%) made injections within a single anatomic regions (62 into the anterior abdominal wall, 19 into theanterolateral surface of the thigh, 5 into shoulders, and 1 into buttocks. 113 (56.5%) patients made injections into two or more regions. 83 (41.5%)developed lipodystrophy at injection sites, 42 (50.6%) continued to use them for injections (12 did it on a regular basis and 30 occasionally). HbA 1c levels were 9.5 and 8.2% in patients who made injections into affected sites and who had no lipodystrophic changes respectively (p=0.02). Over halfof the interviewed patients (106 or 53%) were informed about correct subcutaneous injection technique by the attending endocrinologist, 60 (30%)were taught by the nursing staff while staying in a hospital or visiting an endocrinological dispensary, 28 (14.%) were educated at Diabetes schools,9 (4.5%) when seeing the local therapist, and 19 (9.5%) by non-professionals. Conclusion. Many patients make serious mistakes when self-administering insulin. Incompliance with the guidelines on insulin injections leading tothe impairment of carbohydrate metabolism, the technical aspects of injections must be in the focus of attention of any practitioner. New (2010) internationalguidelines on the injection technique are overviewed.

Objective: To evaluate and compare the pain perception by the pediatric patients, while experiencing computerized injection device comfort control syringe (CCS) and the conventional injection technique during dental clinical procedures. Materials and Methods: Fifty children (31 boys and 19 girls) aged 6-14 years requiring local anaesthesia on both sides of the dental arch for various treatment procedures were selected for this study. The patients served as their own control, and on the appointed day CCS was used on one side of the dental arch and on the subsequent appointment, i.e., the very next day conventional injection technique was used. Visual analogue scale (VAS) and faces pain rating scale (FRS) were used to assess the child's pain perception to each of the techniques immediately after the injection. Various physiological parameters were measured before, during and after the two injection procedures and compared for statistical variation. Results : Paired t-test revealed a statistically significant difference in the pain perception by children using VAS and FRS between computerized and conventional technique. No statistically significant difference was observed when physiological parameters (heart rate, blood pressure and temperature) were compared at various intervals between the computerized and the conventional technique. Conclusion: Computerized injection device (CCS) provides less painful injections when compared to the conventional injection technique.

The dependability of computing systems running cryptographic primitives is a critical factor for evaluating the practical security of any cryptographic scheme. Indeed, the observation of erroneous results produced by a computing device after the artificial injection of transient faults is one of the most effective side-channel attacks. This chapter reviews the (semi-)invasive fault injection techniques that have been successfully used to recover the secret parameters of a cryptographic component. Subsequently, a complete characterization of the fault model derived from the constant underfeeding of a general-purpose microprocessor is described, in order to infer how the faulty behavior causes exploitable software errors.

Rui-yi Zhao,1 Xiao-wen He,1 Yan-min Shan,1 Ling-ling Zhu,2 Quan Zhou3 1Clinical Nurse Specialist Section, Division of Nursing, 2Geriatric VIP Care Ward, Division of Nursing, 3Department of Pharmacy, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People’s Republic of China Background: Diabetes patients are complex due to considerations of polypharmacy, multimorbidities, medication adherence, dietary habits, health literacy, socioeconomic status, and cultural factors. Meanwhile, insulin and oral hypoglycemic agents are high-alert medications. Therefore it is necessary to require a multidisciplinary team’s integrated endeavors to enhance safe medication management and use of antidiabetic drugs.Methods: A 5-year stewardship intervention program, including organizational measures and quality improvement activities in storage, prescription, dispensing, administration, and monitoring, was performed in the Second Affiliated Hospital of Zhejiang University, People’s Republic of China, a 3,200-bed hospital with 3.5 million outpatient visits annually.Results: The Second Affiliated Hospital of Zhejiang University has obtained a 100% implementation rate of standard storage of antidiabetic drugs in the Pharmacy and wards since August 2012. A zero occurrence of dispensing errors related to highly “look-alike” and “sound-alike” NovoMix 30® (biphasic insulin aspart) and NovoRapid® (insulin aspart) has been achieved since October 2011. Insulin injection accuracy among ward nurses significantly increased from 82% (first quarter 2011) to 96% (fourth quarter 2011) (P10 seconds (99.4%), and using the pen needle only once (88.7%). On-site inspection indicated of great improvement in the percentage of drug-related problems in the antidiabetes regimen between the first and second quarter of 2014 (1.08% versus 0.28%) (P

Background: Persons using daily subcutaneous injections to administer medicine perform them in different ways and thereby increase the risk of skin complications related to the injection. It is often part of nurses’ role to administer medicine and educate the patient in injection technique. Course literature in nursing education, commercial patient education pamphlets, and instructional leaflets do not give consistent advice regarding subcutaneous injection technique. Aim: The aim of this review was to identify the scientific foundation for the technical performance of subcutaneous injections. The question to be answered was: How should a subcutaneous injection be administered to achieve the right dose in the right place with minimum complications? Method: The review included a search in three databases, a screening process at abstract level, followed by a quality assessment of included articles. The quality assessment was done independently by two people and followed specific protocols. Result: A total of 38 articles were assessed for quality and covered information on dose, location, and complications of subcutaneous injection. The assessed studies are heterogeneous in design and describe different aspects of the subcutaneous injection technique. Therefore, the scientific foundation for technical performance is weak. However, several studies indicate that the amount of subcutaneous fat and appropriate needle length are of high importance for the drug to reach the target tissue. Conclusion: More research regarding effective subcutaneous injection technique needs to be done.

overall goals for the treatment of diabetes are to prevent acute and long-term complications and maintain a good quality of life. The St Vincent Declaration and the Swedish National Guidelines for the Treatment of Diabetes Mellitus describe patient education in self-treatment as a prerequisite for the achievement of these goals. This survey aimed to evaluate the presence of structured patient education (in advance planned education), its organisation, staffing and goals, and the results in out-patient diabetes care in Sweden. A questionnaire consisting of 35 open and closed questions was mailed to 1250 diabetes educated nurses working in hospitals and primary health care in the entire country. Responses were received from 583 (47%) nurses. Structured diabetes patient education was performed by 486 nurses. It was usually organised by nurses and performed in co-operation with doctors (55%), dietitians (38%), chiropodists (36%), and social workers (9%). The sessions took place individually at pre-scheduled visits (80%), or as group education (26%). Fifty-one percent described explicit goals for the education, most commonly: general knowledge about diabetes, improved metabolic control and increased safety. The structured education was evaluated by 51% of which the HbA1c level at the next scheduled visit was the most frequently used evaluation method (44%), followed by home monitored blood glucose values (37%) and a structured evaluation form (17%). The goals had been achieved to a great or quite great extent by 67% of the responding nurses. To the extent that structured patient education takes place, nurses are usually responsible for its performance. It takes place individually as well as in groups. Many nurses lack evident goals for the education and sufficient evaluation methods. It was concluded that there is confusion about the content of structured education vs information activity. Copyright © 2006 John Wiley & Sons, Ltd. Practical Diabetes Int 2006; 23(3): 138-141

Advances in the treatment of diabetes have led to an increase in the number of injectable therapies, such as human insulin, insulin analogues, and glucagon-like peptide-1 analogues. The efficacy of injection therapy in diabetes depends on correct injection technique, among many other factors. Good injection technique is vital in achieving glycemic control and thus preventing complications of diabetes. From the patients′ and health-care providers′ perspective, it is essential to have guidelines to understand injections and injection techniques. The abridged version of the First Indian Insulin Injection technique guidelines developed by the Forum for Injection Technique (FIT) India presented here acknowledge good insulin injection techniques and provide evidence-based recommendations to assist diabetes care providers in improving their clinical practice.